Homeowners Application
New
Renewal, Prior Policy Number
Date Coverage is To Be Effective:
Policy Type: HO3 H04 H06
                    Builders Risk Rental

Insured Information
Name:
Mailing Address:
City:
State: Zip:
Phone Number:
Insured Location:
City:
State: Zip:
(1)SSN #:
DOB:
(2)SSN #:
DOB:
Occupation:
Name of Employer:
Address of Employer:
Position Held:

Agent Information
Producer:
Address:
City:
State: Zip:
Phone:
Fax:

Mortgagee(s) Information/Additional Interests
Loan Number 1:
Name:
Address:
City:
State: Zip:
Loan Number 2:
Name:
Address:
City:
State: Zip:

Protection Information
Distance To Fire Hydrant: Fire Station:
Is the Fire Department: Paid Volunteer
Fire Dept. Response Time: min. (For PC 9/10 only)
Distance to the nearest water source:
  Type of water source:
Central Alarm
Fire:
Burglar:

Sprinkler System: Full
Partial
None
Protection Class:
Smoke Detectors: Y N
Dead Bolts: Y N

Limits of Policy
Dwelling: $
Other Structures: $
Personal Property: $
Loss of Use/Fair Rental: $
Personal Liability: $
Medical Payments: $
Loss Assessment Coverage: $

Optional Coverages
Replacement Cost on Contents: Y N
Increased Limits - Jewelry, Watches, Furs: Y N
Extending Liability:
#locations
State:
Earthquake Coverage:
Y N
EQ Zone:
(HO6 Only): All Risk Coverage Dwelling Y N

Deductibles (subject to company guidelines)
Requested Deductible: AOP:$
Wind: %
EQ: %
Eligible for Windpool Y N
Exclude Wind Y N
(NC Only) Wind Deductible Buyback Y N
%

Property Information:
Occupancy: Primary
Secondary/Seasonal
Rental
Is the home occupied daily: Y N
Unoccupied more than 30 consecutive days: Y N
If home is rented, number of weeks:
Is the home visible to neighbors: Y N
Home up for sale: Y N
Caretaker/Property Manager: Y N
    Resident Paid Non Resident Paid
Has applicant had a foreclosure, repossession, or bankruptcy during the past five years: Y N
  Describe:
 
Gated Community:
Patrolled:
Y N
Y N
Building undergoing any renovation: Y N
Builders Risk/Renovation: Est. date of completion
Estimated Replacement cost upon completion:
ISO Territory #:
BCEGS#:

Type/Size of Construction:
Brick, Stone, or Masonry
Frame or Stucco
# of families:

Type of Foundation:

Concrete Slab
Concrete Blocks
Pilings/Stilts
Year Built Year Purchased
Type of Roof Age of Roof
Square Footage Market Value
Flood Insurance Carried: Y N Flood Zone A/V? Y N
Distance To Ocean/Bay/Gulf
Ft. Miles

Elevation above Sea Level Ft.
Hurricane Straps Y N
Stormshutters Y N
Type of Stormshutters
Update Information - Required if home is over 25 years old, 20 years for roof.
Type Full Partial Year Comp.
Wiring
Plumbing
Heating
Roof
Additional Exposures:(comment in remarks section)
Animals on the premises? Y N Type: Training: Y N
Years owned
Swimming Pool on premises? Y N Fenced/Screened? Y N Other?
Any Business Conducted on the Premises? Y N   Any Child Care/Day Care Activities? Y N
Any Wood Stoves or Supplemental Heating? Y N Within 300 feet of any commercial structures? Y N

List other structures and values on the premises:

Remarks:

Prior Carrier and Loss Information
Previous carrier: Expirers:
Expiring or renewal premium: $

Non-renewing Y N Reason:

Three year loss history - Must be filled out Completely
Date Type of Loss Cause Amount

What preventative measures have been taken to prevent future losses? Explain:

NOTICE OF INSURANCE INFORMATION PRACTICES:
Personal information about you may be collected from persons other than you. Such information as well as other personal and privileged. Information collected by us or your agent may in certain surcomstances be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent/broker for instruction on how to submit a request to us.

NOTE TO AGENTS: No binding or quoting authority! Please call or fax for same day binding and follow up with an application. Application must be signed by the named insured. Any incomplete applications recieved could jeopardize binding coverage!