Fillable DWELLING APPLICATION FORM (Abram Interstate Insurance)

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DWELLING APPLICATION FORM (Abram Interstate Insurance)

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DWELLING APPLICATION FORM
THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS
APPLICATION SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO
OFFER COVERAGE OR OFFER COVERAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT BY THE APPLICANT.
ELIGIBILITY QUESTIONS
1. In which state is the property to be insured:
2. Please select Type of Occupancy: Owner OnlyTenant OnlyOwner and Tenant(s) Seasonal and/or Secondary Short Term and/or Vacation Rental
3. Please confirm all rentals are for minimum two nights with a security deposit and written rental agreement in place and signed by
all owners and tenants? (Applicable for Short Term and/or Vacation Rental quotes only) Yes No
4. Please select Type of Dwelling: One Family Two Family Three Family Four Family Five Or More
5. Has the applicant had any application of property insurance refused, cancelled or non-renewed in the
past 3 (three) years? (other than vacancy) Yes No
If the answer above is Yes, were they for any of the following reasons only:
- Insurer no longer writing class of business?
- Insurer no longer writing class of business in territory? Yes No
- Risk no longer qualifying for an Admitted Carrier program?
- Loss History?
6. Has the applicant ever been involved in any bankruptcy proceedings and/or convicted of arson or
insurance fraud? Yes No
7. Has the applicant had more than three claims OR any one claim exceeding $25,000 in total in the past five years?
8. Has the applicant had more than two water damage claims in the past five years? Yes No
9. Does the property have any galvanized plumbing pipes? Yes No
10. Is the property to be insured subject to mortgage foreclosure proceedings or tax liens?
11. Is there any existing damage to building(s) to be insured?
12. Is the property to be insured subject to more than two mortgages or other encumbrances?
13. Is the property to be insured subject to a mortgage provided by an individual or entity other than a financial institution?
14. Is the property attached to, occupied as, or converted from a commercial building? Yes No
15. Is the property to be insured a Rooming House, Boarding House or used for Student
Housing?
16. Is the property located in a landslide, or brush fire area (with less than 200 feet brush clearance)?
17. Does the property have any knob & tube aluminium wiring or is on fuses?
18. Does any wiring at the property have less than 100amp circuit breakers?
19. Are kerosene, paraffin, or portable space heaters used?
19. Is the property situated on more than 25 acres?
20. Is the property an earth home, dome home, open pier or stilt home? Yes No
21. Is the property a mobile home, manufactured home, farm, hobby farm or any non-conventional dwelling? Yes No
ATR – 59 Dwelling Application
Page 2 of 3
ELIGIBILITY QUESTIONS (continued)
22. Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work
due to commence while insurance is in effect? Yes No
23. Is the renovation or construction work (i) being performed by a contractor or owner where project costs exceed $150,000; or (ii) involve
structural repairs being performed by any person? Yes No
GENERAL DETAILS
Name and Mailing Address of Applicant:
State Zip code
Telephone Email
Address of Property to be Insured:
State Zip code
Name and Address of Retail Broker:
State
Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
24. Protection Class:
25. Is Condominium Unit Owners Coverage required? (Applicable for Owner Only One FamilyRU7HQDQWRQO\2QH)DPLO\ quotes) Yes  No
26. Total square footage of building to be insured:
27. Construction Type:
Frame Joisted Masonry Masonry Non Combustible Non Combustible Modified Fire Resistive Fire Resistive Other
28. Age of building or full electrical and plumbing upgrade? 0-35 Years 36-50 Years Over 50 Years
29. When was the roof last replaced? 0-25 Years 26-50 Years Over 50 Years
30. Value of Coverage A – Dwelling to be insured:
31. Is Coverage B – Other Structures cover required? Yes No 31a. Value of Coverage B – Other Structures:
32. Is Coverage C – Personal Property (ex-theft) cover required? Yes No 32a. Value of Coverage C – Personal Property (ex-theft):
33. If available, is Coverage D – Fair Rental cover required? Yes No 33a. Value of Coverage D – Fair Rental:
34. If available, is Coverage E – Additional Living Expenses cover required? Yes No
35. Value of Coverage E – Additional Living Expenses:
36. Wind and Hail Deductible per occurrence: $1,000 $2,500 $5,000 $10,000
37. All Other Perils Deductible per occurrence: $1,000 $2,500 $5,000 $10,000
38. Which type of quote do you require? DP1 DP3 39. Is there a wood stove on the premises? Yes No
40. Would you like to buy coverage for the peril of Earthquake? (applicable for CA quotes only) Yes No
41. Premises Liability: Yes No
42. Premises Liability Limits: $25,000 $50,000 $100,000 $300,000 $500,000 $1,000,000
43. Medical Payments: $1,000 $2,500 $5,000 $10,000
ATR – 59 Dwelling Application
Page 3 of 3
COVERAGE AND PROPERTY DETAILS (continued)
44. Is dwelling situated on more than five acres? Yes No 44a. How many acres? 6-15 16-25 25+
44b. Please describe use of land:
45. Do you want to buy coverage for the swimming pool liability? Yes No 45a. Is it fenced and does it have a self locking gate? Yes No
45b. W hat limit would you like for swimming pool liability? $25,000 $50,000 $100,000
46. Have there been any insured or uninsured property or liability losses at the property to be insured since the applicant has
owned the property? Yes No
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
47. Identify all mortgagees, lien holders and additional loss payees (if any, including account numbers and outstanding amounts):
48. If required, please enter below details of Additional Insured:
DECLARATION
THE ANSWERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THESE
ANSWERS WILL FORM PART OF A POLICY THAT IS SUBSEQUENTLY OFFERED. I ALSO UNDERSTAND THAT ANY FALSE
STATEMENT MAY VOID THE INSURANCE IN ITS ENTIRETY OR RESULT IN A CLAIM BEING DENIED.
ANY 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 AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH,
OK, OR, VT FOR WHICH SEE ATTACHED). IN DC,
LA, ME, TN AND VA, INSURANCE BENEFIT
S MAY ALSO BE DENIED.
Applicant’s Signature Retail Broker’s Signature
Date Date
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DWELLING APPLICATION FORM (Abram Interstate Insurance)

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Completed 10 July 2021

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