Insurance HO3 Form

INSURANCE HO3 FORM

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Occupation:    Years at Residence:

Policy Details

Policy Number:    Insurer Name:

Policy Type: HO-3 (Special Form) HO-4 (Tenant) HO-6 (Condo)

Effective Date:    Expiration Date:

Coverages and Limits

Coverage A — Dwelling Limit: $    Coverage B — Other Structures: $

Coverage C — Personal Property Limit: $    Coverage D — Loss of Use: $

Coverage E — Personal Liability Limit: $    Coverage F — Medical Payments: $

Coverage Options and Endorsements

Replacement Cost on Dwelling    Limit: $

Actual Cash Value on Personal Property    Scheduled Items:

Ordinance or Law Coverage    Limit: $

Water Backup / Sewer Overflow Endorsement    Limit: $

Identity Theft Coverage    Limit: $

Exclusions (Selected Examples)

The policy does not cover loss or damage caused directly or indirectly by the following, except as expressly provided by endorsement or additional coverage: wear and tear, gradual deterioration, mechanical breakdown, inherent vice, war, nuclear hazard, government action, neglect of proper maintenance, intentional acts by the insured, and loss due to earth movement (including earthquake and landslide) unless earthquake coverage is purchased.

The insured acknowledges understanding of principal exclusions listed above and that additional exclusions may apply under the full policy language. Failure to disclose material information may render coverage void as permitted by law.

Insured acknowledges exclusion for flood and surface water unless flood coverage has been purchased: Acknowledged

Claims and Duties After Loss

In the event of loss or damage that may give rise to a claim under this policy, the insured must: (1) give prompt notice to the insurer or its representative; (2) protect the property from further damage and make reasonable temporary repairs; (3) provide a detailed inventory of damaged property and, upon request, submit to examination under oath; (4) cooperate with the insurer in the investigation and settlement of the claim. Failure to comply may result in denial or reduction of claim payment to the extent prejudicial to the insurer.

Mortgagee / Additional Interested Parties

Loan / Account Number:    Interest Type:

Additional Information / Remarks

Declarations and Certification

By signing below, the insured declares that the information provided in this application and all attachments is true, complete and accurate to the best of the insured's knowledge. The insured understands that material misrepresentation or omission may result in denial of coverage or rescission of the policy. The insured authorizes the insurer to obtain and verify information relevant to underwriting or claims handling, including inspection of the insured property and review of prior loss history. The insured acknowledges receipt of a copy of the declarations page upon issuance of the policy.

The insured understands and agrees that coverages are subject to terms, conditions, limitations and exclusions contained in the policy form and any endorsements. This application does not bind coverage until accepted in writing by the insurer or its authorized representative.

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