Insurance Dwelling Application

INSURANCE DWELLING APPLICATION

Applicant / Insured Information

Applicant Name:

Mailing Address:

Date of Birth:

Entity Type: Individual Trust Corporation Partnership

Property to be Insured

Year Built:   Construction Type:

Number of Dwellings on Premises:   Units Occupied By: Owner Tenant Vacant Seasonal

Protection & Utilities

Alarm / Security System: Local Monitored None

Fire Protection Proximity to Fire Hydrant (feet):   Nearest Fire Station (miles):

Coverage Requested

Please indicate the limits and options desired. Limits are subject to underwriting approval.

Deductible:   Policy Effective Date Requested:   Policy Term (months):

Coverage Options: Replacement Cost Actual Cash Value Extended Replacement Cost

Prior Insurance & Loss History

Prior Insurance Carrier (most recent):

Policy Period: From to

Any prior claims, losses, or underwriting denials? Yes No

Additional Interest / Mortgagee / Loss Payee

Name of Mortgagee / Additional Interested Party:

Mailing Address:

Payee / Beneficiary for Claim Proceeds (if applicable)

Name:

Relationship to Insured:   Percentage of Proceeds:

Exclusions, Limitations & Important Notices

The coverage applied for is subject to the terms, conditions, exclusions and limits contained in the policy form and endorsements issued. Typical exclusions include but are not limited to: wear and tear, gradual deterioration, flood and earthquake unless specifically endorsed, intentional acts, and loss due to infestation. Coverage for certain perils and increased limits may require specific endorsements and additional premium.

Underwriting reserves the right to require inspection, additional protective devices, proof of prior insurance, and other reasonable conditions as a prerequisite to binding coverage. Submission of this application does not bind the company to provide coverage; coverage shall be effective only upon issuance of a policy or binder by the company.

Declarations & Applicant Certification

I declare that the statements made in this application are true and complete to the best of my knowledge and belief. I understand that any material misrepresentation, omission, or concealment of fact made in this application may void coverage and may result in refusal to provide coverage or rescission of any issued policy, as permitted by applicable law. I authorize the insurer to obtain inspection reports, claims history, and to verify any statement made herein with previous insurers, credit reporting agencies, lienholders, and other lawful sources as necessary to underwrite the risk.

I agree to notify the insurer promptly of any material change in the risk, including but not limited to changes in occupancy, vacancy in excess of 30 consecutive days, substantial renovations, or changes in the use of the premises. I understand that coverage is effective only if and when the insurer accepts this application and issues a policy or binder, and that any acceptance may be conditioned upon payment of premium and satisfaction of underwriting requirements.

Fraud Warning: Any person who knowingly presents false information in an application for insurance may be subject to civil or criminal penalties in accordance with applicable law.

Authorization to Bind & Payment

Requested deposit or premium paid with this application does not bind coverage unless specifically accepted by an authorized representative of the insurer. If accepted, payment of premium constitutes acceptance of terms and conditions and authorizes the insurer to issue a policy and endorsements. For installment plans, the insured is responsible for timely payment in accordance with the policy and billing terms.

Payment Method: Check Credit/Debit Card Automatic Bank Debit

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