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

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Dwelling Liability Application (Colonial General Insurance Agency, Inc)

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P.O. Box 14770, Scottsdale, AZ 85267-4770 P.O. Box 571770, Murray, UT 84157-1770
8475 E. Hartford Dr., Scottsdale, AZ 85255 5373 S. Green St., Suite 525, Murray, UT 84123
(480) 991-7889 WATS (800) 848-8860 (801) 290-1144 WATS (800) 594-8900
Fax (480) 948-1394 Toll Free (866) 240-8807 Fax (801) 290-1160 Toll Free (
800) 332-9285
Agent’s E-mail Address____________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Applicant’s E-mail Address _________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Dwelling Liability Application
Applicant’s Name
Agent Name
Mailing Address Address
Agent Code No.
PROPOSED EFFECTIVE DATES: From To 12:01 A.M., Standard Time at the address of the Applicant
REQUESTED COVERAGE: PERSONAL LIABILITY PREMISES LIABILITY
LIMIT OF LIABILITY: $
MEDICAL PAYMENTS $
LOCATION #1
Located at:
Value of Dwelling: $
1 family 2 family 3 family 4 family
Owner Tenant Renovation
Vacant Seasonal Builder’s risk
Vacant land Condo Short-term rental
Year of construction:
Updated?.................................................... Yes No
If yes, provide the date the following items were
updated
:
Roof:
Wiring:
Plumbing:
Heating & Air Conditioning:
Physical condition of property:
Additional insured:
LOCATION #2
Located at:
Value of Dwelling: $
1 family 2 family 3 family 4 family
Owner Tenant Renovation
Vacant Seasonal Builder’s risk
Vacant land Condo Short-term rental
Year of construction:
Updated?.................................................... Yes No
If yes, provide the date the following items were
updated
:
Roof:
Wiring:
Plumbing:
Heating & Air Conditioning:
Physical condition of property:
Additional insured:
DL-APP (6-07) Page 1 of 3
Please answer all questions:
1. Is there a swimming pool on premises?.................................................................................................
Yes No
If yes, is there a diving board or s
lide?........................................................................................................
Yes No
If yes, is the pool fenced with a self-l
ocking gate? ......................................................................................
Yes No
2. Any other water exposure; i.e., ponds, lakes, jacuzzi/hot tubs?..........................................................
Yes No
If yes, describe:
3. Any animals on premises?.......................................................................................................................
Yes No
If yes, describe:
If yes, any bite/aggressive behavior hist
ory? ..............................................................................................
Yes No
4. Any smoke detectors?..............................................................................................................................
Yes No
5. Any trampolines? ...............................................................................................................................
.......
Yes No
6. Trip and fall hazards? ...............................................................................................................................
Yes No
If yes, explain:
7. Do steps have secured handrails?..........................................................................................................
Yes No
8. Applicant’s occupation:
9. Any business on premises?..................................................................................................................... Yes No
If yes, describe:
10. Is there a day care operation on premises? ...........................................................................................
Yes No
If yes, is commercial General Liability coverage written?
............................................................................
Yes No
Number of children:
11. Any hobbies?............................................................................................................................................. Yes No
If yes, what are they?
12. Is the dwelling under renovation or builder’s risk?...............................................................................
Yes No
If yes: Provide contractor’s name:
Duration of project:
Provide certificate of insurance from contractor.
13. Any adjacent structures on premises, other than a garage? ...............................................................
Yes No
If yes, what are they used for?
14. Any acreage? ...............................................................................................................................
..............
Yes No
If yes: Number of acres:
How is it used?
15. Any losses at this location or any other location owned/rented within the last three years? .......... Yes No
If yes, details:
DL-APP (6-07) Page 2 of 3
16. Any residence employees? ......................................................................................................................
DL-APP (6-07) Page 3 of 3
Yes No
If yes: Number of: In-servants:
Hours/week per employee:
Number of: Out servants: Hours/week per employee:
17. Has any company canceled or refused coverage to the applicant (Not applicable in Missouri or
California)?.................................................................................................................................................
Yes No
18. Additional space to explain yes answers:
19. Please provide:
Prior insurance carrier:
Policy number: Expiration date:
(Not applicable in Missouri or California.)
INCLUDE PHOTO OF PREMISES WITH APPLICATION.
PRIVACY POLICY:
I have received and read a copy of the “National Casualty Company Privacy Statement an
d 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 National Casualty 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:
This notice is given to comply with Federal Fair Credit Reporting A
ct (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 insu
rance 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.
FRAUD WARNING (APPLICABLE IN
TENNESSEE AND WASHINGTON):
It is a crime to knowingly provide false, incomplete, or misleadi
ng information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insu
rance 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 a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: _______________________________________________________________ DATE:
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Dwelling Liability Application (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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