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Home Insurance
elopezexcelins
2017-09-01T17:16:40+00:00
Home Insurance
Interested in Home insurance? Fill out the form below and one of our specialists will contact you.
Applicant Information
Name of Applicant / Primary Owner
*
Home Phone Number
*
Date of Birth
*
MM slash DD slash YYYY
Marital Status
*
Select One
Single
Married
Divorced
Widowed
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
*
-Select State-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
*
Number of Stories
*
Square Footage
*
Year Built / Construction Year
*
Number of Families
*
Select One
One Family
Two Family
Three Family
Four Family
Dwelling Construction Type
*
Select One
Frame
Brick
Fire-Resistive
Other
Roof Type
*
Select One
Asphalt / Shingle
Tar
Flat
Tile
Wood
Slate
Other
Primary Heat Source
*
Select One
Gas
Oil
Other
If Oil, Tank Is
*
Select One
Above Ground
Below Ground
Fire Protection
*
Select One
Smoke Detectors Only
Fire Alarm Reporting
Central Station Reporting Fire Alarm
Local Fire Alarm & Smoke Detector
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
*
Select One
$100,000
$200,000
$300,000
$400,000
$500,000
F. Medical Payments Limit
*
Select One
$1,000
$2,000
$3,000
$4,000
$5,000
Water Back-Up
Select One
Yes
No
Replacement Cost Personal Property?
Select One
Yes
No
Any Other Coverages?
Additional Information
Loan Number
Mortgage Holder Name
Mortgage Holder Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
*
Select One
No
Yes
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
Select files
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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