DWELLING FIRE APPLICATION - …

1 KNOB & TUBE ORALUMINUM WIRINGPARTYEARYEARS INCURR OCCYEARS W/ CURR EMPLYEARS W/ PRIOR EMPLABOVE GROUND ONMASONRY FLOORABOVEGROUNDABOVE GROUND NOTON MASONRY FLOORBELOWGROUNDMANNEDSECURITYOFF PREMISESTHEFT EXCLDATE ATCURR RESBURGLARSWIMMING POOLYESDATE (MM/DD/YYYY)PHONE(A/C, No, Ext):AGENCYAPPLICANT'S NAME AND MAILING ADDRESS (Include county & ZIP+4)FAX(A/C, No):NAIC CODEFACILITY CODEPOLICY #HOME PHONE #CO/PLANCODE:SUBCODE:EFFECTIVE DATEEXPIRATION DATEBUSINESS PHONE #AGENCY CUSTOMER IDPREVIOUS ADDRESS (If less than 3 years)YRS ATPREVADDRLOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP)APPLICANT'S OCCUPATION(State nature of business if self-employed)MARSTATAPPLICANT'S EMPLOYER NAME AND ADDRESSDATE OF BIRTHSOCIAL SECURITY #CO-APPLICANT'S OCCUPATION(State nature of business if self-employed)

2 CO-APPLICANT'S EMPLOYER NAME AND ADDRESSDATE OF BIRTHSOCIAL SECURITY #RENTAL VALUEDWELLINGOTHERSTRUCTURESPERSONALPROP ERTYPERSONALLIABILITYMEDICALPAYMENTSPOLI CYTYPE$ADDITIONAL EXPENSE$$$$$$FIREFIRE & ECFIRE, EC & VMMBROADSPECIALEST TOTAL PREMIUM$DEPOSIT$BALANCE$MAIL POLICY TO:ACCOUNT #:BILLINGIF DIRECT BILL:IF APPLICANT BILL:#HSEHLDRESYR BUILT# ROOMSMARKET VALUESTRUCTURE TYPEUSAGE TYPE# FAM-ILIESPURCHASEDATE/PRICE$SQ FT# APTSREPLACEMENT COST$RENOVATION TYPENUMBER OFTERRCODEPREMGROUPPROTECTCLASSDISTANCE TOPROTECTION DEVICE TYPEHEAT TYPEFIREDIVSUNITS INFIRE DIVFIRESTATIONHYDRANTFIRE/EC RATEFIRE DISTRICT/CODE NUMBERHOUSEKEEPING CONDITIONDATE HEATING SYSTEMLAST SERVICEDNUM OF AMPS(ELEC SYST)

3 CIRCUIT BREAKERSFUSESPLUMBING SYSTEMCONDITIONPLUMBING SYSTEMANY KNOWN LEAKSFOUNDATIONOIL STORAGE TANK LOCATIONWINDSTORM LOSS MITIGATIONFEATURESDWELLING LOCATIONOCCUPANCYINSPECTED?TAX CODECONDITION OF ROOFBLDG CODEGRADE# WKSRENTEDOCCUPIED DAILY?WIND CLASSRATINGROOF MATERIALNOIF REPLACEMENT COST APPLIES, ACORD 42 ATTACHED:SPRINKLERBASEMENTGARAGEBREEZEWA YDAYEVEDAYEVEALL PERILEACH OCCURRENCEEACH PERSONWIND/HAILTHEFTNAMEDHURRICANE *AGENTDIRECT BILLBILL APPLICANTFULL PAYAPPLICANTAGENCY BILLBILL MORTGAGEEFRAMEMFG HOMEFARMMASONRYVINYL SIDINGDWELLINGTOWNHOUSEPRIMARYCOCCOMP.

4 DATE:APARTROWHOUSESECONDARYFIRE RESCONDOCO-OPSEASONALNONEWIRINGSYSTEMSMO KETEMPPRIMARY:PLUMBINGFTMICENTRALSECONDA RY:HEATINGDIRECTROOFINGLOCALEXTERIOR PAINTCLOSEDYESNOYESNOYESNOYESNOOPENNONEY ESNODEADBOLTUNOCCFIRE EXTINDOORSOUTDOORSWITHINCITY LIMITSAPPROVEDFENCEOWNERVACANTVISIBLE TONEIGHBORSABOVEGROUNDWITHINFIRE DISTDIVINGBOARDTENANTWITHIN PROTSUBURBSLIDEIN -GROUNDSEMI-RESISTIVEYESNORESISTIVEOTHER CLASSSPECNON-SMOKERCHIMNEYSPRE-FABPARTIA LLIGHTNINGPROTECTIONHEARTHSWOOD STOVEINSERTSQ FTSQ FTSQ FTFULLRATING CREDITSFIREPLACES (Enter Number)* Not Applicable in NCHOW LONG HAVE YOU KNOWN THE APPLICANT?

5 DATE AGENT LAST INSPECTED PROPERTY:APPLICANT INFORMATIONDED (Type & Amount)ENDORSEMENTSPREMIUMACORD 610 Attached (NOT APPLICABLE IN NC)PAYMENT PLANRATING/UNDERWRITINGPLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1981-2005 ACORD 84 (2005/08) DWELLING fire APPLICATIONYEARS W/ PRIOR EMPLYEARS W/ CURR EMPLYEARS INCURR OCCMARSTATCOVERAGES/LIMITS OF LIABILITYMASONRYVENEERALUMINUMSIDINGCOMP PRIOR CARRIERPRIOR POLICY NUMBEREXPIRATION DATEPRIOR COVERAGEANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURINGPERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU INCONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS.

6 CREDIT SCORING INFORMATION MAY BE USED TODETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THEDEVELOPMENT OF YOUR SCORE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY INCERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATIONIN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDINGSUCH INFORMATION IS AVAILABLE UPON REQUEST.

7 CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO , AT THIS OR AT ANY OTHER LOCATION?THE LASTTHIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION . THIS INSURANCE IS SUBJECT TOTHE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:STATE SUPPLEMENT(S) (If applicable)APPLICANT'SINITIALS:IF YES, INDICATE BELOWCAT #DATETYPEDESCRIPTION OF LOSSAMOUNTINT #NAME AND ADDRESSLOAN NUMBERINSURANCE BINDEREFFECTIVE DATEEXPIRATION DATETIMEAPPLICANT'S SIGNATUREDATEPRODUCER'S SIGNATURENATIONAL PRODUCER NUMBERYESNOMORTG'EADDL INTPROTECTION DEVICE CERTIFICATEPERS EXCESS/UMBRELLA APPINLAND MARINE APPLICATIONREPLACEMENT COST ESTIMATERECREATIONAL VEHICLE APPPHOTOGRAPHWATERCRAFT APPLICATIONLEAD FREE PAINT CERTIFICATIONSOLID FUEL SUPPLEMENTHOME BASED BUSINESS SUPP12.

8 01 AMNOONCOVERAGE IS NOT BOUNDTHIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THECOMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BYNOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHENREPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE APREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY.

9 THE QUOTED PREMIUM ISSUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states)ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE FORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND[NY: SUBSTANTIAL] CIVILPENALTIES.

10 (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE,COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUETHE POLICY FOR WHICH I AM HISTORYADDITIONAL INTERESTREMARKS (Attach Additional Sheets if More Space is Required)ATTACHMENTSBINDER/SIGNATUREACOR D 84 (2005/08)ANY LEAD PAINT HAZARD?