Fillable 1-4 Family Dwelling 11--44 FFAAMMIILLYY DDWWEELLLLIINNGG AAPPPPLLIICCAATTIIOONN -- (Risk Placement Services, Inc.)

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1-4 Family Dwelling 11--44 FFAAMMIILLYY DDWWEELLLLIINNGG AAPPPPLLIICCAATTIIOONN -- (Risk Placement Services, Inc.)

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11--44 FFAAMMIILLYY DDWWEELLLLIINNGG AAPPPPLLIICCAATTIIOONN -- AALLLL SSTTAATTEESS
Please complete all sections of this application and have signed by the applicant.
1-4 Family Dwelling
Named Insured:_______________________________________________________________________________________________________________
Mailing Address_______________________________________________________________________________________________________________
Inspection Contact: ____________________________________________________________________________________________________________
Contact Phone Number: __________________________________
Coverage Desired: Monoline Liability Monoline Property Package
SScchheedduullee ooff LLooccaattiioonnss
Please indicate any owner occupied locations. If that location is a 1 Family Dwelling, it is not eligible for this product
GGeenneerraall IInnffoorrmmaattiioonn
Complete for all submissions
PPrroohhiibbiitteedd EElliiggiibbllee
1. Any locations in Alaska or Louisiana? Yes No
2. Any locations with swimming pools? Yes No
3. Any owner-occupied one family dwelling locations? Yes No
4. Any student residents? Yes No
5. Any government subsidized residents? Yes No
6. Is this a rooming or boarding house? (Any common facilities other than laundry) Yes No
7. Any building with knob and tube or aluminum wiring? Yes No
8. Do all buildings have 100% of the wiring on circuit breakers with 100 amp service? No Yes
9. Are smoke detectors and fire extinguishers in every unit and all common areas? No Yes
10. Does any location allow the use of wood stoves, space heaters, or temporary heating devices? Yes No
11. Are there any insurance company loss control recommendations outstanding? Yes No
SSuubbmmiitt
EElliiggiibbllee
12. Any renovations, development plans or other construction activities being performed or proposed during
our policy term? Yes No
Please describe any “Yes” answers to #12:________________________________________________________________
13. Loss information for the past 3 years:
Street Address City
Stat
e
Zip
Code
# of
Units
Year
Built
Construction
Sq
Ft
PC
# of
Storie
s
Annual
Seasonal or
Timeshare
1
2
3
4
5
Year # of Claims Incurred Amounts Descriptions
$
$
$
DWGA 12/04
page 1 of 3
LLiiaabbiilliittyy IInnffoorrmmaattiioonn NNoott AApppplliiccaabbllee
Occurrence Limit : $100,000 $300,000 $500,000 $1,000,000
PPrroohhiibbiitteedd
EElliiggiibbllee
1. Are any Professional Services or meals provided to residents (i.e. assistance with daily living)? Yes No
2. Does any location have security bars on the windows? Yes (see below) No
If yes, do they have safety release mechanisms from the inside? No Yes
3. Are all locks re-keyed prior to leasing to new tenants? No Yes
4. For 2-4 family dwelling locations that are over 2 stories, is there an outside fire escape? No Yes
HHoommee OOffffiiccee WWeebbQQuuoottee HHiitt ZZoonnee
PPrroohhiibbiitteedd
EElliiggiibbllee EElliiggiibbllee
EElliiggiibbllee
5. Total number of locations >100 1-100 1-25 1-5
6 Number of stories >4 1-4 1-4 1-3
7. Total number of GL losses in the past 3 years >1 1 0 0
PPrrooppeerrttyy IInnffoorrmmaattiioonn
NNoott AApppplliiccaabbllee
Co
verage Option
We can consider 1-4 Family Dwelling submissions requesting Monoline Property and Package quotes for either a Commercial Lines or
Personal Lines option. An account is eligible for a Personal Lines option if:
- Applicant is an Individual, Limited or Family Partnership, Trust or Estate
- Schedule is limited to only 1 location
- The Dwelling limit does not exceed $400,000 ($200,000 coastal)
If the 3 items above apply, please contact your Underwriter to discuss the benefits of each option
Requested Coverage: Commercial Lines Form Personal Lines Form
Building limit $_______________ Detached Garage limit $______________ Contents limit $ ____________ Loss of income $ ___________
Requested Coinsurance (Commercial Lines Only) 80% 90% 100%
Cause of loss: Basic Special Exclude: Theft Wind & Hail Neither
Property deductible: $1,000 $2,500 $5,000
Type of roof: Composite Shingles Flat Tar & Gravel Metal Tile Slate
