Home Insurance

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Applicant Information
Name of Applicant / Primary Owner*
Home Phone Number*
Date of Birth*
MM slash DD slash YYYY
Marital Status*
Occupation*
Email*
Name of Co-Applicant
Occupation
Date of Birth
MM slash DD slash YYYY
Projected Effective Date (If Any)*
Dwelling Information
Address of Dwelling*
City*
State*
ZIP Code*
Number of Stories*
Square Footage*
Year Built / Construction Year*
Number of Families*
Dwelling Construction Type*
Roof Type*
Primary Heat Source*
If Oil, Tank Is*
Fire Protection*
Distance to Nearest Fire Hydrant (Feet)
Distance to Nearest Fire Station (Miles)
PLEASE PROVIDE UPDATE YEARS IF KNOWN.
Wiring
Plumbing
Roof
Heat
Coverages
A. Dwelling Limit ($)*
B. Other Structures Limit (If Blank, 10% Of Dwelling Will Be Used For ACV Valuation)
C. Personal Property Limit (If Blank, 50% Of Dwelling Will Be Used For ACV Valuation)
D. Loss Of Use Limit (If Blank, 30% Of Dwelling Will Be Used For ACV Valuation)
E. Liability Limit*
F. Medical Payments Limit*
Water Back-Up
Replacement Cost Personal Property?
Any Other Coverages?
Additional Information
Loan Number
Mortgage Holder Name
Mortgage Holder Address
Street Address City State ZIP Code
Applicant's Mailing Address (If Different From Location)
Previous Address (If At This Locations Less Than 2 Years)
Any Losses In The Last 3 Years?*
Date Of Loss*
MM slash DD slash YYYY
Type Of Loss*
Paid / Reserve Amount*
Is There A Swimming Pool?*
- Yes
- No
Is It Fenced?*
- Yes
- No
Is There A Diving Board?*
- Yes
- No
Is It Above Ground Or Below Ground?*
- Above Ground
- Below Ground
Is The Dwelling A Mobile Home Or Trailer?*
- Yes
- No
Is The Dwelling A Modular Home Not On A Permanent Foundation?*
- Yes
- No
Has This Risk Been Cancelled, Declined Or Non-Renewed For Underwriting Reasons?*
- Yes
- No
Is The Dwelling Undergoing Renovation Or Reconstruction?*
- Yes
- No
Is There A Trampoline On The Premises?*
- Yes
- No
Is The Dwelling Vacant?*
- Yes
- No
Has Applicant Had A Foreclosure, Repossession, Judgment, Lien, Bankruptcy During The Past Five Years?*
- Yes
- No
Has Any Applicant Been Convicted Of Any Degree Of The Crimes Of Arson Or Fraud?*
- Yes
- No
Is The Dwelling Built On Pilings, Piers, Wharves, Jetties Or Is The Dwelling Foundation Open?*
- Yes
- No
Does The Dwelling Have An Electrical System With Knob And Tube Or Aluminum Wiring?*
- Yes
- No
Does The Applicant Own A Firearm?*
- Yes
- No
Is The Dwelling For Sale?*
- Yes
- No
Are There Any Resident Employees?*
- Yes
- No
Is The Exterior Of The Dwelling Of E.I.F.S. (Exterior Insulating Finish System) Construction?*
- Yes
- No
Has There Been A Lapse In Coverage In The Past Three Years?*
- Yes
- No
Is There A Supplemental Heat Type?*
- No
- Yes
What Type?*
Are There Any Animals Or Exotic Pets Owned By The Applicant?*
- Yes
- No
Breed*
Age (If A Dog)*
Bite History*
Has Any Applicant Been Convicted Of Any Degree Of The Crime Of Arson In The Last Five Years?*
- Yes
- No
Is The Electrical System Less Than 100 AMPS Or Without A Circuit Breaker?*
- Yes
- No
(If Yes, Provide Details.)*
Is There Any Farming Or Other Business Conducted On Premises (Including Day/Child Care)?*
- Yes
- No
(If Yes, Provide Details)*
Is There Any Other Residence On The Property?*
- Yes
- No
Any Solid Fuel Burning Stoves?*
- Yes
- No
Is The Property Within 250 Feet Of A Commercial Or Non-Residential Property?*
- Yes
- No
Are Any ATV's Or Snowmobiles Used By The Applicant Or Co-Applicant?*
- Yes
- No
Does The Applicant Employ Any Full Time Residence Employees Or Domestic Workers?*
- Yes
- No
Is The Dwelling In Or Pending Foreclosure?*
- Yes
- No
Is There A Skateboard Ramp On The Premises?*
- Yes
- No
Does The Dwelling Have A Plumbing System With Polybutylene Or Lead Pipes?*
- Yes
- No
Is There Any Existing Damage Present On The Dwelling?*
- Yes
- No
Do you have a fireplace?
- Yes
- No
Prior Carrier Information (If Applicable)
Carrier
Policy Number
Premium
Effective Date
MM slash DD slash YYYY
Upload Policy
Drop files here or

Max. file size: 10 MB.
The undersigned is an authorized representative of the applicant and represents that reasonable inquiry has been made to obtain the answers to questions on this application. He/she represents that the answers are true, correct and complete to the best of his/her knowledge.
Remarks:
Applicable in NY and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation). Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties
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Home Insurance

Applicant Information

Dwelling Information

Coverages

Additional Information

Prior Carrier Information (If Applicable)