Insured Information:
Name: __________________________________________
Mailing Address: __________________________________
City:______________ State_____________ Zip_________
Phone Number:____________________________________
Insured Location: __________________________________
City ______________ State ____________Zip__________
County:_________________________________________
(1) SSN #:___________________________DOB:_________
(2) SSN#:___________________________ DOB:_________
Occupation:_______________________________________
Name of Employer:__________________________________
Position Held:______________________________________Agent
Information:
Producer:_________________________________________
Address:_________________________________________
City:_______________ State:___________ Zip:__________
Phone/Fax Number:_________________________________
Mortgage(s) Information /Additional Interests:
Loan Number 1:____________________________________
Name:___________________________________________
Address:_________________________________________
City:_____________ State ____________ Zip: ___________
Loan Number 2:____________________________________
Name:___________________________________________
Address:_________________________________________
City:_____________ State ____________ Zip: ___________
Protection Information:
Distance to Fire Hydrant:__________ Fire Station:__________
Is the Fire Department: ___________Paid ______ Volunteer
Fire Dept. Response Time:____ Min. (for PC 9/10 only)
Distance to Nearest water source:_______________________
Type of water source: _______________________________
Central Alarm: Fire: Y N
Burglar: Y
N
Sprinkler System: _____ Full _____Partial _____ None
Protection Class:______________
Smoke Detectors: Y N |
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Limits of Policy:
Dwelling:
$_________________
Other Structures:
$_________________
Personal Property:
$_________________
Loss of Use/Fair Rental $_________________
Personal Liability:
$_________________
Medical Payments: $_________________
Loss Assessment
Coverage:
$_________________
Optional Coverages:
Replacement Cost of Contents: Y
N
Increase Limits -
Jewelry, Watches, Furs :
Y N
Extending Liability:
#Locations_________ State:_____________
Earthquake Coverage: Y N EQ Zone:_______
HO6 Only: All Risk Coverage-Dwelling Y
N
Deductibles:
(Subject to company guidelines)
Occupancy: _____ Primary
____ Secondary/Seasonal ______ Rental
Is Home Occupied Daily:
Y
N
Unoccupied>30 consecutive days: Y
N
If home is rented: # of weeks______
Under Lease ? Y N
Is the Home visible to neighbors: Y
N
Home up for sale:
Y
N
Caretaker/Property Manager:
Y
N
Resident Paid_______ Non Resident Paid_______
Has applicant had a foreclosure, repossession, or
bankruptcy during the last five years: Y
N
Describe:________________________________
Gated Community: Y N Patrolled:
Y
N
Building undergoing any renovation: Y
N
Builders Risk/Renovation:
Est. Date of completion: ______________________
Estimated Replacement
cost upon completion:________________________
ISO Territory #. ___________ BCEGS#___________
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