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 Veneer Floor/Wall Furnace 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 Wood burning Stove > 1000’ > 5 miles Subscription
(1-2 Only) (Submit 5+) $ If other, describe: Yes No Portable Heater
Size: If other, describe: Name of F.D.
Dwelling Limit Other Structures Limit (10% Included) Contents Limit (50% Included) Loss of Use (20% Included) Personal Liability ($100,000 PL/$1,000 Med Pay Included)
$ $ $ $ $ PL Limit $ Med Pay Limit
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 (past 36 months)………………………….+10%
$
3. Is the dwelling without permanently installed water, elec. or sewage utility?
2 Previous Losses (past 36 months) …………….....…..+25%
$
4. Any existing non-structural damage (inside or out)?
Bankruptcy (Under 3 years)…………..…….………..….…+35%
$
5. Has the applicant filed bankruptcy in the past 36 months?
Loss Free/Prior Insurance Transfer (furnish dec)……......–10%
$
6. Is there a swimming pool or trampoline? (Trampoline liability excluded)
Protective Devices (listed on back)…………………….…____%
$
7. Was the home built prior to 1960? (Requires dwelling update form)
Supplemental Heat Surcharge…………………………..…..+5%
$
8. Is insured currently unemployed (unless retired or on disability income)?
New Home Discount 10 years or less ………………..…..-15%
$
9. Does the applicants own, keep or shelter any Akita, Anatolian Shepherd, Chow,
Doberman, Pit Bull, Presa Canario, Rottweiler, Wolf or Wolf hybrid, any mix of these
Other Structures Increase Premium $
breeds with any other breed, whether listed or not?
Contents Increase Premium $
10. Has applicant been 30 days past due on mortgage payments in the last 12 months?
OPTIONAL Loss of Use Increase Premium $
11 .Is dwelling within 1500 feet of water or located in special flood hazard area?
COVERAGES Liability Increase $
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 damage (inside or out)?
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 home have fuses or knob and tube wiring?
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) or tenant occupied?
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 the risk a mobile home, row home, earth home, dome home, or straw built?
(Use Separate Sheet if necessary, if none – so state)
27. Has applicant been convicted of arson or insurance fraud?
Cause Amount
28. Any vicious or exotic animals on premises?
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?
32. Has your agency NOT personally inspected the risk in last 60 days?
33. Has there been a fire loss in the past three years?
PLEASE SIGN ON REVERSE SIDE
HO-3 Homeowners
