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Section Name |
Field Name |
Field and/or Section Description |
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Title ACORD 80 (2008/01) |
Homeowner Application |
The underwriting process for any personal lines policy begins with the submission of a completed application. These instructions will assist in the completion of ACORD 80, Homeowner Application. The ACORD Personal Inland Marine Application (ACORD 81) should be used for scheduling personal property which is being submitted as part of the Homeowner Application. See also newly released ACORD 88, Personal Insurance Application, Applicant Information Section and ACORD 89, Residential Section. IMPORTANT NOTICE ACORD 80, Homeowners Application, will be withdrawn in September of 2008. ACORD forms participants should plan to implement ACORD 88, Personal Insurance Application, Applicant Information Section and ACORD 89, Residential Section as soon as possible. |
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IDENTIFICATION SECTION |
Date |
Month/day/year (MM/DD/YYYY) on which the form is completed. |
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IDENTIFICATION SECTION |
Agency |
Producer's name and address. |
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IDENTIFICATION SECTION |
Contact Name |
Enter the name individual at the agency that is the primary contact. |
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IDENTIFICATION SECTION |
Phone No. |
Producer's telephone number. (Include area code and extension if applicable) |
|
IDENTIFICATION SECTION |
Fax No. |
Producer's fax number. (Include area code) |
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IDENTIFICATION SECTION |
E-Mail Address |
Agency's e-mail address. |
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IDENTIFICATION SECTION |
Code |
Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. |
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IDENTIFICATION SECTION |
Subcode |
If the agency or brokerage uses a sub-code identification system with the company, enter the appropriate code. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Customer's identification number assigned by the agency or brokerage. |
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IDENTIFICATION SECTION |
Named Insured |
Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail. Address should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.: 150 Central Ave N); City; County; State; ZIP code If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal description if required by the mortgage holder. |
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IDENTIFICATION SECTION |
Carrier |
Enter the name of the insurance company that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. |
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IDENTIFICATION SECTION |
NAIC Code |
The identification code assigned to the company by the NAIC. |
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IDENTIFICATION SECTION |
Policy # |
The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time. |
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IDENTIFICATION SECTION |
Date at Curr Res |
Indicate the date applicant moved into current residence. |
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IDENTIFICATION SECTION |
Plan |
If applicable, indicate the type of plan or policy program (example: Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company. |
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IDENTIFICATION SECTION |
Facility Code |
Enter the identification code used by assigned risk plans, FAIR plans and other associations (only applicable in a few states). When using this field, also enter the name of the facility in the PLAN field. |
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IDENTIFICATION SECTION |
Effective Date |
Enter the date (MM/DD/YYYY) on which the terms and conditions of the policy will commence. |
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IDENTIFICATION SECTION |
Expiration Date |
Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless renewed. |
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IDENTIFICATION SECTION |
Home Phone # |
Home telephone number at which the applicant may be reached. Include area code. |
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IDENTIFICATION SECTION |
Business Phone # |
Business telephone number at which the applicant may be reached. Include area code and extension, if applicable. |
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APPLICANT INFORMATION |
Previous Address |
Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address. |
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APPLICANT INFORMATION |
Location of Property if Different From Above |
Enter the physical address of the property to be insured only if it is different from the mailing address listed above. |
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APPLICANT INFORMATION |
Applicant's Occupation |
Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed. |
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APPLICANT INFORMATION |
Applicant's Employer Name and Address |
Name and address of the organization that employs the applicant(s) named in the identification section. |
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APPLICANT INFORMATION |
Yrs in Curr. Occ. |
Number of years in current occupation or business. |
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APPLICANT INFORMATION |
Yrs w/Curr. Empl. |
Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section. |
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APPLICANT INFORMATION |
Yrs w/Prior Empl. |
Number of years with the prior employer. |
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APPLICANT INFORMATION |
Mar Stat |
Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed C. . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic Partner (unmarried) V . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Union U . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unkown O . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other |
