Fillable Form 1: HUBB APPLICATION C ClientsInformation 2 2211 (Abram Interstate Insurance)

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Form 1: HUBB APPLICATION C ClientsInformation 2 2211 (Abram Interstate Insurance)

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C
HUBB APPLICATION
ClientsInformation
1
st
namedinsured:
first last
2
nd
namedinsured:
first last
1
st
namedinsuredoccupation:
2
nd
namedinsuredoccupation:
Forretiredclientsprovidetheoccupationpriortoretirement:
Clientsemail:
Forentitiesotherthananindividual(LLC/Corp/LTD)confirmiftheyengageinbusinessand/orown
businessorcommercialpropertyundertheentityname:
DwellingInformation
DwellingAddress:
Prior/CurrentCarrier:
IfFireman’sFund/AceorChubbprovidereasonapplicantisshopping:
ConstructionType: Frame BrickVeneer Brick FireResistive
(Select) EIFSOnFrame EIFSOnMasonry(EIFSissyntheticstucco)
Ifyesprovidedetails:
Yes NoDwellingunderconstruction:
Numberofmortgages:
Retrofitted: Yes No
Yearretrofitted:
Distancetobrush: WithinBrush 1ft.–499ft 500ft.–999ft.
(Select) 2500 ft.-4999ft. +5000ft.
Roofshape:
Flat
Gable Gambrel
Metal
Hip Mansard
Slate
1000ft.–2499ft.
Shed
Other
Tile WoodShake/Shingle
2211 Plaza Dr.,Suite 100
Rocklin, CA, 95765
Tel: 916.780.7000
Roofcovering: Asphalt Shingle
(Select) Other
CreditsAvailable–checkallthatapply
FireStationWithin5Miles
CentralStationBurglarAlarm
FireHydrantWithin1000Feet
CentralStationFireAlarm
GatedCommunity GatedCommunityPatrolService
ResidentialSprinklerSystem
SuperiorCreditsAvailable–checkallthatapply
WaterFlowAlarm TemperatureMonitor
24‐HourSecurity FullTimeCaretaker
Backup Generator GasLeakDetector
SeismicShutOffValve LightingProtection
WaterLeakDetectionAlarm GatedHouse ManualWildfireSuppressionSystem
AutomaticWildfireSuppressionSystem
CoveragesSection
BuildingValue:
LiabilityLimit:
Deductible: $500 $1,000
$2,500 $5,000 $7,500 $10,000
$25,000 $50,000
Earthquakecoverageoption: Yes No
AdditionalHomeownerassessmentamount:
$50,000providedincluded
Landscapingcoverageadditionalpercentage:
5%ofbuildingvalueincludedPertree/shrubamount$10kincluded
Businesspropertycoverage:
$25,000included
Description
Numberofout‐servants:
Totalsquarefootage:
RaisedFoundation Post&Pier
Slab Stilt
Basement
DwellingInformationCont.
Numberofin‐servants:
Numberofstories:
Typeof foundation:
(FinishedorUnfinished)
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Form 1: HUBB APPLICATION C ClientsInformation 2 2211 (Abram Interstate Insurance)

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Completed 10 July 2021

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