Insurance Residential Disclosure

INSURANCE RESIDENTIAL DISCLOSURE

Applicant / Insured Information

Property Information

Occupancy status: Owner-occupied Tenant-occupied Vacant

Heating present: Central Other    Air conditioning: Central None

Protection, Location, and Hazards

Distance to nearest fire hydrant (approx.):   Distance to nearest fire station (approx.):

Protective devices present: Smoke detectors Sprinkler system Security system None

Is the property located in a designated flood zone or subject to frequent flooding? Yes No

Policy Details and Coverage Selection

Select coverages requested (check all that apply):

Dwelling (Coverage A) — Limit: $

Other structures (Coverage B) — Limit: $

Personal property (Coverage C) — Limit: $

Loss of use / Additional living expenses (Coverage D)    Deductible: $

Personal liability — Limit: $

Prior Losses and Claims (last 5 years)

Provide all claims or losses in the last five years. Failure to disclose material losses may result in denial of coverage or rescission.

Exclusions and Important Notices

The coverage applied for and any policy issued will be subject to the terms, conditions, limitations and exclusions contained in the policy form. Typical exclusions include but are not limited to: intentional acts, gradual deterioration and wear and tear, damage from earth movement (including earthquake and landslide) unless specifically endorsed, flood and surface water unless flood coverage is purchased, nuclear hazard, and governmental action. Coverage for mold, infestation, or latent defects may be limited or excluded unless specifically endorsed by the insurer.

Submission of this disclosure does not bind the insurer to provide coverage. Coverage will be effective only upon issuance of a policy and payment of any required premium. Any material misrepresentation, nondisclosure, or omission of facts may permit the insurer to rescind the policy, deny a claim, or adjust coverage or premium retroactively as allowed by law and policy terms.

Loss Payee / Beneficiary (if applicable)

Name of mortgagee, loss payee or beneficiary:   Relationship:   Percentage of proceeds:

Declaration, Acknowledgement and Authorization

I certify that the answers and statements in this Residential Disclosure are true and complete to the best of my knowledge. I understand that the insurer will rely upon this information in evaluating the risk and determining eligibility, coverage terms, and premium. I acknowledge that failure to disclose material facts or misrepresenting information may result in denial of claims or rescission of coverage in accordance with policy provisions and applicable law.

I authorize the insurer and its agents to obtain and verify information regarding the property, prior claims history, and any other information material to the underwriting of this policy from third parties, claim reporting databases, and other insurers where permitted by law.

Acknowledgement: I acknowledge that I have read and understand the foregoing statements and disclosures.

Applicant Certification

By signing below I attest under penalty of perjury that the information provided in this Residential Disclosure form is true, correct, and complete. I understand that this form becomes part of the application and that coverage decisions will be based on the representations herein.

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