Fillable XPRESS INDICATION FORM

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XPRESS INDICATION FORM

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  • 55 check-boxes
  • 40 other fields

Country of origin: OTHERS
File type: PDF

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Year Built:
___________
Square Feet:
___________
# of Stories:
___________
Fire/Burglary Protection
Monitored Burglar Alarm
Monitored Fire Alarm
Monitored Combo Alarm
Distance from Hydrant:
________________
Distance from Fire Dept.:
_______________
Other Water Source:
___________________
phone 888-376-9633 ext. 2223 | fax 866 -206-2343 | plsubmissions@appund.com
Insured Name:
Date of Birth:
Occupation:
Spouse Name:
Spouse Date of Birth:
Occupation:
Phone Number:
Agency Name:
Agent Name:
Phone Number:
Email Addess:
Current Insurance Carrier:
(If lapsed/canceled/non-renewed enter last date of coverage)
Effective Date Requested:
Dwelling Limit:
Personal Property:
Liability:
Medical Payments:
Other Structures:
Loss of Use:
AOP Deductible:
Hurricane Deductible:
HOMEOWNERS COVERAGE INFORMATION
Location Address:
Mailing Address:
PROPERTY INFORMATION
Construction Type:
Frame
Masonry
Masonry Veneer
Reinforced Masonry
Fire Resistive
Other
(please list)
__________________________
ADDITIONAL UNDERWRITING INFORMATION
Swimming Pool:
Yes No
Any Bankruptcy:
Yes No
Animal on Premises:
Yes No
If YES , what type/ breed? ___________________________________
Is this a New Home
Yes No
Closing?
HO3
HO4
HO5
HO6
HO8
DP1
DP3
Primary
Secondary
Secondary/Rental
Short-Term Rental
Annual Rental
Builders Risk
Vacant
MITIGATION INFORMATION
Roof Type:
Gable
Hip
Flat
UPDATE INFORMATION
Roof Last Replaced:
Partial
Complete
Year: ___________
Electric Last Replaced:
Partial
Complete
Year: ___________
Plumbing Last Replaced:
Partial
Complete
Year: ___________
Heating Last Replaced:
Partial
Complete
Year: ___________
Claims Information (list all details for last 5 years)
Comments to Underwriter
(target price, situation on risk, any special coverage or endorsements needs)
Roof Covering:
Asphalt Shingle
Architectural Shingle
Clay Tile
Cement Tile
Metal
Built-up Tar & Gravel
Roof to Wall Connections:
Toenails
Clips
Straps
Hurricane Class A Shutters/Impact Glass:
Yes No
Distance to Coast
(miles to coastline or waterways)
:
_____________
Florida Building Code
(Florida Properties only)
:
Yes No
XPRESS INDICATION FORM
Target Premium:
SUBMIT FORM
Protection Class:
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XPRESS INDICATION FORM

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Completed 15 December 2021

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