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APPLICANT INFORMATION |
Date of Birth |
Birth date of each named applicant (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.) |
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APPLICANT INFORMATION |
Social Security # |
Social security number for each named applicant. |
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APPLICANT INFORMATION |
Co-Applicant's Occupation |
Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed. |
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APPLICANT INFORMATION |
Co-Applicant's Employer Name and Address |
Name and address of the organization that employs the applicant(s) named in the identification section. |
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APPLICANT INFORMATION |
Yrs in Curr. Occ. |
Number of years in current occupation or business. |
|
APPLICANT INFORMATION |
Yrs w/Curr. Empl. |
Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section. |
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APPLICANT INFORMATION |
Yrs w/Prior Empl. |
Number of years with the prior employer. |
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APPLICANT INFORMATION |
Mar Stat |
Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed C. . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic Partner (unmarried) V . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Union U . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unkown O . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other |
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APPLICANT INFORMATION |
Date of Birth |
Birth date of each named applicant (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.) |
|
APPLICANT INFORMATION |
Social Security # |
Social security number for each named applicant. |
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APPLICANT INFORMATION |
How long have you known the applicant? |
Indicate how long the applicant is known to the agent. |
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APPLICANT INFORMATION |
Date Agent last inspected Property. |
Indicate the date of the last property inspection. |
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COVERAGES/LIMITS OF LIABILITY |
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Enter the anticipated dollar limit and premium charge for each applicable coverage. List any optional endorsement(s), corresponding limit(s) and any endorsement information that is to be included in this policy. |
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COVERAGES/LIMITS OF LIABILITY |
HO Form |
Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are: 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents 4A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Tenants 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Condominium 6A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Condominium. |
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PREMIUM |
Premium |
Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit and balance, if any owed. |
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DED |
Deductibles |
Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.) |
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ENDORSEMENTS |
Endorsements |
See page 4 of the application. |
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PAYMENT PLAN |
Payment Plan |
Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment. Blank check boxes are provided for other options. |
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RATING/UNDERWRITING |
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Provide the information below for each dwelling. |
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RATING/UNDERWRITING |
Construction Type |
Check the primary type of building material used to construct the dwelling. Also indicate the siding type. Examples of siding types not shown on the form include stucco, log, asbestos, and synthetic stucco/ EIFS (Exterior Insulation Finishing System). Synthetic stucco is an artificial stucco used for exterior insulation and finishing systems (EIFS). It is created by affixing a styrofoam panel to the wall sheathing. The styrofoam is covered with reinforcing mesh, followed by a base coat and a finish coat. Both the base coat and the finish coats include an acrylic resin. The resin is water soluble in its liquid form, but once applied and dried, it becomes waterproof. Typically, this type of surface is less than a half-inch thick. It is relatively light, and sounds hollow when tapped. Real stucco is relatively heavy and feels and sounds solid when tapped. It is a much harder material than synthetic stucco, and is more resistant to injury by a blow or impact. NOTE: you must advise the insurer if synthetic stucco (EIFS) siding is present. |
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RATING/UNDERWRITING |
Yr Built |
Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alternations in the Remarks section. Also complete the Renovation Update section. |
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RATING/UNDERWRITING |
Sq Ft |
Dwelling's total square footage of living area. |
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RATING/UNDERWRITING |
# Rooms |
Total number of rooms in a residence, including full and half rooms (bath). |
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RATING/UNDERWRITING |
# Apts |
Complete only for tenant or condominium policies. Enter the number of apartments (residences) in the building. |
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RATING/UNDERWRITING |
Market Value |
Estimated total dollar amount for which the dwelling could be sold under current market conditions. |
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RATING/UNDERWRITING |
Replacement Cost |
Estimated total dollar amount required to rebuild the dwelling without depreciation. |
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RATING/UNDERWRITING |
Structure Type |
Indicate the residence type. The full meaning of each abbreviation is: * DWELLING - Dwelling, intended to be a free standing, up to 4 family building. * APART - Apartment. * CONDO - Condominium. * TOWNHOUSE - Townhouse. * ROWHOUSE - Rowhouse. * CO-OP - Co-operative. |
