Insurance Dwellings Supplement

INSURANCE DWELLINGS SUPPLEMENT

Insured and Policy Information

Insured Name:

Applicant Date of Birth:     Policy Number:

Policy Period: From to     Policy Type:

Property Location and Construction

Year Built:     Number of Dwelling Units:     Total Square Footage:

Frame    Masonry    Fire Resistive    Mixed

Roof Material:     Heating Type:

Public Hydrant Within 1,000 ft: Yes    No     Distance to Fire Station (miles):

Burglar Alarm: Yes    No     Central Station Monitoring: Yes    No     Smoke Detectors Present: Yes    No

Coverage, Limits and Premium

Deductible:     Annual Premium:

Optional Coverages / Endorsements

Replacement Cost on Dwelling    Limit:

Ordinance or Law (Increased Cost of Construction)    Limit:

Earthquake Coverage    Deductible:

Flood Coverage    Amount Requested:

Personal Liability    Limit:

Exclusions and Limitations

The following are examples of perils or conditions that are commonly excluded or limited under this supplement: wear and tear, faulty workmanship, deliberate loss, flood (unless endorsed), earth movement (unless endorsed), war, nuclear hazard, and government action. Coverage for certain perils may be subject to separate deductibles, coinsurance provisions, or sublimits. The insurer reserves the right to apply specific exclusions and limitations as set forth in the policy forms and endorsements.

By initialing below, the insured acknowledges receipt of this supplemental disclosure of common exclusions and understands that additional endorsements may be required for full protection against excluded perils.    Initials:

Prior Loss History

Additional Parties / Beneficiaries

Documentation Checklist

Please attach the following documents where required and indicate below:

Recent photos of the dwelling and exposures    Building plans/measurements    Prior claims history / loss runs

Declaration and Certification

I certify that all information provided in this Insurance Dwellings Supplement is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may constitute grounds for denial of coverage or rescission of the policy. I authorize the insurer and its representatives to obtain and verify information relevant to underwriting and claims, including inspection of the described property. I further acknowledge that acceptance of this supplement is subject to underwriting approval and that coverage, limits, exclusions and premiums will be governed by the policy, its endorsements, and applicable law.

By checking the box below I affirm that I have read and understood the statements above and that the information provided is material to the risk being insured.    I certify the accuracy and completeness of this supplement.

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