Fillable HOMEOWNER APPLICATION (Standard Lines Services)

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HOMEOWNER APPLICATION (Standard Lines Services)

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CIVIL UNION (if applicable)
MARITAL STATUS * /
CIVIL UNION (if applicable)
HOW LONG HAVE YOU KNOWN THE APPLICANT
FORM NAMEITEM #BOAT #VEH #
FORMS AND ENDORSEMENTS (Attach ACORD 829, Forms and Endorsements Schedule, if more space is required)
LOC # FORM NUMBER EDITION DATE COPYRIGHT OWNER CODE
SUSTAINED
ACTUAL LOSS
OF USE
**
*
Not Applicable in North Carolina
Named Storm Percentage Deductible in North Carolina
HO FORM #:
$ $
$
$
$
% MAX
HURRICANE**
HURRICANE*
$
$
$
$
AMOUNT TYPE
%
%
%
%
PERCENT
$
$
$
$
DEDUCTIBLEAMOUNT
LIMIT
INCLUDED
INCLUDED
INCLUDED
OPTION
REPL COST - CONTENTS
REPL COST - DWELLING
REPL COST - FULL VALUE
COVERAGE
* Includes Dwelling, Other Structures, Personal Property, Loss of Use
TYPE
%
%
%
ANNUAL
NAMED
THEFT
WIND / HAIL
BASE
PREMIUM
%
DEDUCTIBLE PERCENT
MEDICAL PAYMENTS EA PER
PERSONAL LIABILITY EA OCC
LOSS
PERSONAL PROPERTY
COVERAGE LIMIT
BLANKET *
DWELLING
OTHER STRUCTURES
PREMIUM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
COVERAGES / LIMITS OF LIABILITY LOC #:
DATE AGENT LAST INSPECTED PROPERTY
EFFECTIVE DATE
STATUS OF TRANSACTION
RENEW
NEW
POLICY CHANGE
POLICY CHANGE
TIME
AM
PM
Check if same as Applicant
* This field may not be utilized for policyholders applying for residential property insurance in CA.
DATE OF BIRTH SOCIAL SECURITY # MARITAL STATUS * /
DATE OF BIRTH SOCIAL SECURITY #
* This field may not be utilized for policyholders applying for residential property insurance in CA.
YEARS WITH PREVIOUS EMPLOYER:YEARS IN CURRENT OCCUPATION:
YEARS WITH PREVIOUS EMPLOYER:YEARS IN CURRENT OCCUPATION:
YRS WITH CURRENT EMPLOYER:
YRS WITH CURRENT EMPLOYER:
RENTEDOWNEDCheck if same as mailing addressCURRENT RESIDENCE
NAMED INSURED(S)
POLICY NUMBER
EFFECTIVE DATE EXPIRATION DATE
CARRIER
NAIC CODE
PLAN
FACILITY CODE
DATE AT CURRENT RESIDENCE:
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
CO-APPLICANT'S ADDRESSCO-APPLICANT'S NAME (First, Middle, Last)
PRIMARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
CO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)CO-APPLICANT'S EMPLOYER NAME AND ADDRESS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
APPLICANT'S EMPLOYER NAME AND ADDRESS APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed)
YEARS AT PREVIOUS ADDRESS (if less than three years):PREVIOUS ADDRESS
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
APPLICANT'S NAME (First, Middle, Last) APPLICANT'S MAILING ADDRESS
APPLICANT INFORMATION
FAX
(A/C, No):
AGENCY
NAME:
CONTACT
(A/C, No, Ext):
PHONE
SUBCODE:CODE:
AGENCY CUSTOMER ID:
ADDRESS:
E-MAIL
The ACORD name and logo are registered marks of ACORD
Page 1 of 6
© 1981-2016 ACORD CORPORATION. All rights reserved.
HOMEOWNER APPLICATION
DATE (MM/DD/YYYY)
ACORD 80 (2016/11)
YEARS, AT THIS OR ANY LOCATION?
ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURING
THE LAST
$
APPLICANT'S
INITIALS:
IF YES, INDICATE BELOW
Y / N
LOSS HISTORY
(Y / N)
DISPUTE
IN
(C)OMPANY
(A)GENT
LOSS TYPE
$
$
$
ENTERED BY
DESCRIPTION OF LOSSLOSS DATE AMOUNT PAIDCAT #
NO PRIOR COVERAGE
PRIOR POLICY NUMBERPRIOR CARRIER
PRIOR COVERAGE
EXPIRATION DATE
LOCATION SCHEDULE
LOC #
STREET CITY STATE ZIP + 4COUNTY
Page 2 of 6
SEMI-RESISTIVE
WIND CLASS
RESISTIVE
STORM SHUTTERS
BA
HURRICANE RESISTIVE GLASS
WINDSTORM
INDOORS ABOVE GROUND NO MASONRY FLOOR
NONEFUEL STORAGE TANK LOCATION
OUTDOORS ABOVE GROUND
INDOORS ABOVE GROUND MASONRY FLOOR
OUTDOORS BELOW GROUND
FUEL LINE LOCATION
UNDER GROUND
THROUGH FOUNDATION
DIVING BOARD
SLIDE
IN GROUND
ABOVE GROUND
APPROVED FENCE
SWIMMING POOL NONE
RENOVATIONS
WIRING
PLUMBING
HEATING
ROOFING
EXTERIOR PAINT
PART COMP YEAR
CLASS SPECIFIC
RATING
CLOSED
NONEFOUNDATION
OPEN
IN FIRE DISTRICT
IN CITY LIMITS
IN PROT SUBURB
DWELLING LOCATIONRATING CREDITS
NON-SMOKER
LIGHTNING PROTECTION
MANNED SECURITY
OFF PREMISE THEFT EXCL
RESIDENTS
# ROOMS
# APARTMENTS
# FAMILIES
# HOUSEHOLD
# WEEKS RENTED TAX CODE
BLDG CODE GRADE
INSPECTED (Y/N):
FIREPLACES (Enter # or 0 for none)
PRE-FAB
CHIMNEYS
HEARTHS
WOOD STOVE INSERTSQ FT
BREEZEWAY AREA
SQ FT
GARAGE AREA
SQ FT
BASEMENT AREA
SQ FT
TOTAL LIVING AREA
$
REPLACEMENT COST
$
MARKET VALUE
YEAR BUILT
NEIGHBORSROAD
ROOF MATERIAL
ROOF CONDITION
AVERAGEEXCELLENT
GOOD BELOW AVG
ANY KNOWN LEAKS? (Y/N)
BELOW AVGGOOD
EXCELLENT AVERAGE
PLUMBING CONDITION
TOWNHOUSE
ROWHOUSE
APARTMENT
DWELLING
CONDOMINIUM
CO-OP
RESIDENCE TYPE
CONSTRUCTION TYPE
MASONRY VENEER
MASONRY
FRAME
%
OCCUPIED DAILY
VISIBLE TOVISIBLE FROM
SECURITY
EIFSS (on studs)
SHINGLE
STUCCO
ALUMINUM SIDING
VINYL SIDING / PLASTIC
SIDING
CEDAR, WOOD,
EIFSCB (on cinder block)
YEAR EIFS INSTALLED:
%
FIRE DIST CODEFIRE DISTRICT NAME
DISTANCE TO TIDAL WATER
Miles Feet
COURSE OF CONSTRUCTION
RENOVATION
BUILDERS RISK
RECONSTRUCTION
KNOB & TUBE
WIRING
LAST INSPECTED DATECOPPER
ALUMINUM FUSES
ELECTRICAL SYSTEMS
CIRCUIT BREAKERS
NUMBER OF AMPS
SPRING
DOOR LOCK
DEADBOLT PARTIAL
SPRINKLER
FULL
DATE HEATING SYSTEM LAST SERVICED:
SECONDARY HEAT
NONE
PRIMARY HEAT
NONE
LOCAL
DIRECT
CENTRAL
BURG
TEMPSMOKESYSTEM
PROTECTION DEVICE TYPE
Y / N
FIRE EXTINGUISHERPROT CLASS
TERRITORY
# UNITS FIRE DIV
# FIRE DIVISIONS
FIRE STATION
MIFT
FIRE HYDRANT
DISTANCE TO
$
PURCHASE DATEPURCHASE PRICE
VACANT
TENANT
OWNER
UNOCCUPIED
OCCUPANCY
USAGE TYPE
SEASONALPRIMARY
SECONDARY FARM
HOUSEKEEPING CONDITION
AVERAGEEXCELLENT
GOOD BELOW AVG
RATING / UNDERWRITING LOC #:
PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)
FINANCE COMPANY
Y/N
PREMIUM FINANCED ?
