Lexington Insurance Company - Dwelling Property Application


All fields are required, otherwise enter 'n/a' for not applicable.
Producing Office:
Producer Name:
E-mail:
Address:
Phone #:
Fax #:
Applicant SS# Occupation Employer Date of Birth
Mailing Address:
 		Insured Location: County:
Inspection-Contact: Phone #:
 		Fax #:
 		E-mail:
TYPE COV. PART 1 Effective Date: 
New Renewal  DP-3  DP-2  DP-1 Policy Term:   3 Month  6 Month  12 Month
Prior Carrier: Expires: Expiring/Renewal Premium: $
Within last 5 years has applicant had a: foreclosure bankruptcy repossession
If prior carrier non-renewed, why?
Comments:

Coverage Part 1: Dwelling Fire Information

Mortgagee Information/Additional Interests:
Loan #1 Name/Address:
Loan #2 Name/Address:

General Information:

County: Protection Class #: Distance to Fire Hydrant: ft.
Fire Dept:   Paid     Volunteer ISO Territory: Distance to Fire Station: mi.
Occupancy:   Primary Secondary Rental Vacant Secondary Rental Builder's Risk - use supplemental application
Construction:   Frame/Stucco: Brick,Stone or Masonry: Superior: Pre-Fabricated: EFIS/Synthetic Stucco:
Year Built:
 		Age of Roof
Sq. Ft.
Market Val. $
# of stories
 		# of families
Protection Devices:
  Fire Burglar Motion Det. Smoke Det. Deadbolts 		Sprinklers:
  Interior Exterior Combo None
Caretaker:
  Yes No If yes, resident or non resident 		Gated Community:
  Yes No 		Patrolled:
  Yes No

Loss History - Must be filled out COMPLETELY:

Date Type of Loss Cause Amount Preventative Measures?
$
$
$
$
Foundation: Concrete Slab Concrete/Block Pilings/Stilts Roof: Asphalt Tile Wood Shake 
Other:  

Limits:

Dwelling:$ Other Structures:    $ Personal Property:    $
Fair Rental Value:    $ Personal Liability:   $
Full Property TIV:   Yes No Loss Assessment:   $  
Requested AOP Deductible: $
Eligible for Wind-Pool:    Yes   No
Exclude Wind:    Yes    No    If no, Wind:%
Distance to Ocean/Bay/Gulf:   ft.   mi.
Straps:  Shutters:  Protective Glass: 
Wind Deductible Buyback:    Yes    No    %
Earthquake:   Yes    No    %
If yes, EQ Zone:  Territory:  Soil Type: 
CA Only:  Slope:  Brush Zone: 
   Yes    No
Brush Clearance:  ft.
Limited Theft Coverage:   Yes    No
Property Information:  (Required home > 25 years old)
Update - Update Year for:
Roof:     Full    Partial
Wiring:   Full    Partial
Heating:   Full    Partial
Plumbing:  Full    Partial
Occupied Daily:
Why is Property Vacant:
Dwelling for Sale:    Yes    No
Dwelling Rented:    Yes    No   If yes, how many weeks: 
Under Lease:    Yes    No
Swimming Pool on Premises:    Yes    No   If yes,
Fenced    Screened    Diving Board:   Yes    No
If home is oil heated, is tank underground:    Yes    No
EFIS or or Synthetic Stucco construction:    Yes    No
Prior/current mold exposure:    Yes    No
Wood Stoves/Sup. Heating    Yes    No
Is this a primary heat source:    Yes    No
Explain:
Animals on premises:    Yes    No   
Bite History: Yes
Explain:
NOTICE OF INSURANCE INFORMATION PRACTICES: Personal information about you may be collected from persons other than you. Such information, as well as other personal and privileged information, collected by us or your agent may, in certain circumstances, be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent/broker for instruction on how to submit a request to us.

FL Residents Only: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE (817.234).

NJ Residents Only: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES (Bulletin 95-16, citing P.L.1995, c.132).

VA Residents Only: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS (52-40). Note to Agents: No binding or quoting authority! Please call or fax for same day binding and follow up with an application. Application must be signed by the Named Insured. Any incomplete applications received could jeopardize binding coverage!


Please submit to my following underwriter
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I do not have an assigned underwriter
please assign me an underwriter

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