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DWELLING FIRE APPLICATION - …

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)CO-APPLICANT'S EMPLOYER NAME AND ADDRESSDATE OF BIRTHSOCIAL SECURITY #RENTAL VALUEDWELLINGOTHERSTRUCTURESPERSONALPROP ERTYPERSONALLIABILITYMEDICALPAYMENTSPOLI CYTYPE$ADDITIONAL EXPENSE$$$$$$FIREFIRE & ECFIRE, EC & VMMBROAD

any losses, whether or not paid by insurance, during personal information about you, including information from a credit report, may be collected from persons other than you in

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Transcription of 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)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 #.

2 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)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.

3 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?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.

4 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. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO , AT THIS OR AT ANY OTHER LOCATION?

5 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 SUPP12:01 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.

6 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. 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.

7 (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?EXPLAIN ALL "YES" RESPONSES IN REMARKSYESNOEXPLAIN ALL "YES" RESPONSES IN REMARKS (Except question 15, 16 and 17) FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES?

8 (Including day/child care) 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 INCONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI,failure to disclose the existence of an arson conviction is amisdemeanor punishable by a sentence of up to one (1) year ofimprisonment.) RESIDENCE EMPLOYEES?(Number and type of full and part time employees) FLOODING, BRUSH, FOREST fire HAZARD, LANDSLIDE, ETC?RENTERS ANDCONDOS THERE A MANAGER ON THE PREMISES? OTHER RESIDENCE OWNED, OCCUPIED OR RENTED? THERE A SECURITY ATTENDANT? OTHER INSURANCE WITH THIS COMPANY?

9 (List policy numbers) THE BUILDING ENTRANCE LOCKED? INSURANCE BEEN TRANSFERRED WITHIN AGENCY? UNCORRECTED fire OR BUILDING CODE VIOLATIONS?ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWEDDURING THE LAST 3 YEARS? (Not applicable in MO)IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTION?(Give estimated completion date and dollar value) APPLICANT HAD A FORECLOSURE, REPOSSESSION,BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVEYEARS? HOUSE FOR SALE? PROPERTY W/IN 300 FT OF A COMMERCIAL ORNON-RESIDENTIAL PROPERTY?ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ONPREMISES? (Note breed and bite history) THERE A TRAMPOLINE ON THE PREMISES? THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN APRIVATE RESIDENCE AND THEN CONVERTED?

10 TO TIDAL WATER?IS PROPERTY SITUATED ON MORE THAN FIVE ACRES?(If yes, describe land use) A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCEBEEN OBTAINED FOR THE TANK? (Give First Party and limit, andThird Party and limit)DOES APPLICANT OWN ANY RECREATIONAL VEHICLES(SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATVS, ETC)?(List year, type, make, model) BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANTTHE GENERAL CONTRACTOR? BUILDING RETROFITTED FOR EARTHQUAKE? (If applicable)GENERAL INFORMATIONAPPLICABLE IN COLORADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OF COVERAGE, TO EVALUATE THEISSUANCE OF THE INSURANCE


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