Fillable Dwelling Basic Broad Special Owner (Risk Placement Services, Inc.)

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Dwelling Basic Broad Special Owner (Risk Placement Services, Inc.)

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Requested Effective Date: To
Policy Term: 3 Months 6 Months 12 Months
Name
BROKER NO
Mailing Address
BROKER NAME
County where
City
Risk located
ST Zip
ADDRESS
Social Security #(Ins)
(Spouse)
PHONE FAX
Employer & Occupation: Ins: Spouse:
Mortgagee
DOB (Ins) (Spouse)
Married Single/Separated
Address:
Prior Address(if new purchase)
Street Address or Legal Description (Required if PO Box or RR): City/St/Zip
Loan #
RATE INFORMATION
Yr Built Date of Purchase Construction Square Footage: Primary Heat ISO Distance From: Protection
Purchase Price Frame Living Area: Central Protection Fire Hydrant Fire Station Inside City
(Required if Brick Ven. Floor/Wall Furn. Class < 500’ < 3 miles Inside Fire Dist.
purchased in Brick Space Heater 500-1000’ 3-5 miles Unprotected
# Families # Acres last 12 months) Other Attach. Garage Woodburning Stv > 1000’ > 5 miles Subscription
(1-4 Only) (Submit 5+) $ If other, descrb: Yes No Portable Heater
Size: If other, describe: Name of F.D.
Dwelling Limit Other Structures Limit (optional) Contents Limit (optional) Personal Liability (optional) Excludes Animals
$ $ $ $
UNDERWRITING REQUIREMENTS
PREMIUM CALCULATION
IF ANSWERED “YES” SUBMIT FOR PRIOR APPROVAL Yes No
CHECK APPLICABLE BLOCKS
1. Has the applicant had similar coverage cancelled or non-renewed during past 36 mos.?
No Prior Insurance (Unless New Purchase)……….……..+15%
$
2. Have there been 2 or more claims in the past three years or pending open claims?
1 Previous Loss………………………………………..……..+10%
$
3. Is the dwelling without permanently installed water, elec. or sewage utility?
2 Previous Losses…………………………………….....…..+25%
$
4. Any existing non-structural damage (inside or out)?
Bankruptcy (Under 3 years)…………..…….………..….…+20%
$
5. Has the applicant filed bankruptcy in the past 36 months?
3-4 Family Dwelling………………………………………....+30%
$
6. Is there a swimming pool or trampoline? (Trampoline liability excluded)
Loss Free/Prior Insurance Transfer (furnish dec)…….......–5%
$
7. Was the home built prior to 1960? (Requires dwelling update form)
Central Station Fire Alarm……………………………….……-5%
$
8. If tenant occupied, is owner out of state without local property manager?
Dwelling over 30 years old +10% over 50
years old +25%
$
9. Does the applicants own, keep or shelter any Akita, Anatolian Shepherd, Chow,
Supplemental Heat Surcharge…………………………..…..+5%
$
Doberman, Pit Bull, Presa Canario, Rottweiler, Wolf or Wolf hybrid, any mix of these
New Home discount 10 years or less……………….…….-15%
$
breeds with any other breed, whether listed or not?
Other Structures $
10. Any vicious or exotic animals on premises?
OPTIONAL Contents $
11 .Is dwelling within 1500 feet of water or located in special flood hazard area?
COVERAGES Liability $
12. Is there a home day care exposure?
Deductible $2500 $5,000
$
13. Other structures on premises (including dock, pier or boathouse)? (Need Photos)
NO FLAT Other Coverages (LIST IN COMMENTS) $
14. Is there a commercial or farm exposure? Multiple horses, livestock or farm animals?
CANCELLATION GROSS PREMIUM $
15. Is home equipped w/supplemental heating device not installed by contractor?
Policy Fee $ 50.00
16. Does dwelling have an open foundation or built on stilts, posts or piers? (Need Photo)
6% Tax (On premium & Fee) $
17. Is dwelling without permanently installed steps at all entrances and railings on steps
TOTAL AMOUNT DUE $
over 2 feet in height?
MINIMUM EARNED PREMIUM $50 PLUS FEE & TAX
18. Has the dwelling been uninsured for more than 30 days prior to effective date?
UPDATING
IF ANSWERED “YES” DO NOT SUBMIT:
Roof Type: Comp Shingles Wood Shingles Metal Rolled Roofing
19. Does the dwelling have any existing structural damage?
Date Roof Replaced Date Roof Repaired
20. Is there a lodging, auto repair or chemical processing exposure?
Wiring Date Heating Date Plumbing Date
21. Does the dwelling have knob and tube wiring or elec. service with less than 100 amps?
Circuit Breakers Fuses Both
22. Is risk in foreclosure?
PRIOR INSURANCE-NO LAPSE OVER 6 MONTHS
