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PERSONAL

Name of Applicant: Date of Birth:
Applicant Social Security Number (no dashes):
Home Phone (area code and no dashes): Business Phone:
Applicant Email Address:
Occupation: Employer:

Co-Applicant Name: Date of Birth:
Social Security Number (no dashes):
Home Phone (area code and no dashes): Business Phone:
Occupation: Employer:

STRUCTURE:

CONSTRUCTION TYPE: Frame Masonry Masonry Veneer Aluminum Siding
Plastic Siding Asbestos Siding Fire Resistant

ROOF TYPE: YEAR BUILT:

SQ. FEET: MARKET VALUE:

STRUCTURE TYPE: Dwelling Apart Condo Townhouse Rowhouse Co-0p

USAGE: Primary Secondary Seasonal Unoccupied Vacant

DISTANCE TO: Fire Hydrant: Ft. , Fire Station:miles

HEAT TYPE (Primary): Electric Natural Gas Fuel Oil Wood Stove Other

RENOVATION (Year): Wiring Plumbing Heating
Roof Exterior Paint

LOCATION: Within city limits Within fire district Within protected suburb

OCCUPIED BY: Owner Tenant VISIBLE TO NEIGHBORS: Yes /No

SWIMMING POOL: Yes /No
( IF YES TO POOL ) Approved Fence? Diving Board? Above Ground?

OCCUPIED DAILY: Yes /No STORM SHUTTERS: Type A Type B None

PROTECTION: (For Fire and Burglary): Central System Direct System Local System Deadbolts Smoke Detectors Fire Extinguisher In House Sprinkler System

GENERAL INFORMATION:

Any business conducted on premises? Yes /No

Any full time residence employees? Yes /No

Any flooding, brush, forest fire hazard, landslide, etc.? Yes /No

Any other residence owned. Occupied or rented? Yes /No

Any other insurance with this company? Yes /No

Has insurance been transferred within agency? Yes /No

Any coverage declined, canceled, or non-renewed during the last 3 years ? Yes /No

Has applicant had a foreclosure, repossession or bankruptcy during the past 5 years? Yes /No

Does applicant or any tenant have any animals or exotic pets? Yes /No

Is property located within 2 miles of tidal water? Yes /No

Is property situated on more than five acres? Yes /No

Does Applicant own any recreational vehicles (Snow mobiles), dune buggies, Mini bikes, ATV’s, etc) Yes /No

During the last 10 years, has any applicant been convicted of any degree of the crime of Arson? Yes /No

Any uncorrected fire code violations? Yes /No

Is building undergoing renovation of reconstruction? Yes /No

Is house for sale? Yes /No

Is property within 300 feet of a commercial or non-residential property? Yes /No

Is there a trampoline on the premises? Yes /No

Was the structure originally built for other than a private residence and then converted? Yes /No

FOR RENTERS AND CONDO ONLY:

Is there a manager on the premises? Yes /No

Is there a security attendant? Yes /No

Is the building entrance locked? Yes /No

LOSS HISTORY:

Amy losses whether or not paid by insurance during the past 3 years at this or any other location? Yes /No
If “Yes” please give Date, Type, Description of Loss and Amount

PRIOR COVERAGE:

If this policy is to replace an existing give name of carrier, policy number and expiration date.

ADDITIONAL INTEREST:

Please list mortgage company(s) and/or anyone else who has a loss payee interest in the property.

Please fill out all the sections completely.
After completing form above press

Please fill out all the sections completely. After completing form above press

Please fill out all the sections completely.
After completing form above press