Homeowners Application

Policy Type (*)
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Effective Date (*)
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Insured Information
Name: (*)
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County: (*)
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Street: (*)
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City, State Zip: (*)
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Phone Number:
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Physical street address, if different:
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City, State Zip:
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Mortgagee Information
1st Mortgage:
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Loan No.:
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Lendor No.:
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Address:
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City, State Zip
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2nd Mortgage:
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Loan No.:
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Lendor No.:
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Address:
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City, State Zip:
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Payor:
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Year Purchased: (*)
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Coverages
Dwelling: (*)
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Other Structures:
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Personal Property:
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Loss of Use:
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Personal Liability:
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Medical Payments:
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AOP Deductible:
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Wind and Hail Deductible:
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Exclude Wind and Hail?
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Named Storm Exclusion:
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Replacement Cost on Contents?
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Agent Information
Agency Name: (*)
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Address: (*)
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City, State Zip: (*)
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Contact Name: (*)
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Email Address: (*)
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Home Description
Year Built:
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Construction
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Square Feet: (*)
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Protection Class:
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Number of Stories: (*)
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Number of Familes: (*)
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Year Wiring Updated:
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Year Heating Updated:
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Year Plumbing Updated:
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Age of Roof: (*)
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Type of Roof: (*)
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Roof Material: (*)
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Distance to Fire Hydrant:
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Distance to Fire Department: (*)
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Home Protection: (*)
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Occupancy: (*)
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Loss History
Losses: Include Date, Amount and Description
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Additional Questions
Is dwelling located on 10 or more acres of land? (*)
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Does the applicant have any roomer or boarders? (*)
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Are there any other structures on the premises? (*)
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Has coverage been declined, cancelled or non-renewed in the past 3 years? (If yes, please list reason in the comments section.) (*)
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Has the applicant had any bankruptcies, forclosures or repossessions in the past 4 years? (If yes, please list reason in the comments section.) (*)
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Is there a swimming pool, spa or jacuzzi on premises? (*)
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If you answered yes to the previous question, is it fenced or enclosed?
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Any existing sinkhole exposure on residence? (*)
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Is roof worn down, more than 25 years old if tile, or more than 15 years old if shingle? (*)
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Is primary source of heat for dwelling space heaters, fireplace, wood burning stove or portible kerosene? (if yes, risk is unacceptable) (*)
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Is there a fuse box, aluminum wiring, or knob and tube wiring? (if yes, risk is unacceptable) (*)
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Is the dwelling currently undergoing any building or renovation work? (*)
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Is there any business that occurs on the insured residence? (*)
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Is unit primary residence of the insured? (*)
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Any additional comments on this risk?
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Please enter the email address where you would like to receive your confirmation: (*)
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