Fillable Lexington Insurance Company Personal Inland Marine Application (RT Specialty)

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Lexington Insurance Company Personal Inland Marine Application (RT Specialty)

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The Lexington Insurance Company Personal Inland Marine Application (RT Specialty) form is 3 pages long and contains:

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  • 34 check-boxes
  • 192 other fields

Country of origin: US
File type: PDF

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Lex PAF App 11 12 Page 1 of 3
Lexington Insurance Company
Personal Inland Marine Application
Applicant
Occupation
Employer
Date of Birth
Mailing Address
City/State/Zip
County
Insured Location
City/ State /Zip
County
Producer Name
Email Address
Surplus Lines License #
Prior Carrier
Expiration Date
Expiring Premium
Effective Date of this policy
Within the last 5 years has the applicant had a: Foreclosure? Bankruptcy? Repossession?
If prior carrier non-renewed, why? (MISSOURI APPLICANTS NEED NOT REPLY)
If the insured has not carried insurance within the last 12 months please explain why?
Has Schedule coverage ever been cancelled or denied?
If yes, please explain why. (MISSOURI APPLICANTS NEED NOT REPLY)
Y N
Additional Insured
Address/City/State/Zip
Please indicate the total amount of coverage requested by category:
#
Property
Limit Requested
#
Property
Limit Requested
#
Property
Limit Requested
1
Jewelry
4
Musical Instruments
10
Fine Arts
Men’s
Private Use
Limited Brkg
Women’s
Professional Use
Full Brkg
In –Vault
5
Silverware
11
Guns/Firearms
2
Furs
6
Golfer’s Equipment
12
Bicycles
3
Cameras
7
Golf Carts
13
Miscellaneous
Private Use
8
Stamps
Professional Use
9
Rare Coins
DWELLING INFORMATION
County
Territory #
Protection Class
(if PC 9 & 10 please use supplemental application)
Construction Type: Frame/Stucco/EIFS Brick/Stone/Masonry Superior
Occupancy Type: Primary Secondary
Year Built
Type of Roof: Comp Metal Shake Tile Slate Other
How long has the insured lived in the home?
Foundation Type: Concrete Slab Concrete Block Pilings/Stilts
Is the dwelling vacant > 30 days?
Is dwelling within 1 mile of the seacoast? Y N
If yes, are there storm shutters? Y N
Protective Devices: Fire Alarm Burglar Alarm Motion Detector Smoke Detector Deadbolts Interior Sprinklers
Dwelling Insurance Carrier
Coverage A limit $
1) Have you been told or are you otherwise aware of the use of Chinese Drywall in the dwelling or any other structure
on the premises? Y N
2) Is there any odor of sulfur in the dwelling, any corrosion of any personal property, wiring, or any heating, ventilation or air
conditioning system? Y N
Submit Application
Lex PAF App 11 12 Page 2 of 3
UNDERWRITING INFORMATION
YES
NO
YES
NO
Is there a safe in the residence? Specify Below
Wall Safe Freestanding Under floor
Is dwelling located in a gated community?
Is the property protected by any other means?
Description
Is the community patrolled?
Is dwelling used professionally / commercially?
If the residence is not a primary, is there a caretaker?
Dwelling / Unit within Downtown City Limits?
Are any items loaned to museums or on exhibit?
Is any professional equipment stored off premises?
Any jewelry with unset, damaged stones?
Any paid / non-paid caretakers / housekeepers?
Any in–vault items removed from the vault?
Number of times?
Travel for more than 30 days at a time with items?
Have you or any member of your household been
convicted of arson, dishonesty or theft?
If apartment or condominium is the unit located
on the first floor?
Animals on the Premises?
Type:
Are items kept away from the listed premises?
Are any items kept outside the USA for more than
one month?
Has any of the property been previously damaged?
If yes, please describe in the loss history section
of the application.
Are any items worn by anyone besides a household
member?
Any articles at a student’s dorm or apartment?
Is business conducted on premises?
Is there a wood stove on premises?
Has anyone with financial interest in the property been
convicted of arson, fraud, or other crime related to a loss
on the property now or within the last 5 years?
Is the home undergoing any self construction or
remodeling?
If yes, please explain.
Have you had any previous loss, theft or
damage to any scheduled item either claimed or unclaimed?
If yes, please explain below.
Have you attempted to sell within the past year or
intend to sell any of the scheduled items?
If yes, please explain.
cA
LOSS HISTORY- MUST BE FILLED OUT COMPLETELY
Date
Type of Loss
Cause
Amount
Preventative Measures
Additional Information/ Comments
NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND
MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY
OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO COLORADO APPLICANTS: 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 AUTHORITIES.
Lex PAF App 11 12 Page 3 of 3
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER
FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN
INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
NOTICE TO FLORIDA APPLICANTS: 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 IN
THE THIRD DEGREE.
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE 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.
NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR
BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO
FINES AND CONFINEMENT IN PRISON.
NOTICE TO MAINE APPLICANTS: 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 OR A DENIAL OF
INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS
GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN
INSURER IS GUILTY OF A CRIME.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN
INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF
THE CLAIM FOR EACH SUCH VIOLATION.
NOTICE TO OHIO APPLICANTS: 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 DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1).
NOTICE TO OREGON APPLICANTS: 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 ACT, WHICH MAY BE
A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO PENNSYLVANIA APPLICANTS: 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.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY
BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
NOTICE: RISK SPECIALISTS COMPANIES INSURANCE AGENCY, INC., THE SURPLUS LINES INSURANCE BROKER THAT IS SUBMITTING THIS
APPLICATION TO LEXINGTON INSURANCE COMPANY (“LEXINGTON”), MAY CHARGE YOU A FEE FOR PLACEMENT OF INSURANCE IN THE EVENT
THAT THE INSURANCE YOU ARE REQUESTING IS ACCEPTED BY LEXINGTON. IF LEXINGTON ACCEPTS SUCH INSURANCE, THIS FEE WILL BE
STATED IN THE QUOTE, BINDER, AND POLICY. YOUR ACCEPTANCE OF ANY SUCH QUOTE WILL CONSTITUTE YOUR AGREEMENT TO PAY SUCH
FEE.
PRODUCER’S SIGNATURE: _____________________________________________DATE:____________________________________________
Applicant’s Statement: The undersigned applicant declares that if the information supplied on this application changes between the date
of this application and the time when the insurance policy is issued, the applicant will immediately notify the insurer of such changes, and
the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance.
The undersigned applicant further declares that I have read and understand the entire application including the applicable fraud warning, if
any, and that the statements set forth in this application are true and complete.
APPLICANT’S SIGNATURE: ___________________________________________DATE: ____________________________________________
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Lexington Insurance Company Personal Inland Marine Application (RT Specialty)

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Completed 31 July 2020

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