Mortgagee(s) Information/Additional Interests
Limits of Policy
Deductibles (subject to company guidelines)
Type of Foundation:
List other structures and values on the premises:
Three year loss history - Must be filled out Completely
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!