23. Is dwelling vacant? (Refer to Vacant Program if vacant)
Previous Home Carrier
24. Is dwelling under construction or renovation? (Refer to Renovation Program)
Policy # Exp. Date
25. Is primary source of heat wood/coal/pellet device or is the dwelling equipped
If no prior ins., state reason and date of last policy:
with a liquid fuel-powered space heater or heat-reclaiming device? LOSS HISTORY (past 3 years)-NO SURCHARGE FOR WEATHER
26. Is home equipped with fuses only? (Applies to DP-3 Special Form only)
(Use Separate Sheet if necessary, if none – so state)
27. Has applicant been convicted of arson or insurance fraud?
Cause Amount
28. Has applicant been 30 days past due on mortgage payments in the last 12 months?
Cause Amount
29. Does any other structure or garage have a wood/coal/pellet burning device?
ALL PRIOR FIRE, LIABILITY, THEFT AND WATER CLAIMS ARE SUBMIT FOR APPROVAL
(Acceptable with signed other structure exclusion) Comments:
30. Does the dwelling have Exterior Insulation Finish System (EIFS) siding?
31. Does the home have polybutelene or galvanized pipes? ( Applies to DP2 & DP3 only)
32.
Is the dwelling a mobile home, dome home, straw built home or condominium?
33. Has your agency NOT personally inspected the risk in last 60 days?
34. Has there been a fire loss in th
e past 3 years?
PLEASE SIGN ON REVERSE SIDE
Owner
Occupied
Seasonal
Rental
Dwelling
Basic
Broad
Special
DWELLING PROGRAM
Rates Available on line at www.rpsins.com
Basic Dwelling
Minimum value $25,000 actual cash value
Broad Form Dwelling
Minimum value $50,000 replacement cost value, actual cash value if over 20 years old
Special Form Dwelling
Minimum value $75,000 replacement cost value, actual cash value if over 20 years old
Exclusions Notice:
Flood and Earthquake are excluded
I understand that the following exclusion endorsements will be added to my policy if Liability is purchased
and that bodily injury, property damage or any other loss or expense arising out of an occurrence involving
these listed exclusions will not be covered:
Animal Liability Exclusion
Swimming Pool Liability Exclusion
Firearms Liability Exclusion
Home Day Care Business Exclusion
Punitive or Exemplary Damage Exclusion
Hazardous Substance Exclusion
Trampoline Exclusion
Mold Exclusion
Assault and Battery Exclusion
Sexual Molestation, Corporal Punishment, or
Physical or Mental Abuse Exclusion
Roof exclusion if age of roof is 15 years or older, wood, clay, flat or roll roofing
FRAUD WARNING: Any person who with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim contai ning a false or deceptive statement is guilty of insurance
fraud.
IMPORTANT NOTICE: Personal Information about you, including information from a credit or inv estigative
report, may be collected from persons other than you in connection with this application for insurance and
subseque nt amendments and renewals. Such information as well as other personal and privileged
information coll ected by us or our agents may in certain circumstances be disclosed to a third parties without
your authorization. Credit scoring informa tion 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 c an request a correction of
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.
I understand that no i nsurance is bound hereunder and agree that no insurance shall be in effect until this
application is approved by R PS, Inc. and this may be written with a non-admitte d market. I further agree that
the foregoing statem ents and answers are true and correct a nd request RPS, Inc. to issue the ins urance policy
and an y renewals thereof in reliance thereon.
If the property is located in a rural fire protection district or in an area protected by a rural fire department,
has the applicant paid all fire protection association dues or subscription payments? Yes ___ No ___
X____________________________________ ________________ Insured's Phone:____________________
Must be signed (Applicant) Date
X____________________________________ _________________
Must be signed (Producer) Date
DWG
0707
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Dwelling Basic Broad Special Owner (Risk Placement Services, Inc.)

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Completed 23 November 2020

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