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RATING/UNDERWRITING |
Usage Type |
Applicant's use for the dwelling within the guidelines listed. COC refers to dwellings in the "course of construction". If so, provide estimated date of completion. |
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RATING/UNDERWRITING |
# Families |
Number of separate family units in the dwelling. Not required for HO-4 or HO-6. |
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RATING/UNDERWRITING |
# Hsehold Res |
Number of residents in the household. |
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RATING/UNDERWRITING |
Purchase Date/Price |
Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format. |
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RATING/UNDERWRITING |
# of Fire Div/ # of Units in Fire Div |
Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved firewalls. |
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RATING/UNDERWRITING |
Terr Code |
Dwelling location based on individual state bureau or company homeowners manual pages. |
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RATING/UNDERWRITING |
Prem Group |
Premium group codes are found in individual state homeowner manuals. Some companies may require this data, others will generate it. Premium Group is a combination of Protection Class, Territory Code and Construction Type Code used to determine the applicable rate based upon the dwelling's location, construction and fire protection code. |
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RATING/UNDERWRITING |
Protect Class |
Dwelling's four-character fire protection grade found in individual state homeowners manuals. |
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RATING/UNDERWRITING |
Distance to Hydrant |
Distance in feet from the nearest hydrant to support the protection class used. |
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RATING/UNDERWRITING |
Distance to Fire Station |
Distance in miles from the nearest fire station to support the protection class used. |
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RATING/UNDERWRITING |
Fire/EC Rate |
Complete if residence is specifically rated. Refer to the company rate manual. |
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RATING/UNDERWRITING |
Fire District/Code Number |
Residence's fire district name and corresponding code number, which can be found in the individual state manual pages. |
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RATING/UNDERWRITING |
Protection Device Type |
For temperature, smoke and burglar alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies. |
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RATING/UNDERWRITING |
Heat Type |
Type of heating device for the residence. If there is more than one type, indicate the primary and secondary types. Use the Remarks section if necessary. Some possible types are: * Electric - Permanent/Portable * Liquid Propane - Permanent/Portable * Natural Gas * Kerosene - Permanent/Portable * Coal -Professionally/Non-Professionally Installed * Oil * Wood * Solar * Other - Explain the heating system in Remarks |
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RATING/UNDERWRITING |
Housekeeping Condition |
Enter the evaluation of the interior upkeep of the dwelling. |
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RATING/UNDERWRITING |
Renovation Type |
If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year. |
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RATING/UNDERWRITING |
Date Heating System Last Serviced |
Indicate the date (MM/DD/YYYY) ) heating system was last serviced. |
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RATING/UNDERWRITING |
Num of Amps (Elec. Syst) |
Indicate the number of amps in the electrical system. |
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RATING/UNDERWRITING |
Circuit Breakers |
Check the applicable box. |
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RATING/UNDERWRITING |
Fuses |
Check the applicable box. |
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RATING/UNDERWRITING |
Knob & Tube or Aluminum Wiring |
Check the applicable box. |
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RATING/UNDERWRITING |
Plumbing System Condition |
Indicate condition of the plumbing system. |
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RATING/UNDERWRITING |
Plumbing System – Any Known Leaks |
Indicate if there are any known leaks in the plumbing system. |
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RATING/UNDERWRITING |
Foundation |
Check the applicable box. |
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RATING/UNDERWRITING |
Dwelling Location |
Location of the dwelling within the guidelines listed. Complete only if applicable. |
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RATING/UNDERWRITING |
Occupancy |
Indicate if the dwelling is occupied by the owner or a tenant, unoccupied or vacant. |
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RATING/UNDERWRITING |
Deadbolt |
If all entry (exterior) doors are fitted with deadbolt locks, check the box. |
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RATING/UNDERWRITING |
Fire Extinguisher |
If the dwelling is equipped with fire extinguisher(s), check the box. |
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RATING/UNDERWRITING |
Visible to Neighbors |
If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box. |
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RATING/UNDERWRITING |
Oil Storage Tank Location |
If the fuel type is oil, provide the location of the fuel oil storage tank. Options are: * Indoors above ground on masonry floor * Indoors above ground not on a masonry floor * Outdoors above ground * Outdoors below ground Also show the distance from the dwelling, if the storage tank is outdoors. If no fuel oil storage tank exists, check NONE. |
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RATING/UNDERWRITING |
Swimming Pool |
If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board, slide or approved fence. |
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RATING/UNDERWRITING |
Windstorm Loss Mitigation Features |
