Transcription of Acord Homeowner Application - Abram Interstate Insurance
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Acord CORPORATION 1981-2006. All rights 1 of 4 The Acord name and logo are registered marks of ACORDACORD 80 (2006/10)COMP. date :COCFARMSEASONALSECONDARYPRIMARYUSAG E TYPEGROUNDSWIMMING POOLYESNOAPPROVEDFENCEDIVINGBOARDABOVEGR OUNDIN -SLIDENONEOIL STORAGE TANK LOCATIONABOVE GROUND ONMASONRY FLOORABOVE GROUND NOTON MASONRY FLOORABOVEGROUNDBELOWGROUNDINDOORSOUTDOO RSFIRE DISTRICT / CODE NUMBERFIRE / EC RATEFIRE EXTNEIGHBORSVACANTUNOCCDEADBOLTVISIBLE TOTENANTOWNEROCCUPANCYHOUSEKEEPING CONDITION# WKSRENTEDNOYESOCCUPIED DAILY?SPECCLASSRATING# ROOMS# APTS$MARKET VALUE$REPLACEMENT COSTHEAT TYPENONEPRIMARY:SECONDARY:ROOF MATERIALNONECLOSEDOPENFOUNDATIONCIRCUIT BREAKERSNOYESFUSESNOYESYR BUILTSQ FTSUBURBWITHIN PROTFIRE DISTWITHINCITY LIMITSWITHINDWELLING LOCATIONNUMBER OFFIREDIVSUNITS INFIRE DIVTERRCODEDATE HEATING SYSTEMLAST SERVICEDNUM OF AMPS(ELEC SYST)ALUMINUM WIRINGYESNOKNOB & TUBE ORCONDITIONPLUMBING SYSTEMANY KNOWN LEAKSYESNOPLUMBING SYSTEMDATE/PRICEPURCHASERESHSEHLD#ILIES# FAM-RENOVATION TYPEW
personal property loss of use personal liability medical payments $ ... date at homeowner application date (mm/dd/yyyy) if applicant bill: full pay ... inland marine application lead free paint certification applicant's statement: i have read the above application and any attachments.
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