Application for Home, Auto, and Umbrella Coverage

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1 Application for Home, Auto, and Umbrella Coverage Total Pages: 6 pages including cover page Thank you for requesting quotes for your Home, Auto, and Umbrella insurance from TDIC Insurance Solutions. Please indicate the products you are interested in receiving a quote: Homeowner/Renter (Complete Section A) Auto (Complete Section B) Umbrella (Complete Section C) Other (please specify) Please remember to fill out the first three lines of Section A, for all products types, as this will give us your address and phone numbers. Please fax copies of your existing insurance policies along with the attached applications to complete your quote request. Any information that is missing such as the Property Address, Vehicle Information, Birthdates or Driver License numbers will cause delays in completing your quote request. To process your quote request, fax your applications to If you have any questions about completing the applications, please call Prompt 1 for assistance. Thank you again for trusting TDIC Insurance Solutions for your insurance needs! **Fax all completed documents to ** Attention: Personal Lines Department of 5

2 Application for Home, Auto, & Umbrella Coverage Name: SECTION A: HOMEOWNERS QUOTE DETAILS Desired Effective Date: Phone: Fax: Address: City: Zip code: Prop. #1 Current Coverage A: Liability: Medical: Deductible: Year Built: Year Purchased: Square Footage: Is this home a 1, 2, 3 or 4 story home: Fireplace: Yes No How many Home Apartment Condo Townhouse Primary Secondary Rental property Foundation: Concrete Slab Crawlspace Basement How many Full Bathrooms: How many Half Bathrooms: Exterior Construction: Stucco Brick Wood Frame Vinyl Siding Roof Type: Shingle Concrete Tile Wood Shake Kitchen: Standard Custom Designer Garage (2,3,4 cars): Type: Attached Detached Burglar Alarm: Yes No if Yes, is it Monitored Yes No Fire Alarm: Yes No if Yes, is it Monitored Yes No Sprinkled: Yes No if Yes, is it entire home or partial Entire Home Partial Swimming Pool Yes No If yes, In Ground or Above Ground Dog? If so, what is the breed: Any updates to home and what year: Roof Heat Electric Plumbing Any property claims in the past 5 years for all properties owned: Yes No Prop. #2 Address: City: Zip code: Prop. #2 Current Coverage A: Liability: Medical: Deductible: Year Built: Year Purchased: Square Footage: Is this home a 1, 2, 3 or 4 story home: Fireplace: Yes No How many Home Apartment Condo Townhouse Primary Secondary Rental property Foundation: Concrete Slab Crawlspace Basement How many Full Bathrooms: How many Half Bathrooms: Exterior Construction: Stucco Brick Wood Frame Vinyl Siding Roof Type: Shingle Concrete Tile Wood Shake Kitchen: Standard Custom Designer Garage (2,3,4 cars): Type: Attached Detached Burglar Alarm: Yes No if Yes, is it Monitored Yes No Fire Alarm: Yes No if Yes, is it Monitored Yes No Sprinkled: Yes No if Yes, is it entire home or partial Entire Home Partial Swimming Pool Yes No If yes, In Ground or Above Ground Dog? If so, what is the breed: Any updates to home and what year: Roof Heat Electric Plumbing Any property claims in the past 5 years for all properties owned: Yes No of 5

3 SECTION B: AUTO QUOTE DETAILS Current Liability limits: Property Damage limits: Med Pay: Comp Deductible: Collision Deductible: Towing: Yes/No Rental Car: Yes/No Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 DRIVERS #1 #2 #3 #4 #5 Name Date of Birth Driver s License Number USAGE One-Way and Accidents/ Tickets Odom Reading Annual Miles Last 3 Years Vehicle 1 School/Work Pleasure Use Driver #1 Yes/No Vehicle 2 School/Work Pleasure Use Driver #2 Yes/No Vehicle 3 School/Work Pleasure Use Driver #3 Yes/No Vehicle 4 School/Work Pleasure Use Driver #4 Yes/No Vehicle 5 School/Work Pleasure Use Driver #5 Yes/No Are all vehicles parked at the same address daily? Yes No Any Good Student Drivers? Yes No High School College: Away with car Away no car of 5

4 SECTION C: UMBRELLA POLICY SUPPLEMENTAL APPLICATION Umbrella Limit Desired: 1 Million 2 Million 3 Million 4 Million 5 Million 10 Million Do you own a RV/Motor Home? Yes No Do you own a boat/yacht? Yes No If yes, provide info: Do you own personal watercraft (Jet Skis, Sea-Doos, etc.)? Yes No If yes provide info: Do you have any dogs, farm animals or horses? Yes No Dog breed: Do you travel to foreign countries more than 6 months a year? Yes No Do you conduct any farming activities (Livestock, Agriculture, Wine Vineyards)? Yes No Any primary policies, which eliminate or restrict any coverage? Yes No Any accidents or traffic violations in 3 years (Auto, RV, Watercraft)? Yes No Do you have any physical, medical, or mental/emotional Impairment? Yes No Do you participate in unpaid civic duties, volunteer work, or a non-profit corporation? Yes No Any liability claims or lawsuits against a household member in 5yrs? Yes No Real estate, vehicle, watercraft, aircraft, owned or leased that is not insured? Yes No Aircraft owned, leased, or chartered for regular use? Yes No Any household employees/domestic and whether they reside on premises? Yes No Any dependents under age 25 living at home? How many? Yes No Do you belong to a Condo/Homeowners Association? Yes No Any property rented to others? How many locations? Yes No Total number of Automobiles? Any owned recreational vehicles? (Motorcycles, Snowmobiles, Dune Buggies) Yes No Do you own watercraft such as boats, sailboats or powerboats greater than 26 feet long? Yes No Do you have a swimming pool on premises? Yes No Do you have a business in your home residence? Yes No Do you have a farm on your property? Yes No If yes, is this your occupation? Yes No LIST ALL HOUSEHOLD OCCUPANTS (include all fulltime resident employees, nanny etc.) Name Gender Relationship Occupation of 5

5 What are your Auto Insurance Liability Limits? Example: Bodily Injury $250,000/$500,000 Property Damage $100,000 Bodily Injury Limit: Property Damage Limit: What are your Homeowners Insurance Liability Limits? $300,000 $500,000 $1,000,000 LIST ALL PROPERTY OWNED Address Primary (please check) Rental (please check) LIST ALL AUTOS Year Make Model Number LIST WATERCRAFT OWNED (Boats, Jet Skis) Year Make/Model Length/Total HP LIST RECREATIONAL VEHICLES OWNED (Motorcycles, Snowmobiles, Dune Buggies) Year Make Model Number I have answered the questions in this application truthfully. I agree to notify TDIC Insurance Solutions and my carrier of any change in the information contained in the application before and after a policy is issued and to supply such further underwriting information as the carrier may require. I further agree to be bound by the underwriting guidelines of the insurance carrier that I am requesting coverage. I understand the importance of requesting sufficient insurance equal to 100 percent of the replacement value of my property. If I have not requested sufficient coverage, I understand a loss I might have may affect future insurability. Applicants Signature Date Fax completed application together with copies of your existing insurance policies to of 5

Index: Page 1 2: AUTO Insurance Questionnaire. Page 3 4: HOME Insurance Questionnaire. Page 5 6: HEALTH Insurance Questionnaire

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