Describe the construction features which may qualify for credit under the rules in the company manual. General categories of construction features are: * Roof Covering * Roof Deck Attachment * Roof/Wall Connection * Window Protection * Door Type * Roof Geometry Use an additional sheet if more space is required. |
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RATING/UNDERWRITING |
Bldg Code Grade |
Enter the ISO Building Code Grade, if applicable. Also check the appropriate box to indicate whether or not the building was inspected. |
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RATING/UNDERWRITING |
Tax Code |
Enter the city, county or state tax code, if required. |
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RATING/UNDERWRITING |
Rating |
Check the applicable box. |
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RATING/UNDERWRITING |
Occupied Daily |
Check the applicable box. |
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RATING/UNDERWRITING |
# Weeks Rented |
Number of weeks the dwelling is rented by the insured to others. |
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RATING/UNDERWRITING |
Wind Class |
Check the applicable box. |
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RATING/UNDERWRITING |
Roof Material |
Enter the material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle * Other If used, explain in Remarks |
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RATING/UNDERWRITING |
Condition of Roof |
Indicate the condition of the roof. |
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RATING/UNDERWRITING |
If Replacement Cost coverage applies |
check the appropriate box if an ACORD replacement cost worksheet has been used (i.e., ACORD 42.) |
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RATING/UNDERWRITING |
Basement |
Indicate the number of square feet in the basement. Leave this field blank if there is no basement. |
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RATING/UNDERWRITING |
Garage |
Indicate the number of square feet in the garage. Leave this field blank if there is no garage. |
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RATING/UNDERWRITING |
Breezeway |
Indicate the number of square feet in the breezeway. Leave this field blank if there is no breezeway. |
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RATING/UNDERWRITING |
Rating Credits |
Check the applicable box(es) if any rating credits apply. |
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RATING/UNDERWRITING |
Sprinkler |
If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system. |
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RATING/UNDERWRITING |
Fireplaces |
Enter the number in the applicable box(es) to describe the fireplace(s.) |
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GENERAL INFORMATION |
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Use space provided below each question to provide additional information for any questions answered with a "Yes" response (Except questions 15, 16, 17 and 26.) |
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GENERAL INFORMATION |
1. Any farming or other business conducted on premises? |
Describe the business, where business is conducted on the premises, and if applicable, whether corporal punishment or day care coverage is to be provided. |
|
GENERAL INFORMATION |
2. Any residence employees? |
Provide information regarding the number of employees, the nature of their employment, hours worked per week, and whether employed inside (inservants) or outside (outservants). |
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GENERAL INFORMATION |
3. Any flooding/brush, forest fire hazard/landslide, etc.? |
Describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph. |
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GENERAL INFORMATION |
4. Any other residence owned, occupied or rented? |
Detail the occupancy or use of the other residence. If no liability coverage is requested for this residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property. |
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GENERAL INFORMATION |
5. Any other insurance with this company? |
Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it along with any policy numbers available. If other insurance is in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal. |
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GENERAL INFORMATION |
6. Has insurance been transferred within agency? |
Indicate why this insurance has been moved from the last company. |
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GENERAL INFORMATION |
7. Any coverage declined, cancelled, or non-renewed? |
Explain the circumstances surrounding this situation, including the reason for the cancellation. This question cannot be asked in Missouri. |
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GENERAL INFORMATION |
8. Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five (5) years? |
Provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing, judgment or lien during the specified time period. |
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GENERAL INFORMATION |
9. Are there any animals or exotic pets kept on the premises? |
Give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others or to other animals. |
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GENERAL INFORMATION |
10. Distance to Tidal Water? |
Indicate the actual distance to tidal water. Check the appropriate box indicating whether this distance is in miles or feet. |
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GENERAL INFORMATION |
11. Is property situated on more than five acres? |
Indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose. |
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GENERAL INFORMATION |
12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? |
Describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description. |
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GENERAL INFORMATION |
13. Is building retrofitted for earthquake? |
Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest "earthquake resistant" technology and building codes. |
