1-4 Family Dwelling Product Application – All States

Instant quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.

Applicant's Name *

Location Address *

City *

State *

Zip *

Email *

Tel Number *

Description of Operations *

How many individual units are there at this location?

Is the location completely vacant

Yes

No

If 'YES', will the tenant(s) occupy within 60 days?

Yes

No

Are there any student residents at any location?

Yes

No

(Not applicable in D.C.)

Are there any subsidized residents at any location?

Yes

No

(Not applicable in CA, CT, DC, ME, MA, NJ, OR, UT, VT, WI)

Property Section

Construction

Protection Class

Requested Cause of Loss

Basic

Special

Requested Valuation

Replacement cost

Actual cash value

Deductible

$1,000

$2,500

$5,000

Coinsurance

80%

90%

100%

Building limit $

What year was the building constructed?

What is the square footage of the entire structure?

Business Personal Property Limit $

Business Income with Extra Expense Limit $

Coinsurance per above OR Monthly Limit of Idemnity

Yes coinsurance per above

1/3 Monthly Limit of Idemnity

1/4 Monthly Limit of Idemnity

1/6 Monthly Limit of Idemnity

Is the building fully protected by an operational sprinkler system covering 100% of the premises?

Yes

No

Liability Section

Number of Stories

Limit

$100,000/$200,000

$300,000/$600,000

$500,000/$1,000,000

$1,000,000/$2,000,000

How is the dwelling rented?

Annual

Seasonal/Timeshare

Are any units owner occupied?

Yes

No

Does the applicant utilise a real estate property manager?

Yes

No

Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgage)

Name

Relationship

Address, City, Zip

AI / LP / M

AI

LP

M

Name

Relationship

Address, City, Zip

AI / LP / M

AI

LP

M

Name

Relationship

Address, City, Zip

AI / LP / M

AI

LP

M

II. LOSS INFORMATION FOR THE PAST 3 YEARS

PROPERTY COVERAGES

None, or provide details below

Year

Status

Open

Closed

Incurred $

Description

Year

Status

Open

Closed

Incurred $

Description

Year

Status

Open

Closed

Incurred $

Description

LIABILITY COVERAGES

None, or provide details below

Year

Status

Open

Closed

Incurred $

Description

Year

Status

Open

Closed

Incurred $

Description

Year

Status

Open

Closed

Incurred $

Description

III. ADDITIONAL PROPERTY INFORMATION

If you own the building and it is more than 10 years old, please complete the following:

Age of roof (yrs)

Roof Type

Plumbing Type

What type of burglar alarm is on the premises?

Central station

Local

None

IV. ELIGIBILITY CRITERIA

1. For any building built prior to 1978, 100% of the electric wiring is on functioning and operating circuit breakers

N/A

True

False

2. For any building built prior to 1978, there is no aluminium wiring or knob and tube wiring

N/A

True

False

3. Functioning and operational smoke detectors and/or heat detectors in all units and/or occupancies

True

False

4. No past, pending or planned foreclosure and/or bankruptcy or judgement for unpaid taxes, tax liens or credit liens against the name insured or any office, partner, member or owner of the applicant individually in the past five years

True

False

5. No boarding or rooming houses

True

False

6. No owner-occupied one-family locations

True

False

7. No locations in which wood-burning stoves, space heaters or temporary heating devices are used or permitted for use

True

False

8. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri)

True

False

If "False" advise reason:

9. No tenants have been evicted from the premises in the past 6 months and no one is in the process of being evicted

True

False

PROPERTY

1. No location is a mobile home

True

False

2. For any location in California, the named insured is NOT an individual or husband and wife

N/A

True

False

GENERAL LIABILITY

1. Applicant re-keys or will re-key all locks prior to leasing to new tenants (not applicable if rented on seasonal/timeshare basis)

N/A

True

False

2. No assisted living or group home facilities

True

False

3. No locations with swimming pools

True

False

4. All units have functioning and operational carbon monoxide detection alarms if requested by law or code of the municipality in which building is located.

True

False

V. ADDITIONAL APPLICANT INFORMATION

What year did the applicant purchase this property?

Form of Business

Individual

Corporation

Partnership

LLC

Other

Applicant's mailing address (if different than the location address)

City

State

Zip

Email address of primary contact

Phone

Contact Name

Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.”

Colorado Fraud Statement: 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.

District of Columbia Fraud Statement: 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.

Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Kentucky Fraud Statement: 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.

Maine and Washington Fraud Statement: 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.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New York Fraud Statement: 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.

Ohio Fraud Statement: 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.

Oklahoma Fraud Statement: 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.

Pennsylvania Fraud Statement: 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.

Tennessee and Virginia Fraud Statement: 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.

Fraud Statement (All Other States): 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 may be guilty of a crime and may be subject to fines and confinement in prison.

reCAPTCHA