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Dwelling Application Form

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DWELLING APPLICATION FORM

THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS

APPLICATION SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO

OFFER COVERAGE OR OFFER COVERAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT BY THE APPLICANT.

ELIGIBILITY QUESTIONS

n which state i the property to be insured:

Please select Type of Occupancy:

Owner Only

Tenant Only

Owner and Tenant(s)

Seasonal

lease select Type of Dwelling:

One Family

Two Family

Three Family

Four Family

Five Or More

Has the applicant had any application of property insurance refused, cancelled or non-renewed in the

past 3 (three) years? (other than vacancy)

Yes

If the answer above is Yes, were they for any of the following reasons

Insurer no longer writing class of business?

Insurer no longer writing class of business in territory?

Yes

Risk no longer qualifying for an Admitted Carrier program?

Loss History?

. Is the applicant currently involved in bankruptcy proceedings?

. Has the applicant been convicted of the crimes of arson or insurance fraud?

Yes

. Has the applicant had more than two water damage claims in the past five years?

. Is the property to be insured subject to mortgage foreclosure proceedings or tax liens?

Is there any existing damage to building(s) to be insured?

. Is the property to be insured subject to more than two mortgages or other encumbrances?

. Is the property to be insured subject to a mortgage provided by an individual or entity other than a financial institution?

. Is the property attached to, occupied as, or converted from a commercial building?

. Is the property an earth home, dome home, open pier, stilt home (built prior to 1990), row home,

Yes

mobile home, manufactured home, farm, hobby farm or any other non-conventional dwelling?

. Is the property to be insured a Rooming House, Boarding House or used for Student

Housing?

. Is the property located in a landslide, forest fire or brush fire area (with less than 200 feet brush clearance)?

. Does the property have any knob & tube aluminium wiring or is on fuses?

. Does any wiring at the property have less than 100amp circuit breakers?

. Are kerosene, paraffin, or portable space heaters used?

. Is the property situated on more than 25 acres?

. Is the property to be insured undergoing any renovation or construction work of any kind, or is any such work due to commence while

insurance is in effect?

Yes

If the answer above is ‘Yes’, please answer the following uestion

. Is the renovation or construction work (i) being performed by a contractor or owner where project costs exceed $150,000; or (ii) involve

structural repairs being performed by any person?

Yes

Dwelling Application Form

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