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GENERAL INFORMATION (continued) |
14. During the last five (5) years [ten (10) in Rhode Island], has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or 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.) |
Rhode Island law requires that all applicants for property insurance must answer this question. |
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GENERAL INFORMATION (continued) |
15. Is there is a manager on the premises. |
This question should be answered by applicants who reside in condos or are renters only. |
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GENERAL INFORMATION (continued) |
16. Is there a security attendant. |
This question should be answered by applicants who reside in condos or are renters only. |
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GENERAL INFORMATION (continued) |
17. Is the building entrance is locked. |
This question should be answered by applicants who reside in condos or are renters only. |
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GENERAL INFORMATION (continued) |
18. Any uncorrected code violations? |
Describe any violations of applicable building codes that have not been corrected. |
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GENERAL INFORMATION (continued) |
19. Is the house for sale? |
Provide the length of time the house has been for sale, and the expected sale date if known. |
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GENERAL INFORMATION (continued) |
20. Is property within 300 ft. of a commercial or non-residential property? |
Describe the occupancy of any commercial or non-residential property. |
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GENERAL INFORMATION (continued) |
21. Is there a trampoline on the premises? |
Describe the device. |
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GENERAL INFORMATION (continued) |
22. Was structure originally built & converted for other than private residence? |
Indicate what the structure was originally built for. |
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GENERAL INFORMATION (continued) |
23. Any lead paint hazard? |
Describe the location and the extent of the hazard. |
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GENERAL INFORMATION (continued) |
24. If a fuel tank is on premises, has other insurance been obtained for the tank? |
If yes, provide the name of the insurance company and the applicable limit. |
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GENERAL INFORMATION (continued) |
25. Is building under construction or undergoing renovation or reconstruction? |
Describe the type and scope of construction, renovation or reconstruction of any part of the building. If "YES", give estimated completion date and dollar value. |
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GENERAL INFORMATION (continued) |
26. If building is under construction, is the applicant the general contractor? |
Enter Y for a "YES" response. Enter N for a "NO" response. |
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PRIOR COVERAGE |
Prior Carrier |
Provide the prior insurance company's name. |
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PRIOR COVERAGE |
Prior Policy Number/Expiration Date |
List the complete policy number including prefix and suffix, and the policy's expiration date. |
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LOSS HISTORY |
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This section shows the losses this applicant has had in the past. List losses for the time period required by the company. Provision is made for the applicant to initial this section. |
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LOSS HISTORY |
Date |
Date of Loss (MM/DD/YYYY) |
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LOSS HISTORY |
Type |
Identify the type of loss. |
|
LOSS HISTORY |
Description of Loss |
Describe the loss in detail. |
|
LOSS HISTORY |
CAT# |
CAT# refers to a Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
|
LOSS HISTORY |
Amount |
Indicate the amount of the loss. |
|
ADDITIONAL INTEREST |
INT# |
Provide the interest number or rank (1st, 2nd) |
|
ADDITIONAL INTEREST |
Check boxes |
Identify whether the additional interest is the mortgage holder (i.e., bank in which the mortgage is held), or other interest |
|
ADDITIONAL INTEREST |
Name and Address |
Enter the complete name and address for the additional interest, including the city, state and country (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010 USA) for each entity having an interest in the dwelling(s) to be insured. |
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ADDITIONAL INTEREST |
Loan Number |
Provide the loan number. |
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REMARKS |
Remarks |
Use this space for any additional information. Attach additional sheets if more space is required. |
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ATTACHMENTS |
Attachments |
If there are any attachments to the application, check the applicable box. Blank check boxes are provided for other options. |
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REMARKS |
Remarks |
Use this space for any additional information. Attach additional sheets if more space is required. |
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BINDER/SIGNATURE |
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This section is to be used by producers with the permission of the company underwriter or when the producer has binding authority for this line of business. If the coverage is bound, complete the Insurance Binder section. If coverage is not bound, check the box. |
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BINDER/SIGNATURE |
Effective Date |
Month/day/year (MM/DD/YYYY) on which the insurance applied for is bound. This insurance is subject to the terms, conditions, and limitations of the company. |
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BINDER/SIGNATURE |
Time |
Time the provisions of the binder become effective. |
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BINDER/SIGNATURE |
Expiration Date |
Month/day/year (MM/DD/YYYY) on which the binder terminates. |
