Insurance Earthquake Application

Insurance Earthquake Application

Applicant / Insured Information

Date of Birth:    Telephone:    Email:

Property to be Insured

Year Built:    Number of Stories:    Number of Dwelling Units:

Construction Type: Wood frame Masonry Concrete Steel

Foundation Type: Slab Crawl space Basement

Yes No If yes, provide details below.

Policy Coverage Requested

Coverage Types (select all applicable): Building/Structure Personal Property/Contents Loss of Use / Additional Living Expense Detached Structures

Deductible Preference: 1% of Coverage Limit 2% of Coverage Limit Fixed Amount:

From:    To:

Prior Loss History

Have you sustained any earthquake-related loss at this property or elsewhere in the past 10 years? Yes No

Exclusions and Acknowledgements

The undersigned acknowledges that earthquake coverage typically excludes loss or damage caused directly or indirectly by flood, tsunami, landslide or earth movement resulting from subsidence or sinkhole where such perils are expressly excluded in the policy. Coverage for such perils must be applied for separately where available and is not implied by this application.

Applicant further acknowledges that any policy issued will include specific terms, conditions, limitations and exclusions. Acceptance of this application by the insurer is subject to underwriting review and verification of all information supplied herein.

Mortgagee / Additional Payee

Declarations, Consent and Certification

I hereby apply for earthquake insurance coverage as requested above. I warrant that the information provided in this application is true, complete and correct to the best of my knowledge and belief. I understand that any material misrepresentation, omission or concealment of fact may void coverage or permit rescission of any policy issued on the basis of this application.

I authorize the insurer and its representatives to inspect the described property and to obtain relevant records and information necessary to evaluate underwriting and claims, including prior loss history and property inspection reports. I understand that any inspection does not constitute a warranty of condition by the insurer.

I agree that acceptance of this application and issuance of an insurance policy is subject to the insurer's underwriting guidelines, payment of premium, and execution of a policy document. I further agree to notify the insurer promptly of any material change in the information supplied, including changes in occupancy, construction, or any damage to the property.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance, may be guilty of insurance fraud under applicable law.

Acknowledgements (Initials)

Applicant initials to acknowledge review of the following items:

Policy Limitations and Exclusions:    Premium Payment Terms:    Inspection Authorization:

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