Dwelling Application Form Page 2
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1
2
3GENERAL DETAILS
Name and Mailing Address of Applicant:
State
Zip code
Telephone
Email
Address of Property to be Insured:
State
Zip code
Name and Address of Retail Broker:
State
Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
. Protection Class:
. Total square footage of building to be insured:
. Construction Type:
Frame
Joisted Masonry
Masonry Non Combustible
Non Combustible
Modified Fire Resistive
Fire Resistive
Other
. Age of building or full electrical and plumbing upgrade?
0-35 Years
36-50 Years
Over 50 Years
. When was the roof last replaced?
0-25 Years
26-50 Years
Over 50 Years
. Value of Coverage A – Dwelling to be insured:
. Is Coverage B – Other Structures cover required?
a. Value of Coverage B – Other Structures:
es
No
. Is Coverage C – Personal Property (ex-theft) cover required?
Yes
o
a. Value of Coverage C – Personal Property (ex-theft):
. If available, is Coverage D – Fair Rental cover required?
es
No
a. Value of Coverage D – Fair Rental:
1. If available, is Coverage E – Additional Living Expenses cover required? Yes
No
a. Value of Coverage E – Additional Living Expenses:
. Wind and Hail Deductible per occurrence:
$1,000
$2,500
$5,000
$10,000
. All Other Perils Deductible per occurrence:
$1,000
2,500
$5,000
$10,000
. Which type of quote do you require?
DP1
DP3
. Is there a wood stove on the premises?
es
o
. Would you like to buy coverage for the peril of Earthquake? (applicable for CA quotes only)
es
No
. Premises Liability:
Yes
No
. Premises Liability Limits:
$25,000
$50,000
$100,000
$300,000
$500,000
$1,000,000
. Medical Payments:
1,000
$2,500
$5,000
$10,000
Is dwelling situated on more than five acres? Yes
o
a. How many acres? 6-15
16-25
5+
b. Please describe use of land:
. Do you want to buy coverage for the swimming pool liability? Yes
o
a. Is it fenced and does it have a self locking gate? Yes
o
b. What limit would you like for swimming pool liability? $25,000
$50,000
$100,000
4 . Have there been any insured or uninsured property or liability losses at the property to be insured since the applicant has
owned the property? Yes
No
Describe all prior losses or claims including the date, the nature or occurrence, the status, the amount, and whether the damage has been
repaired:
ATR – 59 Dwelling Application
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Parent category: Business