Fillable Dwelling Fire Application (Colonial General Insurance Agency, Inc)

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Dwelling Fire Application (Colonial General Insurance Agency, Inc)

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Includes copyrighted material of ACORD CORPORATON, with its permission.
Copyright, ACORD CORPORATION, 2012
DFS-APP-2 (2-13) Page 1 of 4
Dwelling Fire Application
Date:
Agency Name / Address:
Phone: Fax:
E-mail:
Applicant’s Name:
Mailing Address:
City:
ST: Zip: County:
Code: Subcode:
E-mail: Phone No.: Bus. P
hone No.:
Agency Customer ID: Effective Date:
Expiration Date:
APPLICANT INFORMATION
Previous Address
(If less than three years) Years at Previous Address:
Street:
City: ST: Zip:
Location of property if different from above (attach Additional Location Supplemental Application, if necessary):
Street:
City:
ST:
Zip:
County:
Applicant’s Occupation (State nature of business if self-employed): Marital Status DOB Applicant’s Employer Name and Address:
Co-Applicant’s Occupation
(State nature of business if self-employed):
Marital Status
DOB
Co-Applicant’s Employer Name and Address:
COVERAGES / LIMITS OF LIABILITY PREMIUM
Policy
Type
Dwelling
Other
Structures
Personal
Property
ALE/Fair Rental
Value
Personal /
Premises
Liability Each
Occurrence
Med Pay
Each Person
Est.
Total
Premium
$
Deposit
$
$ $ $ $ $ $
Balance
$
PERILS Fire EC VMM
Deductible Type & Amount (%/$)
All perils: Wind & Hail: Named Storm: Other:
ENDORSEMENTS / ADDITIONAL COVERAGES
Replacement Cost Dwelling
Personal Injury (Primary Owner Only)
Residence Burglary $
Earthquake Zone:
Workers Comp (CA & NY - Primary Owner Only)
Tenant Relocation (MA only)
Other:
PAYMENT PLAN
Billing:
Insured
Mortgagee
Agency Bill
RATING / UNDERWRITING
Year Built
Purchase Date Construction Type
Frame Modular Home
Masonry EIFS
Masonry Veneer Log Home
Joisted Masonry Hand-hewn
Fire Resistive Milled
MFG/Mobile Home
Other:
Structure
Type
Dwelling
Townhouse
Apartment
Rowhouse
Condo
Co-op
Usage Type
Primary
Secondary
Seasonal
Vacation Rental
Farm
COC/Reno
Completion Date:
Occupancy
Owner
Unoccupied
Tenant
No. Weeks
Rented:
Vacant
No. of
Months:
No.
Stories
Windstorm Loss
Mitigation
Features
Hurricane
Straps
Hurricane
Shutters
HIP Roof
Impact Resistant
Glass
Square Feet Replacement Cost
$
Market Value
$
No.
Families
No. H/H
Residents
Territory
Code
Protection Class Distance To Protection Device Type Foundation: Open Closed Stilts
Hydrant Fire Station System Smoke Temp Burglar Deadbolt Fire Extinguisher Visible to Neighbors
FT MI
Central
Sprinklers: Full Partial
Fire District / Code No.:
/
Local
Swimming Pool: Yes No
Approved Fencing Diving Board Slide
Includes copyrighted material of ACORD CORPORATON, with its permission.
Copyright, ACORD CORPORATION, 2012
DFS-APP-2 (2-13) Page 2 of 4
Updates Partial Complete Year
Details
Wiring
Circuit Breakers: Yes No Fuses: Yes No No. of Amps
Aluminum: Yes No Knob & Tube: Yes No
Plumbing
Type: Copper PVC Other: Any known leaks? Yes No
Heating
Primary: Secondary: None
Wood Stove? Yes No Portable Space Heaters? Yes No
Roofing
Roof Type/Material: Condition of Roof:
Any known leaks? Yes No Exclude Roof? Yes No
LOSS HISTORY
Any losses, whether or not paid by insurance, in the last three years, at this or any other location?
