Insurance HO-3 Application

Insurance HO-3 Application

Applicant / Insured Information

Applicant Name:

Phone:    Email:

Date of Birth:    Social Security / Tax ID:

Property Information

Property Type: Single-family Multi-family Condominium Mobile home

Owner-occupied Tenant-occupied Seasonal / Secondary Vacant

Year Built:    Construction Type:    Square Footage:

Number of Dwelling Units:    Roof Material:    Foundation Type:

Smoke detectors Central alarm (monitoring) Burglar alarm Sprinkler system

Policy Details Requested

Requested Effective Date:    Policy Period From: to

Deductible:    Estimated Annual Premium:    Payment Plan: Annual Semi-annual Monthly

Coverage Options and Endorsements

Standard HO-3 coverages apply. Applicant requests the following optional coverages (check and provide details where indicated):

Replacement cost on personal property

Scheduled personal property If checked, list categories and scheduled values:

Ordinance or law coverage

Sewer or sump pump backup Limit (if requested):

Water damage (sudden and accidental plumbing)

Earthquake (requires separate endorsement) Deductible for earthquake:

Identity theft protection

Exclusions (Representative)

The policy does not provide coverage for losses caused by: (a) flood or surface water; (b) earth movement, landslide, sinkhole or subsidence, except as may be specifically endorsed; (c) wear, tear, deterioration, rust, corrosion, latent defect or inherent vice; (d) war, insurrection, nuclear hazard; (e) intentional acts or fraudulent conduct by the insured; (f) government seizure or destruction; and (g) business pursuits and losses arising from rental operations except as specifically endorsed. Additional exclusions may apply under the issued policy; the insurer reserves all rights under the contract language.

Prior Insurance & Loss History

Prior Policy Number:    Prior Policy Period: to

Any claims or losses in the last five (5) years? Yes No

Mortgagee / Interested Party / Beneficiary

Is there a mortgagee or lienholder to be listed? Yes No

Relationship to Applicant:    Interest Percentage:

Declarations & Authorization

I declare that the information contained in this application is true, correct and complete to the best of my knowledge. I understand that any material misrepresentation or omission may give the insurer the right to rescind coverage or deny a claim, subject to the terms of the policy and applicable law. I authorize the insurer to make any investigations and inquiries necessary in connection with this application, including but not limited to verifications of prior insurance, claims history, credit and public records, and inspection of the described property. I consent to the release of information to and from loss prevention services and to third parties where permitted by law for underwriting and claims purposes.

Fraud Notice: A false statement or omission made with intent to deceive, or any act committed with intent to obtain an unauthorized benefit, may constitute insurance fraud and may be punishable under state criminal statutes. Where applicable, the insurer may report suspected fraud to law enforcement authorities.

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