MORTGAGEEINSURED
PAYOR
PRE-AUTHORIZED DRAFT/CHECK (PAC)
PAYROLL DEDUCTION
EFT
CREDIT CARD
CHECK
CASH
PAYMENT METHOD
MONTHLY
BI-MONTHLY
QUARTERLY
SEMI-ANNUAL
ANNUAL
FULL PAY
PAYMENT PLAN MAIL POLICY TO:
AGENT
INSURED
AGENCY BILL
DIRECT BILL - ACCT
DIRECT BILL - POLICY
BILLING
BILLING ACCOUNT #:
EST TOTAL PREMIUM:DEPOSIT AMOUNT: $$
AGENCY CUSTOMER ID:
ACORD 80 (2016/11)
(Not applicable in NC)
EQUIP BREAKDOWN
BUSINESS PROP
AWAY FROM HOME
$ DED $$ LIMITINC
LIMIT$
LIMIT$
LIMIT$
LIMIT$
INCREASEINFLATION GUARD % $
$$LOSS ASSESSMENT LIMIT
$ LIMIT
PROP DESC:
CONST MATERIAL:
MINE SUBSIDENCE
$
WORKERS
COMPENSATION -
FULL TIME
INSERVANT
MED PAY (Y/N):
ANY OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION, OWNED, OCCUPIED OR RENTED?5.
4. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS?
3. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS?
1. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
POLICY NUMBER POLICY NUMBERLINE OF BUSINESS LINE OF BUSINESS
2.
HAS ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS?
(Missouri Applicants - Do not answer this question)
GENERAL INFORMATION
Y / NEXPLAIN ALL "YES" RESPONSES
Page 3 of 6
AGENCY CUSTOMER ID:
PREMIUM
TYPE:DESCRIPTION
Y / N:
CODE
TERR:
$
$
$
$
TYPE:DESCRIPTION
Y / N:
CODE
TERR:
$
$
$
$
TYPE:DESCRIPTION
Y / N:
CODE
TERR:
$
$
$
$
TYPE:
DEDUCTIBLE
DESCRIPTION
Y / N:
OPTS LIMITCOVERAGE TYPE
CODE
TERR:
APPL TO
(Applicable only in CA, MT, NV, NH, NJ, NY, ND, OH,
OR, WA, WV and WY)
# OF EMPLOYEES:
(Not applicable in Arkansas)YESWINDSTORM EXCL
LIMIT$
WATERCRAFT
LIABILITY
WATERCRAFT
PHYSICAL DAMAGE
LIMIT$
LIMIT$
INCLUDED
$
WATER BACKUP OF
SEWERS & DRAINS
INCR$AGG$
UNSCHEDULED
JEWELRY,
WATCHES, FURS
LIMIT$
INCLUDED
UNIT-OWNERS
ADDITIONS &
ALTERATIONS
SPECIAL COVERAGE
INCLUDED
SINK HOLE
COLLAPSE
LIMIT$
INCLUDED
REFRIGERATED
FOOD PRODUCTS
$
LIMIT$
PREMIUMCOVERAGE TYPE COVERAGE INFORMATION
$
$
$
$
$
$
$
$
$
$
$
$
INCRTOTAL
INCRTOTAL
INCRTOTAL
INCRTOTAL
INCR
$
$
$
$
$
$
$
$
$
$$ LIMIT
$
$
$
$
$
$
$
$
$
MED PAY (Y/N):
$
PREMIUM
INCLUDED
PLANTS, SHRUBS &
TREES
STRUCTURE DESC:
LIMIT
OTHER
STRUCTURES -
INDIVIDUAL STRUC
BUS/STRUCT DESC:
STRUCT TYPE:
MED PAY (Y/N) :
TERR:OT. STRUCTS$
INCR CONT NOT REQ
REQ INCR CONTENTS
OFFICE,
PROFESSIONAL
PRIVATE SCHOOL,
STUDIO -
RESIDENCE
PREMISES
LIMIT$
GOLF CARTS -
PHYSICAL DAMAGE
# PREMISES:
MEDICAL PAYMENTS (Y/N):
INCIDENTAL
FARMING PERS LIAB
INCLUDEDIDENTITY FRAUD EXP
DESCRIPTION:
# GOLF CARTS:INCLUDED
$
GOLF CARTS -
LIABILITY
LIABILITY
$
$
EXCL PROP DAMAGE
EXCL LIABILITY PROPERTY
FUNGUS AND MOLD
CONTENTS$BLDGFLOOD $
$
$
DEBRIS REMOVAL INCLUDED
$
FIRE DEPARTMENT
SERVICE CHARGE
INCLUDED
$
# OF EMPLOYEES:LIMIT$EMPLOYERS LIAB
$
SILVERWARE
$
$
$
$
$
$
GUNS
MONEY
SECURITIES
ELECTRONIC APP
IN AND OUT OF
VEHICLE
TOTAL
TOTAL
$
INCR
$
$
INCR COV C
SPECIAL LIAB LIMIT
ELECTRONIC
APP IN VEHICLE
%
% DED
$ DED
MAS VENEER:
RETROFIT TYPE:
