Insurance Cabin Application

Insurance Cabin Application

Applicant / Insured Information

Property Details

Primary Use (select all that apply):

Seasonal/Occasional Use    Primary Residence    Rented/Short-term Rental

Policy Details Requested

Policy Type (select one or more applicable):

Dwelling Fire    Homeowners / Seasonal Home    Vacation Rental Liability    Liability Only

Coverages & Optional Riders

Select coverages to be quoted:

Dwelling Coverage    Other Structures    Personal Property/Contents

Loss of Use / Additional Living Expense    Personal Liability    Theft

Vandalism & Malicious Mischief    Flood (requires separate quote)    Earthquake (requires separate quote)

Optional Riders:

Replacement Cost on Contents    Agreed Value / Stated Amount    Equipment Breakdown    Ordinance or Law Coverage

Exclusions and Limitations

The policy to be issued will include standard exclusions and limitations including, but not limited to: wear and tear, gradual deterioration, mechanical breakdown not resulting from a covered peril, loss caused by war or nuclear hazard, intentional acts by an insured, losses arising from defect or deterioration of construction materials, and losses from flood or earthquake except where specific endorsements are issued. Coverage for mold, fungus or bacterial contamination is limited and subject to specific conditions in the policy.

I acknowledge that I have read and understand the exclusions and limitations described above and that coverage will be subject to the full terms, conditions, and exclusions of the policy.

Prior Loss / Claims History (Last 5 Years)

No prior claims or losses in the last five years

Security, Maintenance & Protective Devices

Smoke detectors installed    Burglar alarm / monitored system    Automatic sprinkler system

Mortgagee / Additional Interest / Beneficiary

Beneficiary for proceeds (if different from mortgagee):

Declarations and Certification

I represent that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may result in denial of coverage, cancellation of the policy, or rescission of coverage effective from inception. Coverage, if issued, will be governed by the terms, conditions, limitations and exclusions of the policy form and any endorsements.

I authorize the insurer, its representatives and its agents to obtain underwriting, claims and credit information relevant to this application from third parties and to inspect the described property for underwriting or loss-prevention purposes. I understand that inspections are for underwriting information only and do not guarantee that repairs or improvements will be made unless specified in the policy.

I acknowledge that acceptance of this application by the insurer is subject to underwriting review and receipt of full information required by the insurer. No coverage is in force until a policy is issued and the first premium paid, except where a temporary binder is expressly provided in writing.

I authorize inspection and information verification as described above.

Fraud Warning: Any person who knowingly and with intent to defraud makes a false statement or representation on this application may be subject to civil and criminal penalties, including denial of benefits and referral to law enforcement, where permitted by law.

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