Insurance Homeowners Agreement

INSURANCE HOMEOWNERS AGREEMENT

PARTIES AND POLICY IDENTIFICATION

Insurer Name:

Insured Name:

Policy Number:     Effective Date:     Expiration Date:

APPLICANT / INSURED INFORMATION

Date of Birth:     Phone:     Email:

PROPERTY DETAILS

Square Footage:     Occupancy (check applicable): Owner-occupied Rental Seasonal/Vacation Other

POLICY COVERAGE SUMMARY

Policy Type: HO-3 HO-5 HO-6 (Condo) Dwelling Fire (DP)

Deductible:     Wind/Hail or Named Storm Deductible (if applicable):     Annual Premium:

ADDITIONAL COVERAGES / ENDORSEMENTS

Optional/Endorsement Coverages (check all that apply):
Scheduled Personal Property endorsement Water backup / sump overflow Identity theft coverage Equipment breakdown Ordinance or law coverage

EXCLUSIONS AND LIMITATIONS

The coverages set forth in this Agreement do not apply to loss or liability caused directly or indirectly by the following, except to the extent expressly provided by endorsement: (a) flood, surface water, tidal water, storm surge, coastal waters, sewer or drain backup unless specifically endorsed; (b) earthquake, landslide, sinkhole, earth movement; (c) nuclear hazard, war (declared or undeclared), insurrection or civil authority seizure; (d) wear and tear, deterioration, latent defect, inherent vice, mechanical breakdown; (e) pollution and contamination except as provided by endorsement; (f) intentional acts by an insured; (g) governmental action and forfeiture of property by authority. Additional exclusions may apply and are incorporated by reference as specified in policy provisions.

Acknowledgement of exclusions: I acknowledge that I have reviewed the exclusions and limitations described above and understand items not covered unless specifically endorsed.

BENEFICIARY DESIGNATION

Designate beneficiaries to receive claim proceeds, where applicable under this policy:

CLAIMS NOTIFICATION AND OBLIGATIONS

In the event of loss or occurrence that may give rise to a claim under this policy, the insured must: (1) give prompt notice to the insurer or its authorized representative; (2) take reasonable steps to protect property from further damage; (3) provide proof of loss, sworn statements, and documentation reasonably required by the insurer; (4) cooperate in any investigation; and (5) not admit liability or settle any claim without the insurer's written consent. Failure to comply may result in denial of coverage to the extent the insurer is prejudiced.

PRIOR LOSS HISTORY

List any losses to the property during the prior five years. If none, state "None".

DECLARATIONS, WARRANTIES, AND CONDITIONS

By signing this Agreement, the insured declares that the statements and facts contained in this application and any attachments are true and complete to the best of the insured's knowledge. The insured warrants that all material facts affecting the risk have been disclosed. Misrepresentation or omission of material fact by the insured may result in denial of coverage, rescission of the policy, or adjustment of claim proceeds in accordance with applicable law.

The insured authorizes the insurer to obtain inspection reports, underwriting information, and claim history as reasonably necessary for underwriting and claim handling. The insurer retains all rights of subrogation against third parties responsible for loss, subject to policy provisions. Assignment of this policy or interest herein requires the insurer's prior written consent unless otherwise provided by law.

Cancellation and nonrenewal provisions: The insurer may cancel or nonrenew this policy in accordance with the terms and conditions set forth in the policy and applicable law. The insured may cancel at any time by providing written notice to the insurer and by surrendering the policy or following the insurer's procedures for cancellation.

ADDITIONAL INFORMATION / REMARKS

CERTIFICATION

I certify under penalty of perjury and subject to applicable fraud statutes that the information provided in this Insurance Homeowners Agreement is true, complete, and correct. I understand that coverage is subject to the full terms, conditions, limitations and exclusions of the issued policy and any attached endorsements. I acknowledge that receipt of this Agreement does not itself create coverage until an insurer has issued a policy and indicated acceptance in writing or as otherwise required by law.

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