Insurance Home Accord Form

INSURANCE HOME ACCORD FORM

This Insurance Home Accord Form ("Accord") documents representations made by the Applicant and the material terms proposed for homeowner insurance coverage. Completion of this form is a declaration under penalty of law that the information provided is true, complete, and submitted to induce the insurer to issue or renew a policy. False statements may result in denial of coverage or rescission of the policy.

1. Applicant / Insured Information

Date of Birth:    Phone:    Email:

2. Property Details

Year Built:    Construction:    Square Footage:

Occupancy (select all that apply):   Owner-Occupied   Tenant-Occupied   Vacant

3. Policy Details

Policy Type (select applicable):   HO-3   HO-2   HO-5   DP-3   Condo   Renters

Liability Limit:    Medical Payments:    Deductible:

Annual Premium:    Policy Period: From to

4. Optional / Endorsed Coverages

Water Backup / Sump Overflow — Limit:

Earthquake Coverage — Limit:

Flood Coverage — Limit:

Scheduled High-Value Items (attach schedule) — Total Scheduled Limit:

5. Exclusions and Endorsements

Standard policy exclusions that apply unless expressly endorsed include: wear and tear; deterioration; mold or fungus except as provided by endorsement; intentional acts; war or nuclear hazard; government action; mold remediation not covered unless specified; loss due to insects or vermin. The insurer retains all rights to apply additional exclusions by endorsement following underwriting review.

Applicant acknowledges these standard exclusions and requests the following endorsements or additional exclusions (describe below):

6. Beneficiary / Payee Designation

Beneficiary Name:    Relationship:

Percentage of Proceeds:    Alternate Beneficiary (if any):

7. Prior Losses / Claims History

Have you had property losses or homeowner claims in the past five years?   Yes   No

8. Certifications and Declarations

By signing below, the Applicant certifies under penalty of law that all statements in this Accord are true and complete to the best of the Applicant's knowledge. The Applicant acknowledges that any material misrepresentation, omission, or concealment of fact may void coverage or allow the insurer to deny payment for a loss and may be a basis for cancellation or nonrenewal. The Applicant authorizes the insurer to obtain claim, loss history, credit, and underwriting information necessary to evaluate insurability and premium.

The Applicant further acknowledges that coverage is not bound by submission of this form alone. Coverage is effective only upon issuance of a policy or binder by the insurer and payment of any required premium unless a separate binder is issued in writing. The insurer reserves the right to request inspections, surveys, photographs, or additional documentation as a condition to binding.

Certifications (check all that apply):

Applicant certifies that the statements are true and complete.  
Applicant authorizes property inspection and verification of submitted information.  
Applicant consents to insurer obtaining prior claim and loss history.  
Applicant understands premiums and fees may be adjusted based on underwriting and exposures disclosed.

9. Authorization and Signature

The Applicant affirms that all information provided on this form is true and complete. Applicant understands that signing below constitutes a legal certification for insurance underwriting purposes.

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