Age of roof _______ Electrical update __________ Plumbing update__________ Heating update ________
PPrroohhiibbiitteedd
EElliiggiibbllee
1. Any locations in Alabama, Hawaii, Kentucky, Mississippi, Tennessee, or West Virginia? Yes No
2. Is the property in Protection Class 9 or 10? Yes No
3. Any locations occupied on a seasonal or a timeshare basis? Yes No
4. Any locations that are mobile homes? Yes No
5. Any 1 or 2 family dwellings currently vacant? Yes No
6. Any 3 or 4 family dwellings with an occupancy rate below 50%? Yes No
PPlleeaassee NNoottee::
* All locations within our restricted Coastal territories must exclude Wind & Hail.
Please contact your Underwriter for clarification or a copy of our Coastal Guidelines.
* All Personal Lines options must
exclude theft.
SSppeecciiaall FFoorrmm RReeqquuiirreemmeennttss
EElliiggiibbllee BBaassiicc OOnnllyy
- Heating System less than 20 years old? Yes No
- Plumbing System is copper or PVC? Yes No
- Electrical System is less than 35 years old? Yes No
- Roofing has been replaced or recoated within the past 10 years for
shingle, 20 years for metal, 25 years for tile or 50 years for slate Yes No
DWGA 12/04
page 2 of 3
7. Has the roof been recoated or replaced within the past 25 years for shingle or composite, 40 years for metal,
50 years for tile, 100 years for slate No Yes
CCoonnttiinnuuee ffoorr tthhee CCoommmmeerrcciiaall LLiinneess ooppttiioonn oonnllyy
:
8. Are the values at any single location over $500,000 or $250,000 coastal zones? Yes No
9. Does the applicant have tax liens on any property or filed for bankruptcy in the past 3 years? Yes No
10. If California, is the Insured an individual or husband & wife? Yes No
VViirrggiinniiaa NNoottiiccee::
Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
MMiinnnneessoottaa NNoottiiccee::
The clause “and/or authorization or agreement to bind the insurance” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the
insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
CCoolloorraaddoo FFrraauudd SSttaatteemmeenntt::
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil dam-
ages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
DDi
issttrriicctt ooff CCoolluummbbiiaa FFrraauudd SSttaatteemmeenntt:: WWAARRNNIINNGG::
It is a crime to pro
vide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
FFlloorriiddaa FFrraauudd SSttaatteemmeenntt::
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
KKeennttuucckkyy FFrraauudd SSttaatteemmeenntt::
An
y person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
MMaaiinnee FFrraauudd SSttaatteemmeenntt::
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NNeeww JJeerrsseeyy FFrraauudd SSttaatteemmeenntt::
Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
NNeeww YYoorrkk FFrraauudd SSttaatteemmeenntt::
Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
OOhhiioo FFrraauudd SSttaatteemmeenntt::
An
y person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OOkkllaahhoommaa FFrraauudd SSttaatteemmeenntt:: WWAARRNNIINNGG::
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PPeennnnssyyllvvaanniiaa FFrraauudd SSttaatteemmeenntt::
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, informa-
tion concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
TTeennnneesssseeee aanndd VViirrggiinniiaa FFrraauudd SSttaatteemmeenntt::
It is a crime to knowingly pro
vide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
FFrraauudd SSttaatteemmeenntt ((AAllll OOtthheerr SSttaatteess))::
Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Applicant’s Signature ____________________________________________ Title __________________________ Date ________________________
(Owner or Officer)
Broker’s Signature ____________________________________________________________________________________________________________
Some states require that we have the Name and Address of your (Insured’s) Authorized Agent or Broker.
Name of Authorized Agent or Broker____________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________________
Mail complete application through local Agent or Broker to: ________________________________________________________________________
DWGA 12/04
page 3 of 3
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1-4 Family Dwelling 11--44 FFAAMMIILLYY DDWWEELLLLIINNGG AAPPPPLLIICCAATTIIOONN -- (Risk Placement Services, Inc.)

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Completed 30 July 2020

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