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ACORD Homeowner Application - Abram Interstate Insurance

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 TYPEWIRINGPLUMBINGHEATINGROOFINGEXTERIOR PAINTPART COMP YEARLOCALDIRECTCENTRALBURGLARTEMPSMOKESY STEMPROTECTION DEVICE TYPEPROTECTCLASSDISTANCE TOHYDRANTFIRESTATIONFTMICO-OPROWHOUSETOW NHOUSECONDOAPARTDWELLINGSTRUCTURE TYPEGROUPPREMWIND CLASSRESISTIVESEMI-RESISTIVEOTHERFRAMEMA SONRYMASONRYVENEERMFG HOMEFIRE RESVINYL SIDINGALUMINUMSIDINGPROTECTIONTHEFT EXCLSECURITYRATING CREDITSNON-SMOKERLIGHTNINGMANNEDOFF PREMISESPRE-FABHEARTHSCHIMNEYSFIREPLACES (Enter Number)WOOD STOVEINSERTFULLPARTIALSPRI

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Transcription of ACORD Homeowner Application - Abram Interstate Insurance

1 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 TYPEWIRINGPLUMBINGHEATINGROOFINGEXTERIOR PAINTPART COMP YEARLOCALDIRECTCENTRALBURGLARTEMPSMOKESY STEMPROTECTION DEVICE TYPEPROTECTCLASSDISTANCE TOHYDRANTFIRESTATIONFTMICO-OPROWHOUSETOW NHOUSECONDOAPARTDWELLINGSTRUCTURE TYPEGROUPPREMWIND CLASSRESISTIVESEMI-RESISTIVEOTHERFRAMEMA SONRYMASONRYVENEERMFG HOMEFIRE RESVINYL SIDINGALUMINUMSIDINGPROTECTIONTHEFT EXCLSECURITYRATING CREDITSNON-SMOKERLIGHTNINGMANNEDOFF PREMISESPRE-FABHEARTHSCHIMNEYSFIREPLACES (Enter Number)WOOD STOVEINSERTFULLPARTIALSPRINKLERTAX CODEGRADEBLDG CODEINSPECTED?

2 YESNOCONDITION OF ROOFRATING/UNDERWRITINGIF REPLACEMENT COST APPLIES, ACORD 42 ATTACHED:BASEMENTSQ FTBREEZEWAYSQ FTSQ FTGARAGEFEATURESWINDSTORM LOSS MITIGATION* Not Applicable in NCDWELLINGOTHERSTRUCTURESPERSONALPROPERT YLOSS OF USEPERSONALLIABILITYMEDICALPAYMENTS$EACH OCCURRENCEEACH PERSONHO FORM$$$$$COVERAGES/LIMITS OF LIABILITYTHEFTANNUALHURRICANE *NAMEDHURRICANE *EARTHQUAKEDED(Type &Amount)$$PREMIUMEST TOTALDEPOSITBALANCE$WIND/HAILALL PERILPREMIUMENDORSEMENTS - See Page 4 SOCIAL SECURITY # date OF BIRTHSTATMARYEARS W/PRIOR EMPLYEARS W/CURR EMPLYEARS INCURR OCCCO- APPLICANT'S EMPLOYER NAME AND ADDRESS(State nature of business if self-employed)CO-APPLICANT'S OCCUPATIONSOCIAL SECURITY # date OF BIRTHSTATMARYEARS W/PRIOR EMPLYEARS W/CURR EMPLYEARS INCURR OCCAPPLICANT'S EMPLOYER NAME AND ADDRESS(State nature of business if self-employed)APPLICANT'S OCCUPATIONAPPLICANT INFORMATIONLOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP)YRS ATPREVADDRPREVIOUS ADDRESS (If less than 3 years) date AGENT LAST INSPECTED PROPERTY:HOW LONG HAVE YOU KNOWN THE APPLICANT?

