Insurance HO-6 Form

INSURANCE HO-6 FORM

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:

Property Information

Unit / Condo Number:    Year Built:

Occupancy: Owner-occupied Rented to others Vacant

Policy Details

Policy Type:    Policy Number:

Policy Period From:   To:

Deductible:    Annual Premium:

Payment Frequency: Monthly Quarterly Annual

Coverages (Select and Specify Limits)

Coverage A — Alterations, Additions and Improvements (Interior) Limit:

Coverage C — Personal Property Limit:    Special Limits for Jewelry/Furs:

Loss of Use (Additional Living Expense) Limit:

Personal Liability Limit:

Medical Payments to Others Limit:

Security Features / Protective Devices

Burglar Alarm: Installed    Fire Alarm/Sprinkler: Installed    Deadbolt Locks: Installed

Exclusions and Limitations (Acknowledgement)

The policy does not provide coverage for certain perils and losses including but not limited to: flood, earthquake, wear and tear, vermin, deliberate loss, ordinance or law requiring repair or demolition, and losses resulting from government action. I acknowledge that these exclusions may apply to my policy.

Applicant Acknowledgement: I have read and understand the stated exclusions.

Prior Loss History

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

Beneficiary / Additional Interested Parties

Beneficiary / Payable To (name):

Relationship to Insured:    Percentage:

Declarations, Authorizations and Certifications

The undersigned declares that the information provided in this application is true, complete and accurate to the best of the applicant's knowledge. The applicant understands that any material misrepresentation, omission or concealment of fact may be grounds for denial of coverage, rescission of the policy or denial of a claim.

The applicant authorizes the insurer and its representatives to obtain, verify and exchange information necessary to underwrite and administer this policy, including but not limited to inspection reports, claims history, and loss control records. The applicant agrees to cooperate with reasonable inspections of the described property.

Premiums are due in accordance with the policy and payment schedule selected. The insurer reserves the right to modify coverage or cancel the policy in accordance with the terms and conditions set forth in the policy contract. Coverage is governed solely by the policy form, endorsements and declarations issued by the insurer.

Subrogation: The insurer may seek recovery from third parties responsible for a loss, and by accepting payment the insured may be required to assign recovery rights to the insurer to the extent of the payment. Arbitration and appraisal provisions contained in the policy may apply to certain disputes.

Claims Reporting and Documentation (If a Claim Occurs)

In the event of a loss, report promptly to the insurer and provide reasonable evidence of loss, including date of loss, description of incident, estimated damage, and any police, fire or other official reports. Retain damaged property for inspection when requested.

Sign Now