A6072A0710
2
of 2
ARIC DW IA
LOSS HISTORY
HAVE YOU HAD ANY PRIOR LOSSES? Yes No If Yes, indicate below.
Description of Loss
Date Amount Paid
Description of Loss
Date Amount Paid
Description of Loss
Date Amount Paid
If the applicant has had 2 or more property losses (paid or unpaid) in the past 36 months or any single fire, theft, liability or water loss in the past 36 months, the risk must be
submitted to the General Agent for acceptability.
UNACCEPTABLE RISKS Any “Yes” response makes the risk unacceptable and it cannot be written!
Yes No
1. Have any of the applicants been convicted of arson or insurance fraud? ..................
2. Is the dwelling without permanently installed water, electricity, and sewage
utility services? (submit Seasonal and DP-1 risks for approval) .................................
3. Does the dwelling have any existing structural damage? ............................................
4. Is the dwelling in foreclosure? ........................................................................................
5. Does the dwelling have more than 4 individual family units? ......................................
6. Is the dwelling equipped with liquid fuel-powered space heater or heat-reclaiming
device(s)? ........................................................................................................................
7. Is the dwelling’s primary source of heat a wood/coal/pellet burning device? (does
not apply to seasonals and DP-1 risks) .........................................................................
8. Are there any other structures or garages with a wood/coal/pellet burning device
on the premises? ............................................................................................................
9. Does the dwelling have knob and tube wiring or electrical service with less than
100 amps? ......................................................................................................................
10. Is the dwelling or other structures used to store flammables or explosive materials? ....
Yes No
11. Is the dwelling under construction or major renovation? ..........................................
12. Is the dwelling next to any burned out or abandoned building? ................................
13. Does the dwelling have a brush clearance of less than 350 feet? ...........................
14. Is the dwelling a mobile home, dome home, log home, earth home, straw built
home or condominium? .............................................................................................
15. Does the dwelling have more than 2 lien holders? Two lien holders are
acceptable if one is a financial institution. ................................................................
16. Does the dwelling have childcare, homecare, lodging, auto repair or chemical
processing conducted on the premises? ..................................................................
17. Does the dwelling have polybutelene pipes? (Applies to DP-2 & DP-3 only) ..........
18. Does the dwelling have Exterior Insulation Finish System (EIFS) siding? ...............
19. Is the dwelling only equipped with fuses? (Applies to DP-3 only) ............................
20. Is the dwelling vacant? (See Vacant Program)
21. Is the dwelling a townhome or rowhome built prior to 1970?.....................................
RISK TO BE WRITTEN WITHOUT LIABILITY COVERAGE Any “Yes” Response Must Be Explained Below.
Yes No
1. Does the applicant own, keep, or shelter any animal with a previous bite history or any non-domestic animal? ..........................................................................................................................
SUBMIT RISKS TO GENERAL AGENT Any “Yes” Response Must Be Explained Below.
Yes No
1. Have the applicants had 2 or more property losses (paid or unpaid) in the past 36
months or any single fire, theft, liability, or flood loss in the past 36 months? If yes,
give date of loss, describe the loss and the amount paid to repair the damage. .........
2. Has the applicant had a homeowners/dwelling policy cancelled or non-renewed
for underwriting reasons (except home age) during the past 36 months?...............
3. Has the applicant filed for bankruptcy in the past 36 months? .................................
4. Has the applicant been 30 days past due on mortgage payments in the last 12 months?
5. Is the applicant unemployed? (Retirees with guaranteed income and disabled
persons with a consistent income are considered employed.) .................................
6. Does the premises have a swimming pool or spa that is not completely fenced and is
not in compliance with all city and/or county ordinances? The swimming pool or spa
must have a fence minimum of four feet high with a self-latching gate, motorized
pool cover or other comparable safety device that is securely fastened to the
perimeter of the pool/spa thus rendering it inaccessible (Risk may be acceptable
with Swimming Pool and Spa Exclusion attached). .................................................
7. Does the dwelling have unrepaired damage or existing non-structural damage? ..
8. Has the dwelling been uninsured for more than 30 days immediately prior to the
requested effective date? (Does not apply to a new purchase) ...............................
9. Is the dwelling attached to, occupied as or converted from a commercial risk? .....
10. Does the dwelling have an open foundation or is it built on stilts, posts or piers?
Photos must be included. ........................................................................................
Yes No
11. Is the dwelling equipped with a supplemental heating device that was not installed
by a licensed contractor? Photos and Woodstove Inspection Report must
be included. ..................................................................................................................
12. Does the dwelling have steps or porches, over 2 feet in height that do not have
a railing? Photos must be included. ........................................................................
13. Is the dwelling without permanently installed steps at all entrances? Photos
must be included. ......................................................................................................
14. Is the dwelling within 1,500 feet of water (ocean, river or creek) or is the dwelling
located on an island or in a Special Flood Hazard Area? .........................................
15. Does the dwelling have multiple horses, livestock or farm animals on the premises?
16. Does the premises have a dock, pier or boathouse? Photos must be included. .....
17. Is the dwelling on a premise with 5 or more acres? ..................................................
18. Does the dwelling have farming activities conducted on the premises? .................
19. Does the dwelling have business pursuits conducted on the premises? .................
20. Does the value of Other Structures exceed 30% of the insured value of the dwelling? ...
21. Does the Personal Property exceed 50% of the insured value of the dwelling for
Primary risk dwellings or 20% of the value of the dwelling for rentals or seasonals? ..
22. Does the Fair Rental Value or Additional Living Expense exceed 20% of the
insured value of the dwelling? .....................................................................................
Explain “Yes” answers
DWELLING LOSS SETTLEMENT OPTIONS (Choose One)
ACV (Depreciation will apply) Replacement Cost (Available to DP-2 and DP-3 risks only. Home must be insured to 100% of replacement cost. A replacement cost estimator is required.)
SPECIFIC BREED ANIMAL EXCLUSION NOTICE: I understand the Specific Breed Animal Exclusion will be attached to my policy and that bodily injury, property damage or
any other loss or expense arising out of any occurrence involving any of the following types of animals and/or breeds of dogs or a mix of any of the breeds with any other breed
whether listed or not will not be covered: Any animal with a previous bite history, snakes, monkeys or ostriches; Breeds of dogs include Akita, Anatolian Shepard, Chow,
Doberman, Pit Bull, Presa Canario, Rottweiler, Wolf or Wolf Hybrid.
FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss for 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.
IMPORTANT NOTICE: Personal Information about you, including information from a credit or other investigative report, may be collected from persons other than you in
connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us
or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring information may be used to determine either your eligibility for
insurance or the premium you will be charged. We may use a third party in connection with the development of your score. 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 will be issued with your policy.
This notice is given in compliance with the Federal Credit Reporting Act.
X_______________________________________________________ _________________ X________________________________________________________ _______________
(Signature of Applicant) Date (Signature of Producer) Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