3 ADDRESS:E-MAILAGENCY CUSTOMER ID:CODE:SUBCODE:AGENCYFAX(A/C, No):PHONE(A/C, No, Ext):FACILITY CODENAIC CODEPOLICY #CO/PLANEXPIRATION DATEEFFECTIVE DATEAPPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4)BUSINESS PHONE #EVEDAYHOME PHONE #EVEDAYCURR RESDATE ATHOMEOWNER APPLICATIONDATE (MM/DD/YYYY)IF APPLICANT BILL:FULL PAYACORD 610 Attached (NOT APPLICABLE IN NC)PAYMENT PLANACCOUNT #:BILLINGDIRECT BILLAGENCY BILLBILL MORTGAGEEBILL APPLICANTIF DIRECT BILL:APPLICANTAGENTMAIL POLICY TO:Page 2 of 4 ACORD 80 (2006/10)IS THE BUILDING ENTRANCE LOCKED?IS THERE A SECURITY ATTENDANT?IS THERE A MANAGER ON THE PREMISES?RENTERS ANDCONDOS ALL "YES" RESPONSESYES NO EXPLAIN ALL "YES" RESPONSES (Except questions 15, 16 and 17) THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODEISLAND], HAS ANY APPLICANT BEEN INDICTED FOR ORCONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY,ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTIONWITH THIS OR ANY OTHER PROPERTY ? (In RI, failure to disclosethe existence of an arson conviction is a misdemeanor punishable by asentence of up to one (1) year of imprisonment.)

4 IS BUILDING RETROFITTED FOR EARTHQUAKE? (If applicable) APPLICANT OWN ANY RECREATIONAL VEHICLES(SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATVS, ETC)?(List year, type, make, model) IS PROPERTY SITUATED ON MORE THAN FIVE ACRES?(If yes, describe land use)ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ONPREMISES? (Note breed and bite history) APPLICANT HAD A FORECLOSURE, REPOSSESSION,BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVEYEARS? COVERAGE DECLINED, CANCELLED OR NON-RENEWEDDURING THE LAST 3 YEARS? (Not applicable in MO) HAS Insurance BEEN TRANSFERRED WITHIN AGENCY?ANY OTHER Insurance WITH THIS COMPANY? (List policy numbers) OTHER RESIDENCE OWNED, OCCUPIED OR RENTED? FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC? ANY RESIDENCE EMPLOYEES?(Number and type of full and part time employees)1. ANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES?(Including day/child care)DISTANCE TO TIDAL INFORMATIONIF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCEBEEN OBTAINED FOR THE TANK?

5 (If "YES", provide the name ofthe Insurance company and the applicable limit) BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANTTHE GENERAL CONTRACTOR? LEAD PAINT HAZARD? BUILDING UNDER CONSTRUCTION OR UNDERGOINGRENOVATION OR RECONSTRUCTION? (Give estimated completiondate and dollar value) WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN APRIVATE RESIDENCE AND THEN CONVERTED?21. IS THERE A TRAMPOLINE ON THE PREMISES?IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL ORNON-RESIDENTIAL PROPERTY? IS HOUSE FOR SALE?ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS? 3 of 4 ACORD 80 (2006/10)PRIOR CARRIERPRIOR POLICY NUMBEREXPIRATION DATEPRIOR COVERAGEREMARKS (Attach Additional Sheets if More Space is Required)ATTACHMENTSSOLID FUEL SUPPLEMENTRESIDENCE BASED BUSINESS SUPPLSTATE SUPPLEMENT(S) (If applicable)PERS EXCESS/UMBRELLA APPPROTECTION DEVICE CERTIFICATEWATERCRAFT APPLICATIONPHOTOGRAPHREPLACEMENT COST ESTIMATEINLAND MARINE APPLICATIONLEAD FREE PAINT CERTIFICATIONAPPLICANT'S STATEMENT:I HAVE READ THE ABOVE Application AND ANY ATTACHMENTS.

6 I DECLARE THAT THEINFORMATION IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE ANDBELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUETHE POLICY FOR WHICH I AM PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY Insurance COMPANY OR ANOTHER PERSON FILES ANAPPLICATION FOR Insurance OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALSFOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Notapplicable in CO, HI, MA, OH, OK, OR or VT; in DC, LA, ME, TN, VA and WA, Insurance benefits may also be denied.)PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BECOLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS Application FOR Insurance AND SUBSEQUENTAMENDMENTS AND RENEWALS.

7 SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATIONCOLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOURAUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FORINSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THEDEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CANREQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICESREGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ONHOW TO SUBMIT A REQUEST TO of the Notice of Information Practices (Privacy) has been given to the applicant. (Not applicable in all states; consult your agent orbroker for your state's requirements.)THIS binder MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICYCONDITIONS.