TERR:
EARTHQUAKE
$
LIMIT
LIMITINCLUDED
INCLUDED
$
$
BUS PROP AT HOME
$
$
AGG
INCLUDED % REBUILD
$ INCR$
BUILDING ORD OR
LAW COVERAGE
$
INCLUDED
COLLAPSE DUE TO
HYDRO-STATIC
PRESSURE
INCLUDED
THEFT BLDG
MATERIALS
BUILDERS RISK
OPTIONAL COVERAGES - ENDORSEMENTS LOC #:
# PREMISES:
COVERAGE TYPE COVERAGE INFORMATION
ADDITIONAL
PREMISES
LIABILITY
EXTENSION
ADDITIONAL
RESIDENCE
RENTED TO
OTHERS
LOC #: TERR:
LOC #: TERR:
LOC #:
TERR:
LOC #:
TERR:
# FAMILIES:
# FAMILIES:MED PAY (Y/N):
$
$
$
$ LIMIT
ACORD 80 (2016/11)
% Y / NEXCLINCLY / Nsq. ft.sq. ft.%
$
COST OF PROJECTOCC DURING RENMATERIALS UNATTACHEDSTRUC CHANGESCOMP DATESTART DATE ADD LEVELADDITIONEXTINT
Page 4 of 6
IS THE BUILDING ENTRANCE LOCKED?3.
PHONE (A/C,No):MANAGER'S NAME:
IS THERE A SECURITY ATTENDANT?
IS THERE A MANAGER ON THE PREMISES?
2.
1.
GENERAL INFORMATION - RENTERS AND CONDOS ONLY LOC #:
EXPLAIN ALL "NO" RESPONSES Y / N
OWNER'S NAME:
IS THE NAMED INSURED THE OWNER OF THE PROPERTY? (If "NO", provide the name of the owner)
16.
IS THERE AN APPROVED CARBON MONOXIDE ALARM IN OPERATING CONDITION WITHIN THE MANDATED NUMBER OF FEET OF EVERY
ROOM USED FOR SLEEPING PURPOSES? (IL - 15 FT) (no explanation needed)
15.
NAME OF COMMUNITY:
13.
IS THE RESIDENCE IN A GATED COMMUNITY?
CLEANUP/SUBLIMIT:LIMIT:INSURANCE COMPANY:
12.
IF A FUEL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK?
(If "YES", provide the name of the insurance company, the applicable limit and the cleanup sublimit)
14.
IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR?
11. ANY LEAD PAINT?
a. IF "YES", IS THERE A SAFETY NET? (no explanation needed)
ORIGINAL OCCUPANCY:
WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED?10.
IS THERE A TRAMPOLINE ON THE PREMISES?9.
LAND USED FOR:# OF ACRES:IS PROPERTY SITUATED ON MORE THAN ONE ACRE?5.
6.
ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS?
IS THE DWELLING / HOME FOR SALE? (no explanation required)7.
8. IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY? (If "YES", describe in detail)
BREEDANIMAL TYPEBITE HISTORY (Y/N)
DESCRIPTION:
BITE HISTORY (Y/N)BREEDANIMAL TYPE
HOME OFFICE/BUSINESS
DAY CARE # OF CHILDREN:TELECOMMUTERFARMING
DESCRIPTION:# PART TIME:# FULL TIME:
4. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES?
Y / NEXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISE
GENERAL INFORMATION - RESIDENTIAL LOC #:
1.
ANY BUSINESS CONDUCTED ON PREMISES?
2. ANY RESIDENCE EMPLOYEES?
3. ANY FLOODING, BRUSH, FOREST FIRE OR LANDSLIDE HAZARD?
HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?6.
GENERAL INFORMATION (continued)
8.
DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE
OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?
(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)
DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGIES, MINI BIKES, ATVS, etc), NOT SCHEDULED ON THIS POLICY?7.
