Fillable Dwelling Fire Application (COC/Renovation/Vacant) (Risk Placement Services, Inc.)

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Dwelling Fire Application (COC/Renovation/Vacant) (Risk Placement Services, Inc.)

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The Dwelling Fire Application (COC/Renovation/Vacant) (Risk Placement Services, Inc.) form is 3 pages long and contains:

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  • 66 check-boxes
  • 122 other fields

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File type: PDF

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DWL-APP (01-13) Page 1 of 3
NOTICE TO AGENT
BILLING INSTRUCTIONS
Indicate below how you wish Renewals to be billed
Insured Mortgage Co.
Dwelling Fire Application (COC/Renovation/Vacant)
Applicant’s Name Agent Name
Mailing Address Address
PROPOSED EFFECTIVE DATE: FROM: TO:
3 Month 6 Month Annual Term 12:01 A.M., Standard Time at the address of the Applicant
COVERAGE INFORMATION
Perils to be Insured: DP-1 DP-3
Fire E.C VMM Premises Liability Personal Liability
Residence Burglary Deductible: $
Territory: County:
Wind Excluded? ........................................... Yes No Wind Deductible: $
Mortgagee:
Address: Loan No.:
Dwelling #1 Limits: Dwelling #2 Limits:
$
a. Masonry Frame EIFS
Log—Hand hewn
Log—Milled Log
$ a. Masonry Frame EIFS
Log—Hog hewn
Log—Milled Log
b.1 family 2 family
3 family 4 family
Condo
b.
1 family 2 family
3 family 4 family
Condo
c.
Owner Tenant Renovation c. Owner Tenant Renovation
d. Vacant Builders Risk
Seasonal Short-Term Rental
d.
Vacant Builders Risk
Seasonal Short-Term Rental
e.Located at: e.Located at:
$ Other Structures—describe: $ Other Structures—describe:
$
On contents in the above dwelling $ On contents in the above dwelling
$
Residence Burglary $ Residence Burglary
$
Additional Living Expense/Loss of Use $ Additional Living Expense/Loss of Use
$
Premises Liability/Personal Liability $ Premises Liability/Personal Liability
$
Medical Payments $ Medical Payments
DWL-APP (01-13) Page 2 of 3
PROPERTY INFORMATION
1. If vacant, how long has dwelling been vacant?
2. If seasonal or short-term rental, is there a caretaker or property manager? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
3. If vacant, seasonal or short-term rental, how often is dwelling checked on?
4. Was dwelling inspected by agent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Comments:
5. Does agent recommend risk? .................................................................................................................. Yes No
Comments:
6. Is there a swimming pool? ....................................................................................................................... Yes No
If yes:
Fenced? .. .. .. .. . . . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. .. . .. .. .. .. .. .. .. .. .. . . .. .. .. .. .. .. .. .. ..........................
Yes No
Locking Gate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...............
Yes No
7. Year of Construction:
Square Feet: Cost per square foot: $
Year of building update in:
Wiring: Year . . . . . . . . . . . . . . . . Full Partial Type: Knob & Tub Fuses Circuit Breakers
Roofing: Year . . . . . . . . . . . . . . . . Full Partial Type:
Plumbing: Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Full Partial
Heating & Air Conditioning: Year ............................................................................. Full Partial
Physical condition of buildings:
8. Fire Protection Class: Fire District: E.C. Class:
Distance from coastal water (Includes an ocean, gulf, bay or sound):
Distance to hydrant:
Distance to fire station (Indicate miles):
9. Primary source of heat:
10. Is there a wood stove on premises? ........................................................................................................ Yes No
If wood burning stove, attach completed questionnaire and photo.
11. Is dwelling under construction or being renovated? .............................................................................
Yes No
If yes
, name of licensed contractor:
Number of years experience: Project completion date:
Extent of renovation:
12. Applicant’s occupation(s):
Applicant’s phone number:
13. Are any business pursuits conducted on the premises, including any volunteer organizations, churches,
profit or non-profit businesses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If yes, describe:
14. Does the Insured have any animals? ......................................................................................................
Yes No
Provide Breed of dog(s) and number if applicable___________________________________________________
If yes, any bite/aggressive behavior history? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If yes, describe:
DWL-APP (01-13) Page 3 of 3
15. Acreage? .................................................................................................................................................... Yes No
If yes, number of acres:
Usage:
16. Has any company canceled or refused coverage to the applicant (not applicable in Missouri or
California)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...................
Yes No
Comments:
17. Previous insurance carrier:
Policy number: Expiration date:
If no previous carrier, why (not applicable in Missouri or California)?
18. Any losses at this location or any other location owned/rented within the last three years? ..........
Yes No
If yes, provide details:
19. Any bankruptcy or foreclosure proceedings filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Reason:
Opened Closed Date Closed:
*ATTACH PHOTO WITH COMPLETED APPLICATION.
Coverage will become effective, if accepted, upon written notice by RPS-MIS and coverage will not commence earlier than the date
received in the office of RPS-MIS.
Applicant Statement: I understand that the amount of insurance applied for represents the current structure(s) described on this form.
Any modifications, improvements, new construction or alterations made hereafter will not be considered covered until I have properly
notified RPS-MIS and the coverage limits have been reviewed and endorsed as necessary.
Applicant/Producer Statement: I hereby state I have been unable to procure the above requested coverage from standard insurers. I
request RPS-MIS to effect coverage and will be responsible for payment of premium, fees and taxes. I understand coverage will not be
effective until accepted by RPS-MIS and flat cancellations are not permitted. I warrant all above answers to be true and understand
coverage, if accepted, will become void at any time the covered property has been vacant or unoccupied for more than 30 days, unless
issued has a vacant risk:
APPLICANT’S SIGNATURE:
DATE:
PRODUCER’S SIGNATURE: DATE:
PRODUCERS NAME:   AGENT CODE:
(Please print)
Forward completed application to:
RPS-MIS
505 S. 336th St., Ste 410
Federal Way, WA 98003
1-800-247-5851, Fax 1-877-329-9647
www.rpsins.com
You can e-mail the completed application to personal_MIS@rpsins.com for a quote.
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Dwelling Fire Application (COCRenovationVacant) (Risk Placement Services, Inc.)

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Completed 30 July 2020

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