Comprehensive Personal Liability Application Form (Page 2 of 2) in pdf

Comprehensive Personal Liability Application (page 2)

8) Is any business conducted on any of the premises?

___ Yes ___ No

9) Is any dwelling under construction or major structural renovation?

___ Yes ___ No

10) Is any dwelling under foreclosure proceedings?

___ Yes ___ No

11) Does the Applicant have an unfavorable credit history or a FICO score below 600?

___ Yes ___ No

12) Do any of the dwellings have unsettled losses?

___ Yes ___ No

13) Do any of the dwellings with pools have diving boards or slides?

___ Yes ___ No

14) Do any of the dwellings have spas or hot tubs on the premises?

___ Yes ___ No

15) Do any of the dwellings have day-care operations?

___ Yes ___ No

16) Do any of the dwellings have trampolines on the premises?

___ Yes ___ No

17) Do any of the dwellings have training, boarding, breeding or stabling of animals?

___ Yes ___ No

18) Are any of the dwellings location on more than 7 acres of land?

___ Yes ___ No

19) Is any acreage used for farming, grazing, hunting, public fishing or any similar purpose?

___ Yes ___ No

20) Are any of the dwellings mobile home that are more than 35 years old?

___ Yes ___ No

21) Are any of the dwellings vacant?

___ Yes ___ No

Applicant's Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and

statements set forth are true and correct and agree that those particulars and statements are material to the acceptance of the

risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the

effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will

immediately be reported in writing to the Company and the Company may withdraw or modify any outstanding quotations

and/or authorization or agreement to bind the insurance. The signing of the application does not bind the undersigned to

purchase the insurance, nor does the review of the application bind the Company to issue a policy. It is agreed that this

application, including any material submitted there with, shall be the basis of the contract should a policy be issued, and

may be attached to and become a part of the policy.

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.

Applicant's Signature ____________________________________ Date __________________________________

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Comprehensive Personal Liability Application Form Page 2