Insurance Home Document

INSURANCE HOME DOCUMENT

Applicant / Insured Information

Applicant Name:

Mailing Address:

Date of Birth:

Property to be Insured

Year Built: Type of Structure: Single-family Condominium Multi-family Mobile home

Occupancy: Owner-occupied Rented to Others Vacant

Policy Details

Coverages and Endorsements

Select requested coverages:
Dwelling coverage (Coverage A)
Other structures (Coverage B)
Personal property (Coverage C)
Loss of use/additional living expense (Coverage D)
Personal liability (Coverage E)
Medical payments to others (Coverage F)

Optional endorsements:
Earthquake coverage — Limit:
Flood coverage — Limit:
Ordinance or law coverage
Scheduled personal property (list items below)

Exclusions and Limitations

The policy does not provide coverage for loss or damage caused by: flood, surface water, sewer or drain backup (unless specifically endorsed), war, nuclear hazard, wear and tear, intentional acts or fraudulent acts by the insured, governmental action, or any loss resulting from failure to take reasonable steps to protect property after loss. Additional limitations apply to mold, pests, and business pursuits. Specific perils, sub-limits and waiting periods are detailed in the policy contract and applicable endorsements.

I acknowledge that the above list is representative and that further exclusions, conditions and limitations are set forth in the policy language. By checking the box below I confirm I have read and accept the standard exclusions and limitations.

I acknowledge and accept the standard exclusions and limitations.

Loss Payee / Beneficiary

Loss Payee / Mortgagee Name:

Address of Loss Payee:

Designated Beneficiary for Personal Property Claims (if any): Relationship: Percentage:

Prior Insurance and Claims

Have you had any homeowners or property insurance declined, cancelled, or non-renewed in the past 5 years? Yes No

Have you had any property claims in the past 5 years? Yes No

Declarations, Representations and Consent

I represent that the information provided in this Insurance Home Document is true, complete and correct to the best of my knowledge. I understand that any material misrepresentation or omission may render coverage null and void and may be grounds for denial of coverage or rescission of the policy. I authorize the insurer and its authorized representatives to obtain and verify relevant information, including prior insurance and claim history, and to inspect the insured property as necessary to evaluate eligibility for coverage.

Premium payment is due in accordance with the terms set forth in the policy and the insurer's payment procedures. Coverage is effective only when: (a) this application is accepted by the insurer or its authorized agent, (b) the policy is issued, and (c) the required premium is received in accordance with insurer procedures. The insurer's obligations are limited to the terms, conditions, exclusions and limits stated in the issued policy and any attached endorsements.

I further acknowledge that this document is an application and declaration of requested coverages and does not itself constitute an insurance policy. The final contract of insurance, if issued, will be evidenced by the policy form, declarations page and endorsements provided by the insurer.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment or knowingly submits false information in an application for insurance may be subject to civil and criminal penalties under applicable law.

I certify that the information contained herein is true and complete and I understand the declarations above.

Agent / Broker (if applicable)

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