YEAR MAKE MODEL BODY TYPE
Y / NEXPLAIN ALL "YES" RESPONSES
AGENCY CUSTOMER ID:
ACORD 80 (2016/11)
APPLICABLE IN ARIZONA: Binders are effective for no more than 90 days. APPLICABLE IN COLORADO: The insurer has thirty (30)
business days, commencing from the effective date of coverage, to evaluate the issuance of the insurance policy. APPLICABLE IN
MARYLAND: The insurer has 45 business days, commencing from the effective date of coverage, to confirm eligibility for coverage under
the insurance policy. APPLICABLE IN MICHIGAN: The policy may be cancelled at any time at the request of the insured. APPLICABLE IN
MONTANA: No binder shall be valid beyond the issuance of the policy with respect to which it was given or beyond 90 days from its
effective date, whichever period is the shorter. If the policy has not been issued, a binder may be extended or renewed beyond such 90
days with the written approval of the insurer. APPLICABLE IN OKLAHOMA: All policies shall expire at 12:01 AM standard time on the
expiration date stated in the policy. APPLICABLE IN OREGON: Binders are effective for no more than ninety (90) days. A binder extension
or renewal beyond such 90 days would require the written approval by the Director of the Department of Consumer and Business Services.
THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY
CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY,
THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE
COMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.
INSURANCE BINDER
EFFECTIVE DATE EXPIRATION DATE
TIME
THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS
INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN
CURRENT USE BY THE COMPANY.
12:01 AM
NOON
COVERAGE IS NOT BOUND
IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:
THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY
WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE.
MA, MN, ND, NY, OR, VA or WV. Specific ACORD 38s are available for applicants in these states.)
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE
COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT
AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION
COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR
AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP 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 MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND
REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE
CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.
THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE
RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED
DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS,
(Applicant's Initials):
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, please contact your agent
or broker for your state's requirements.)
BINDER / NOTICE OF INFORMATION PRACTICES
SEND BILL
REFERENCE / LOAN #:
ITEM:
CLASS:
ITEM DESCRIPTION
INTEREST IN ITEM NUMBER
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
EVIDENCE:RANK:
CERTIFICATE
INTEREST NAME AND ADDRESS
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGEE
LIENHOLDER
TRUSTEE
ADDITIONAL INTEREST (Attach ACORD 45, Additional Interest Schedule, if more space is required)
SEND BILL
REFERENCE / LOAN #:
ITEM:
CLASS:
ITEM DESCRIPTION
INTEREST IN ITEM NUMBER
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
EVIDENCE:RANK:
CERTIFICATE
INTEREST NAME AND ADDRESS
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGEE
LIENHOLDER
TRUSTEE
WATERCRAFT SECTION
PERS UMBRELLA APPLICATION SECTION
EARTHQUAKE APPLICATION PERSONAL INLAND MARINE SECTION
MOBILE HOME SUPPLEMENT
FLOOD EXCLUSION NOTICE
LEAD FREE PAINT CERTIFICATION
REPLACEMENT COST ESTIMATE
PHOTOGRAPH
PROTECTION DEVICE CERTIFICATE
SOLID FUEL SUPPLEMENT
STATE SUPPLEMENT(S) (If applicable)
RESIDENCE BASED BUSINESS SUPP WINDSTORM LOSS MITIGATION
REMARKS / ATTACHMENTS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
AGENCY CUSTOMER ID:
Page 5 of 6
LENDER'S LOSS PAYABLE
LENDER'S LOSS PAYABLE
ACORD 80 (2016/11)
FRAUD STATEMENTS / SIGNATURE
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE
INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS
INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING.
AGENCY CUSTOMER ID:
Page 6 of 6ACORD 80 (2016/11)
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application
containing a false statement as to any material fact may be violating state law.
Applicable in OR
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Applicable in NJ
Any person who knowingly and with intent to defraud any insurance 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in
NY Only.
Applicable in KY, NY, OH and PA
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or
presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents
more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each
violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus
established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
Applicable in PR
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in ME, TN, VA and WA
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief
that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic
impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the
issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit
pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false
information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act.
Applicable in KS
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in FL and OK
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose
of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
Applicable in CO
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or
willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison. *Applies in MD Only.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
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HOMEOWNER APPLICATION (Standard Lines Services)

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Completed 20 April 2022

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