Insurance Home Remarket Application

INSURANCE HOME REMARKET APPLICATION

Applicant / Insured Information

Date of Birth:   Phone:   Email:

Individual    Trust    Corporation    LLC    Other:

Property Details

Construction: Frame    Masonry    Mixed   Square Footage:

Number of Stories:   Number of Units (if multi-family):   Primary Use:

Smoke detectors    Deadbolt locks    Burglar alarm    Sprinkler system    Swimming pool

Prior Insurance & Loss History

Current or Most Recent Insurer:   Policy Number:

Has the property had any losses or claims in the last 5 years?    No    Yes

Requested Policy Details

HO-3 (Special Form)    HO-5 (Comprehensive)    Renters    Other:

Dwelling Limit: $   Other Structures: $   Personal Property: $

Loss of Use / Additional Living Expense: $   Personal Liability: $   Medical Payments: $

Requested Deductible: $   Estimated Annual Premium: $

Requested Effective Date:   Requested Term (months):

Optional Coverages & Endorsements

Replacement cost on dwelling    Personal property replacement cost    Scheduled personal property

Ordinance or law coverage    Sewer backup    Identity theft coverage

Earthquake coverage requested: Yes   Flood coverage requested: Yes (Note: flood typically requires separate policy)

Mortgagee / Beneficiary / Loss Payee

Beneficiary Relationship to Insured:   Beneficiary Percentage (if applicable):

Exclusions & Important Notices

The applicant acknowledges that standard policy exclusions typically include but are not limited to: loss from flood or surface water (unless specifically endorsed), earthquake (unless endorsed), normal wear and tear, deterioration, insect or vermin damage, intentional acts or fraud by the insured, loss attributable to illegal activity, and losses excluded by ordinance, code change or governmental action. The insurer retains underwriting discretion to accept, modify or exclude coverages based on inspection, prior loss history and other risk characteristics.

I acknowledge receipt and review of the exclusions described above and request that the company consider the requested coverages. I understand that issuance of a policy is subject to underwriting approval and may include additional specific exclusions or higher deductibles.

Acknowledgement of exclusions: Applicant acknowledges exclusions and understands underwriting discretion.

Documentation Checklist (submit with application)

Please indicate documents attached or provided to underwriter:
Declarations page of prior policy    Loss runs (5 years)    Current property photos
Proof of ownership or title    Additional documents:

Declarations, Authorization & Certification

I hereby declare that the statements and information provided in this application are true, complete and correct to the best of my knowledge and belief. I understand that any material misrepresentation, omission or concealment of fact may invalidate my application and any resulting coverage. I authorize the insurer and its agents to obtain inspection reports, loss history, credit and other underwriting information relevant to the underwriting of the risk. I agree that any policy issued will be subject to the terms, conditions, limits and exclusions of the issued policy form and endorsements.

I understand that coverage will not be effective until accepted by the insurer and a policy is issued. Premium payment, endorsement requirements, inspections and verification of information may be conditions precedent to binding coverage. I further acknowledge the insurer may cancel or nonrenew in accordance with the policy provisions and applicable law.

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

Sign Now