Fillable 5.21.21 AUID PL Form Xindication2

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5.21.21 AUID PL Form Xindication2

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The 5.21.21 AUID PL Form Xindication2 form is 2 pages long and contains:

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  • 43 check-boxes
  • 58 other fields

Country of origin: OTHERS
File type: PDF

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Page 1
5/21
PERSONAL LINES
HOMEOWNERS INDICATION
AUI DIGITAL
INSURED INFORMATION
Insured Name: Date of Birth: Occupation:
Spouse Name: Spouse Date of Birth:
Occupation: Phone:
Agency Name: Agent Name:
Phone: Email:
Current Insurance Carrier (if lapsed/canceled/non-renewed enter last date of coverage):
Eective Date Requested: Target Premium:
HOMEOWNERS COVERAGE INFORMATION
Location Address:
City: State: ZIP:
Mailing Address:
City: State: ZIP:
HO3 HO4 HO5 HO6 HO8 DP1 DP3
Primary Secondary/Rental Annual Rental Vacant
Secondary Short-Term Rental Builders Risk
Dwelling Limit: Other Structures:
Personal Property: Loss of Use:
Liability: AOP Deductible:
Medical Payments: Hurricane Deductible:
PROPERTY INFORMATION
CONSTRUCTION TYPE
Year Built:
UPDATE INFORMATION
Frame
Square Feet: ROOF LAST REPLACED PLUMBING LAST REPLACED
Masonry
# of Stories:
Partial Partial
Masonry Veneer
Fire/Burglary Protection
Complete Complete
Reinforced Masonry Monitored Burglar Alarm
Year: Year:
Fire Resistive Monitored Fire Alarm
Other (please list) Monitored Combo Alarm
ELECTRIC LAST REPLACED HEATING LAST REPLACED
Distance to Hydrant:
Partial Partial
Distance to Fire Dept.:
Complete Complete
Other Water Source: Year: Year:
888-376-9633 ext. 2026
Page 2
5/21
ADDITIONAL UNDERWRITING INFORMATION
Is there a swimming pool? Yes No
Is there any bankruptcy? Yes No
Are there any animals on premises? Yes No
If YES, what type/breed?
Is this a new home closing? Yes No
Claims Information (list all details for last 5 years)
Comments to Underwriter (target price, situation on risk, any special coverage or endorsements needs)
MITIGATION INFORMATION
ROOF TYPE ROOF TYPE ROOF TO WALL CONNECTIONS:
Gable Asphalt Shingle Toenails
Hip Architectural Shingle Clips
Flat Clay Tile Straps
Cement Tile Hurricane Class A Shutters/Impact Glass: Yes No
Metal
Distance to Coast (miles to coastline/waterways):
Built-up Tar & Gravel Florida Building Code
(Florida Properties only): Yes No
SIGNATURE
Signature: Date:
Name:
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5.21.21 AUID PL Form Xindication2

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Completed 4 March 2022

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