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BINDER/SIGNATURE |
12:01/ Noon |
Indicate the time on which the binder terminates. |
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BINDER/SIGNATURE |
Notice of Information Practices |
Check this box if a copy of the Notice of Information Practices has been given to the applicant. |
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BINDER/SIGNATURE |
(Applicant's Initials) |
The applicant should read and understand the Notice of Insurance Information Practices (Privacy) on the form before personally initialing the application. |
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BINDER/SIGNATURE |
Producer's Signature |
Producer must sign the application. |
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BINDER/SIGNATURE |
Producer's Name (Please Print) |
Enter the full name of the producer. |
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BINDER/SIGNATURE |
State Producer License No |
Enter the state producer license number of the producer. This is required in Florida. |
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BINDER/SIGNATURE |
Applicant's Signature |
The applicant should read and understand the Fair Credit Reporting Act, the Privacy Act (where applicable), the Applicant's Statement, and any other disclosure information on the form before personally signing the application. |
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BINDER/SIGNATURE |
Date |
Date the form was signed. |
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BINDER/SIGNATURE |
National Producer Number |
The National Producer Number assigned by the NAIC should be shown. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Unit-Owners Additions & Alterations Special Coverage -Limit |
Provide the limit of the Condo's additions and alterations which would be added for special coverage |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Unit-Owners Additions & Alterations Special Coverage -Form Number |
Provide the Form Number used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Unit-Owners Additions & Alterations Special Coverage -Form Date |
Provide the edition date of the form used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Unit-Owners Additions & Alterations Special Coverage -Premium |
Provide the additional premium to broaden the Additions & Alterations Coverage |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Loc # |
Enter the Location number of the additional premises |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Contents |
Enter the limit for personal property to be covered at the additional Location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Terr |
Enter the Liability Territory for the additional residence |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - # Premises |
Enter the number of premises at this location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Address 1 |
Provide the street address of the additional location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - City |
Provide the city of the additional location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - State |
Provide the state of the additional location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - ZIP |
Provide the zip code of the additional location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Form Number |
Provide the Form Number used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Form Date |
Provide the edition date of the form used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - Premium |
Provide the additional premium to extend liability to the additional location |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Loc # |
Enter the location number of the additional residences owned by the Insured and rented to others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family- Contents |
Enter the limit for Personal Property that belongs to the Insured |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Terr |
Enter the Liability Territory for the additional residence that is rented to Others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - # Families |
Indicate the Number of Families for the additional Residence Rented to Others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Address 1 |
Provide the Street address for the additional residence owned by Insured and rented to others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - City |
Provide the City of the additional residence owned by Insured and rented to others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - State |
Provide the State of the additional residence owned by Insured and rented to others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - ZIP |
Provide the Zip Code of the additional residence owned by Insured and rented to others |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Med Pay Yes |
Select Yes, to add medical payments, if Medical payments is offered as a separate coverage |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Med Pay No |
If Medical payments is offered as a separate coverage, select No, if medical payments is not to be purchased |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Form Number |
Provide the Form Number used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Form Date |
Provide the edition date of the form used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others 1 or 2 Family - Premium |
Provide the additional premium to extend Liability to the Additional Location owned by the Insured and rented to others. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Limit |
Enter the building limit (The Homeowner policy allows an additional 10% Coverage) |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Increase Limit |
Enter the increased limit for Coverage |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Rebuild PCT |
Enter Increases to this Coverage in increments of 25% |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Form Number |
Provide the Form Number used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Form Date |
Provide the edition date of the form used by the Company |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Premium |
