Insurance Condo Application Form

INSURANCE CONDO APPLICATION FORM

Applicant Name:   Phone:

Applicant Information

Property / Condominium Details

Unit/Apartment #:   Building Name:

Year Built:   Square Footage:

Policy Details

Desired Policy Type: HO-6 (Condo Unitowners) Commercial Condo Other:

Deductible:   Estimated Annual Premium:

Policy Period Start:   End:

Payment Plan: Annual Semi-Annual Monthly Other:

Coverage Selection

Indicate requested coverages: Interior building improvements and betterments Personal property Personal liability Loss assessment (condo association assessments) Additional living expense / Loss of use Optional coverages (e.g. identity theft, equipment breakdown):

Exclusions and Acknowledgments

Applicant acknowledges that standard exclusions may apply. Applicant initialing indicates acknowledgement of common exclusions:

Earthquake (separate endorsement required) Flood (not covered unless specifically endorsed) Mold and fungal remediation (limited or excluded) Wear, tear, gradual deterioration, and maintenance Intentional acts or criminal activity by insured

Beneficiary / Loss Payee Designation

Primary Payee Name:

Relationship to Insured:   Percentage (if applicable):

Contingent Payee Name:

Relationship:   Percentage:

Claims History

Have you had any property or liability claims in the past five (5) years? No Yes — list below

Required Documentation Checklist

Please attach or indicate that the following documents are included: Condo association bylaws and master policy summary Prior insurance declarations page (if available) Photographs of property / unit Repair estimates or invoices Proof of identity (driver's license or ID)

Declarations, Authorizations, and Certification

I certify that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that material misrepresentation or omission of information may result in denial of coverage, cancellation of the policy, or rescission of coverage. I further understand that coverage is subject to the terms, conditions, limitations and exclusions of the policy issued.

I authorize the insurer and its representatives to make inspections of the premises and to obtain and disclose information reasonably related to underwriting and claims handling, including prior loss history and policy information from other insurers, when necessary to evaluate this application or any subsequent claim. I authorize release of such information to my mortgagee or loss payee if so designated.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to civil or criminal penalties under applicable law.

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