Insurance Home EOI Form

INSURANCE HOME EOI FORM

Use this Evidence of Insurability (EOI) Form to provide material information required to evaluate eligibility for homeowners insurance coverage or changes to an existing homeowners policy. Complete all applicable sections and sign the declaration certifying the accuracy of the information provided. Incomplete or false statements may result in declination, rescission of coverage, or denial of a claim.

Applicant / Insured Information

Property Information

Policy Details

Policy Type: HO-3 HO-5 DP-3 Condo Tenant/Renter

Policy Period: From to

Construction, Safety & Exposure

Protective Devices (check all that apply):

Smoke detectors Carbon monoxide detectors Monitored burglar alarm Local (non-monitored) alarm Fire sprinkler system

Exposure Questions: Distance to nearest fire station (miles):

Is the property located in a designated flood zone? Yes No

Is the property in a known earthquake zone? Yes No

Claims / Loss History

Within the last 5 years, has the applicant or property had any claims, losses, or damage events?

Yes No

Coverage Options & Endorsements

Select requested coverages or endorsements:

Replacement cost on dwelling Actual cash value on personal property Ordinance or law coverage Scheduled personal property Additional living expenses

Exclusions & Acknowledgements

The applicant acknowledges that standard homeowners policies commonly exclude loss or damage arising from wear and tear, deterioration, neglect, intentional acts, ordinance or law (unless endorsed), flood and earthquake (unless specifically endorsed), and nuclear hazard. The insurer may require additional endorsements or separate policies for excluded perils. The applicant understands that material misrepresentations or omissions in this form may be grounds for declination or rescission of coverage.

I acknowledge receipt of the exclusions notice and understand that coverage for certain perils requires specific endorsements. Acknowledged

Beneficiary for Contents/Claims Payment (Optional)

Documentation Checklist (attach if requested)

The insurer may request supporting documentation. Indicate which items are available for inspection or submission:

Recent property photos Independent inspection report Repair receipts / contractor estimates Prior policy declarations

Declaration and Authorization

I certify that the information provided in this Insurance Home EOI Form is true, correct and complete to the best of my knowledge. I understand that any material misstatement, omission, or concealment of facts may constitute grounds for denial or rescission of coverage and may be subject to criminal or civil penalties under applicable law.

I authorize the insurer and its authorized representatives to obtain information necessary to evaluate insurability, including but not limited to property inspection reports, prior claim history, and other records relevant to the underwriting process. I further authorize providers of such information to release records to the insurer. This authorization shall survive the execution of this form for the purposes of underwriting and claim handling.

By signing below I acknowledge that I have read and understand the disclosures, that I have provided all material facts known to me, and that I agree to cooperate with reasonable requests from the insurer for additional information or inspection of the property. I understand that submission of this form does not bind coverage until a policy is issued by the insurer.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits false information or conceals information may be subject to criminal and civil penalties. By signing you acknowledge receipt of this warning.

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