Fillable HO-8 Homeowners Married Single/Separated City Prior Address(if new (Risk Placement Services, Inc.)

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HO-8 Homeowners Married Single/Separated City Prior Address(if new (Risk Placement Services, Inc.)

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  • 47 check-boxes
  • 147 other fields

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File type: PDF

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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 Ven. Floor/Wall Furn. 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 Woodburning Stv > 1000’ > 5 miles Subscription
(1-2 Only) (Submit 5+) $ If other, descrb: Yes No Portable Heater
Size: If other, describe: Name of F.D.
Dwelling Limit Other Structures Limit (10% Included) Contents Limit (40% Included) Loss of Use (10% Included) Personal Liability ($25,000 PL/$500 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 home without permanently installed water, elec. or sewage utility?
2 Previous Losses (past 36 months) …………….....…..+25%
$
4. Is the home attached to, converted from or within 300 ft of a commercial risk?
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)
Dwelling over 30 yrs old +10% Over 50 yrs old + 25%
$
8. Is insured currently unemployed (unless retired or on disability income)?
Dwelling 10 years or newer………………………………….-15%
$
9. Does the applicants own, keep or shelter any Akita, Anatolian Shepherd, Chow,
Supplemental Heat Surcharge…………………………..…..+5%
$
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/Med Pay Increase Prem $
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 home have an open foundation or built on stilts, posts or piers? (Need Photo)
6% Tax (On premium & Fee) $
17. Is home 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 home 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 home 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 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. Has a representative of your agency NOT
personally inspected the risk in last 60 days?
32. Has there been a fire loss in the past three years?
PLEASE SIGN ON REVERSE SIDE
HO-8 Homeowners
HOMEOWNERS HO-8
RATES AVAILABLE AT WWW.RPSINS.COM
Minimum Value: $25,000 Maximum Value: $200,,000
Protective
Devices:
(No cap on discount) Local Burglar y Alarm —non reporting (-3%)
Central
Station Burglar Alarm (requires evidence) (-5%)
Central
Station Fire Alarm (requires evidence) (-5%)
Exclusions Notice:
Flood and earthquake are excluded.
I understand that the following exclusion endorsements will be added to my policy if Liability is purchased
and that bodily injury, property damage or any other loss or expense arising out of an occurrence involving
these listed exclusions will not be covered:
Animal Liability Exclusion
Swimming Pool Liability Exclusion
Firearms Liability Exclusion
Home Day Care Business Exclusion
Punitive or Exemplary Damage Exclusion
Hazardous Substance Exclusion
Trampoline Exclusion
Mold Exclusion
Assault and Battery Exclusion
Sexual Molestation, Corporal Punishment, or
Physical or Mental Abuse Exclusion
Roof exclusion if age of roof is 15 years or older, wood, clay, flat or roll roofing
FRAUD WARNING: Any person who with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or decepti ve s ta te ment is guilty of insurance
fraud.
IMPORTANT NOTICE: Personal Information about you, including information from a credit or inv estigative
report, may be collected from persons other than you in connection with this application for insurance and
subsequent amendments and renewals. Such information as we ll as other personal and privileged
information collected by us or our agents may in certain circumstances be disclosed to a third parties without
your authorizati on. Credit scoring information may be used to determine either your eligibility for insurance
or the premium you will be charged. We may use a third party in connection with the development of your
score. You have the right to review your persona l information in our files and can request a correction of
inaccuracies. A more detailed descripti on of your rights and our practices regarding such information will be
issued with your policy. This notice is given in compliance with the Federal Credit Reporting Act.
I understand that no i nsurance is bound hereunder a nd agree that no insurance shall be in effect until this
application is approved by R PS, Inc. and this may be written with a non-admitte d market. I further agree that
the foregoing statem ents and answers are true and correct and request RPS, Inc. to issue the insurance policy
and an y renewals thereof in reliance thereon.
If the property is located in a rural fire protection district or in an area protected by a rural fire department,
has the applicant paid all fire protection association dues or subscription payments? Yes ___ No ___
X__ ________ __________________________ ________________ Insured's Phone:____________________
Must be signe d (Applicant) Date
X__ ________ __________________________ _________________
Must be signe d (Producer) Date
H8A0716
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HO-8 Homeowners Married SingleSeparated City Prior Address(if new (Risk Placement Services, Inc.)

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Completed 23 November 2020

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