Insurance HO6 Application

INSURANCE HO6 APPLICATION

Application Date:

APPLICANT / INSURED INFORMATION

PROPERTY INFORMATION

Occupancy: Owner-occupied Tenant-occupied Seasonal/Vacation

CURRENT / PRIOR INSURANCE & LOSS HISTORY

Any losses, claims, or underwriting declines in the past five (5) years? Yes No

COVERAGES, LIMITS & DEDUCTIBLES

Select coverages desired and specify limit amounts. Coverage limits must reflect full replacement cost where requested and are subject to underwriting approval.

Personal Property Coverage   Limit:

Loss of Use / Additional Living Expenses   Limit:

Personal Liability   Limit:

Medical Payments to Others   Limit:

OPTIONAL ENDORSEMENTS

Water Backup and Sump Overflow Endorsement

Identity Theft Expense Coverage

Ordinance or Law Coverage (Loss to Undamaged Portion & Increased Cost)

Replacement Cost for Personal Property

EXCLUSIONS & LIMITATIONS

The policy applied for will contain exclusions and limitations including, but not limited to: loss caused by wear and tear, gradual deterioration, insect or vermin damage, intentional acts or fraudulent acts by the insured, pollution except as specifically endorsed, loss due to earthquake or flood unless a specific endorsement is issued, and losses arising out of business pursuits unless declared and endorsed. Additional sublimits may apply to jewelry, furs, business property, and collectables.

MORTGAGEE / LOSS PAYEE

Include mortgagee clause on policy: Yes

UNDERWRITING QUESTIONS

Is the unit occupied by anyone other than the named applicant(s)? Yes No

Any dogs, exotic animals, or animals with a history of bite claims at the residence? Yes No

DECLARATIONS, AUTHORIZATIONS & FRAUD WARNINGS

I hereby apply for the insurance coverage indicated. I declare that the information provided on this application is true and complete to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may give the insurer grounds to void coverage or deny a claim in accordance with the terms and conditions of the policy and applicable law.

I authorize the insurer and its agents to obtain and exchange information reasonably required for underwriting and claim handling, including credit history, previous insurance coverage, claim history, and other consumer reports where permitted by law. I understand that such information may be used to determine eligibility and premium.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or who knowingly presents false information in an application for insurance may be guilty of insurance fraud and subject to civil and criminal penalties, including denial of coverage.

The coverage applied for will be governed by the policy form and endorsements issued by the insurer. Coverage will not be binding until the insurer accepts the application and the required premium is paid or until a binder has been issued in writing.

AGENT / PRODUCER INFORMATION

APPLICANT CERTIFICATION

By signing below I certify under penalty of perjury that the foregoing statements and particulars are true and that I have not misstated, suppressed or failed to disclose any material facts. I acknowledge that the insurer may decline this application or adjust premiums or coverage based on the information provided and on underwriting standards.

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