Yes No If Yes, indicate below:
DATE TYPE DESCRIPTION OF LOSS
AMOUNT
PAID / RESERVED
OPEN /
CLOSED
$
Open
Closed
$
Open
Closed
$
Open
Closed
PRIOR / CURRENT COVERAGE
Prior carrier/Current carrier:
Policy number:
Expiration date:
If lapse or no prior coverage, provide explanation:
GENERAL INFORMATION
Explain all “Yes” responses in the “Remarks” section
YES NO
Explain all “Yes” responses in the “Remarks” section
YES NO
1. Any business conducted on premises? (Including farms, day care, etc.)
11. Is property situated on more than five acres?
No. of acres:
Describe land use:
2. Any residence employees?
Number and type of full time and part time employees:
3. Any brush, flooding, forest fire hazard, landslide, etc.?
12. Other structures on premises? (barns, sheds, etc.)
If yes, describe:
4. Any other insurance with this company?
List policy numbers:
13. Is building retrofitted for earthquake?
(If applicable)
5. Any coverage declined, cancelled or non-renewed during the last three
years? (Not applicable in MO or CA)
14. During the last five years (ten [10] years in RI) has any applicant or
household member been indicted or convicted of any crime? (In
Rhode Island, failure to disclose the existence of an arson convic-
tion is a misdemeanor punishable by a sentence of up to one year
of imprisonment.)
6. Has applicant had any foreclosure, repossession, bankruptcy, judgment
or lien procedures filed during the past five years?
15. Is there any existing fire, water or structural damage?
Reason:
16. Is building undergoing renovation or reconstruction?
Starting Date:
Starting Value: $
Open Date closed/discharged:
Contractor Name:
Completion Date:
Completed Value: $
7. Is applicant delinquent on mortgage or tax payments?
17. Is house for sale?
8. Are there any animals or exotic pets kept on premises?
Breed:
Bite History:
18. Is property within 300 ft. of a commercial or non-residential
property?
19. Is there a trampoline on the premises?
9. Any lake, pond or dock on premises?
20. Was the structure originally built for other than a private residence
and then converted?
10. Distance to tidal water: Miles Feet
Includes copyrighted material of ACORD CORPORATON, with its permission.
Copyright, ACORD CORPORATION, 2012
DFS-APP-2 (2-13) Page 3 of 4
REMARKS (Attach additional sheets if more space is required)
ADDITIONAL INTEREST
INT No.: Type Of Interest Mortgagee Information Loan Number:
Mortgagee
Additional Interest
Trust
Name:
Address:
City:
ST:
Zip:
Mortgagee
Additional Interest
Trust
Name:
Address:
City:
ST:
Zip:
ADDITIONAL REQUIREMENTS / ATTACHMENTS
Inspection Photographs Protection Class 9/10 Questionnaire Woodstove Questionnaire/Photos (2) Replacement Cost Estimator
NOTICES, FRAUD WARNINGS AND ATTESTATION
PRIVACY POLICY:
I have received and read a copy of the “Scottsdale Insurance Company Privacy Statement and Procedures.” By submitting this application, I am applying for issuance of a policy of
insurance and, at its expiration, for appropriate renewal policies issued by Scottsdale Insurance Company and/or other members of the Scottsdale group of insurance companies. I
understand and agree that any information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be used by any
company within the Scottsdale group to issue, review, and renew the insurance for which I am applying.
FAIR CREDIT REPORTING ACT NOTICE:
This notice is given to comply with Federal Fair Credit Reporting Act (Public law 91-508) and any similar state law which is applicable as part of our underwriting procedure. A
routine inquiry may be made which will provide information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to nature and scope of the report will be provided.
FRAUD WARNING: 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
subjects such person to criminal and civil penalties. (Not applicable to Oregon).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: 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 damages. Any insurance company or agent of an
insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud
the policy holder 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.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide 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.
NOTICE TO FLORIDA APPLICANTS: 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.
APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: 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
containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: 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.
NOTICE TO RHODE ISLAND APPLICANTS: 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.
Includes copyrighted material of ACORD CORPORATON, with its permission.
Copyright, ACORD CORPORATION, 2012
DFS-APP-2 (2-13) Page 4 of 4
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide 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.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for commercial
insurance or a statement of claim for any commercial or personal insurance benefits containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or
conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or
an insurance company, 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 value of the
subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an
inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: ________________________________________________________________________ DATE:
CO-APPLICANT’S SIGNATURE: _____________________________________________________________________ DATE:
PRODUCER’S SIGNATURE: _______________________________________________________________________ DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
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Dwelling Fire Application (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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