8 THIS binder IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS binder IS NOT REPLACED BY A POLICY,THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE binder ACCORDING TO THE RULES AND RATES IN USE BY THECOMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE binder MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS binder OR BYWRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE COMPANY BINDS THE KIND(S) OF Insurance STIPULATED ON THIS Application . THISINSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) INCURRENT USE BY THE THE " binder " BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:APPLICABLE IN COLORADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE date OFCOVERAGE, TO EVALUATE THE ISSUANCE OF THE Insurance BINDEREFFECTIVE DATEEXPIRATION DATETIME12:01 AMNOONCOVERAGE IS NOT BOUNDPRODUCER'S SIGNATURENATIONAL PRODUCER NUMBERAPPLICANT'S SIGNATUREDATEBINDER/SIGNATUREADDITIONAL INTERESTINT #NAME AND ADDRESSLOAN NUMBERMORTG'EADDL INTAMOUNTDESCRIPTION OF LOSSTYPEDATECAT #LOSS HISTORYANY LOSSES, WHETHER OR NOT PAID BY Insurance , DURINGTHE LAST YEARS, AT THIS OR AT ANY OTHER LOCATION?

9 NOYESIF YES, INDICATE BELOWAPPLICANT'SINITIALS:Page 4 of 4 ACORD 80 (2006/10)OPTIONAL COVERAGES - ENDORSEMENTS$$$$$$$$$FORM NUMBERFORM DATEPREMIUM$$$$$$$$$$$$$$$$$$$$$$$$$$$$O PTIONS$$NOYESTERRAPPLIES TODEDUCTIBLEAPPLIES TOLIMITCOVERAGEDESCRIPTIONCODE# OF EMPLOYEES:# OF EMPLOYEES:# OF EMPLOYEES:$INCREASEDAGGREGATE$$INCLUDEDL IMIT$STRUCTDESC:LIMIT$BUS/STRUCT DESCSTRUCT TYPENOYESMED PAYTERR:OT. STRUCTS$INCR CONT NOT REQUIREDREQUIRES INCR CONTENTSEXCL PROP DAMAGEEXCL LIABILITYLIABILITY$PROPERTY$PROP DESCCONST MATERIALLIMIT$NOYESMEDICAL PAYMENTSINCLUDEDINCLUDEDINCLUDEDINCLUDED NOYESMASONRY VENEERRETROFIT TYPE:TERR:% DEDNOYESMED PAYREBUILD PCT:INCREASEDINCREASEDINCREASEDINCREASED INCREASEDINCREASED$$$$$$$INCREASED$$$$$$ ADDRESSLOC ## FAMILIES:TERR:CONTENTS$ADDRESSLOC ## PREMISES:TERR:CONTENTS$LIMIT$FULL VALUE REPLACEMENT COST$FORM NUMBERFORM DATEREPLACEMENT COST - CONTENTSREPLACEMENT COST - DWELLINGCOVERAGE TYPECOVERAGE INFORMATIONPREMIUMUNIT-OWNERS ADDITIONS &ALTERATIONS SPECIAL COVERAGEADDITIONAL PREMISESLIABILITY EXTENSIONADDITIONALRESIDENCERENTED TOOTHERS 1 OR 2 FAMILYBUILDING ORDINANCE ORLAW COVERAGEELECTRONIC APPARATUSBUSINESS AND VEHICLEELECTRONIC APPARATUSIN VEHICLEINCR.

10 COV. C SPECIALLIABILITY LIMIT - GUNSINCR. COV. C SPECIALLIABILITY LIMIT - MONEYINCR. COV. C SPECIALLIABILITY LIMIT - SECURITIESINCR. COV. C SPECIAL LIABILITYLIMIT - SILVERWAREEARTHQUAKEIDENTITY FRAUD EXPENSE COVINCIDENTALS FARMING PERS LIABMINE SUBSIDENCEMOLDOFFICE, PROFESSIONALPRIVATE SCHOOL, STUDIO -RESIDENCE PREMISESOTHER STRUCTURES -INDIVIDUAL STRUCTUREWATER BACKUP OFSEWERS & DRAINSUNSCHEDULED JEWELRY,WATCHES, FURSWORKERS COMPENSATION -FULL TIME INSERVANTWORKERS COMPENSATION -INCIDENTALWORKERS COMPENSATION -PART TIME OUTSERVANT$$$$$$


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