PRIOR / CURRENT COVERAGE:
Prior carrier / Current carrier:_________________________________________________________________
Policy Number:___________________________________ Expiration Date:__________________
If lapse or no prior coverage, provide explanation:__________________________________________________
_____________________________________________________________________________________________
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
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
ADDITIONAL INTEREST:
# Mortgagee/Additional Interest Information Loan Number
______________________________________________________________________________________________________
______________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
**NOTICE TO PRODUCER**
THE INSURED APPLICANT MUST READ AND INITIAL THE DISCLOSURES BELOW
****WARNING COVERAGE DISCLOSURE****
Wind & Hurricane: The policy you are applying for EXCLUDES Wind & Hurricane Coverage.
Policy Cancellation: NO FLAT CANCELLATIONS – Policy is subject to a 25% minimum Earned Premium.
Limited Personal Liability Coverage: If you are applying to purchase Personal Liability Insurance under the policy, please note that the policy provides
limited Personal liability coverage only and it excludes certain causes of loss. We encourage you to review the exclusions, conditions and provisions of the
liability coverage before purchasing this policy.
Other Disclosures: Any person who knowingly and with intent to injure, defraud, or deceive any insurer and files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Insured’s Signature:___________________________________________________________ Date:_______________________
Producer’s Signature:__________________________________________________________ Date:_______________________
Printed or Typed Name of Producing Agent:_________________________________________________________________________
Producing Agent’s License #:_______________________________
****WARNING COVERAGE DISCLOSURE****
THE INSURED APPLICANT MUST READ AND INITIAL THE DISCLOSURES BELOW
Wind & Hurricane: The policy you are applying for EXCLUDES Wind & Hurricane Coverage.
Policy Cancellation: NO FLAT CANCELLATIONS - Policy is subject to a 25% minimum Earned Premium.
Limited Personal Liability Coverage: If you are applying to purchase Personal Liability Insurance under
the policy, please note that the policy provides limited Personal liability coverage only and it excludes
certain causes of loss. We encourage you to review the exclusions, conditions and provisions of the
liability coverage before purchasing this policy.
Other Disclosures: Any person who knowingly and with intent to injure, defraud, or deceive any insurer
and files a statement of claim or an application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
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