Insurance HO-4 Application

INSURANCE HO-4 APPLICATION

Complete this application to request tenant (HO-4) personal property and liability insurance. Provide responses that are true and complete to the best of your knowledge. Failure to disclose material facts may result in denial of coverage or rescission of the policy.

Applicant / Insured Information

Date of Birth:    Social Security Number:

Primary Phone:    Email:

Policy Details

Policy Type:    Requested Effective Date:

Coverages Requested (check all that apply)

Personal Property Coverage (Contents)
Replacement Cost Settlement (vs. Actual Cash Value)
Personal Liability Coverage
Medical Payments to Others
Additional Living Expenses / Loss of Use
Scheduled Personal Property (list items below)

Residence Information

Type of Residence: Apartment Condominium Single-family rental Mobile home

Year Unit Built:    Occupancy:

Prior Insurance and Loss History

Have you had insurance coverage on this residence within the past 12 months? Yes No

Any claims or losses in the past 5 years? Yes No

Additional Interested Parties / Beneficiary

Name:    Relationship:

Percentage of Proceeds (if applicable):

Exclusions and Notices

Applicant acknowledges that standard HO-4 policy forms exclude loss caused by: flood and surface water; earth movement and landslide; nuclear hazard; war or civil insurrection; intentional loss by an insured; wear and tear, deterioration, and inherent vice; ordinances and laws requiring repair or demolition; governmental action; defects and vermin or pests. Additional exclusions specific to scheduled items or endorsements may apply. Coverage for certain perils may be available by endorsement and will be subject to separate terms, conditions and premium.

I acknowledge that I have read and understand the exclusions above and that this application does not bind the insurer to issue a policy. Acceptance is subject to underwriting approval and completion of any additional inspection or documentation requested by the insurer.

Declarations, Authorizations and Fraud Warning

By signing below I declare that the information provided in this application is true, correct and complete. I authorize the insurer and its representatives to obtain underwriting and claim-related information necessary to process this application, including prior claims and credit-related information where permitted by law. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of the policy.

Fraud Warning: Where applicable by law, any person who knowingly presents a false or fraudulent claim or application for insurance may be guilty of a crime and subject to fines and confinement. I understand that this warning applies to intentional misstatements in this application.

Agent / Producer (if applicable)

Acknowledgment and Certification

I certify that I am the named applicant or a person authorized to act on behalf of the applicant. I have read the foregoing application and understand that acceptance of this application is subject to underwriting review. I understand that any coverage bound prior to issuance of a policy is subject to all terms and conditions of the policy once issued.

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