DWELLING FIRE APPLICATION

Transcription

1 DWELLING FIRE APPLICATION DATE (MM/DD/YYYY) AGENCY PHONE APPLICANT S NAME AND MAILING ADDRESS (Include county & ZIP+4) (A/C, No, Ext): FAX NAIC CODE FACILITY CODE (A/C, No): POLICY # DATE AT CURR RES CO/PLAN HOME PHONE # CODE: SUBCODE: EFFECTIVE DATE EXPIRATION DATE BUSINESS PHONE # AGENCY CUSTOMER ID APPLICANT INFORMATION PREVIOUS ADDRESS (If less than 3 years) YRS AT LOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP) PREV ADDR DAY EVE DAY EVE APPLICANT S OCCUPATION (State nature of business if self-employed) APPLICANT S EMPLOYER NAME AND ADDRESS YEARS IN YEARS W/ YEARS W/ MAR DATE OF BIRTH SOCIAL SECURITY # CURR OCC CURR EMPL PRIOR EMPL STAT CO-APPLICANT S OCCUPATION (State nature of business if self-employed) CO-APPLICANT S EMPLOYER NAME AND ADDRESS YEARS IN YEARS W/ YEARS W/ MAR DATE OF BIRTH SOCIAL SECURITY # CURR OCC CURR EMPL PRIOR EMPL STAT HOW LONG HAVE YOU KNOWN THE APPLICANT? COVERAGES/LIMITS OF LIABILITY POLICY DWELLING OTHER PERSONAL RENTAL VALUE PERSONAL MEDICAL ALL PERIL TYPE STRUCTURES PROPERTY LIABILITY PAYMENTS $ EACH OCCURRENCE EACH PERSON WIND/HAIL ADDITIONAL EXPENSE THEFT $ $ $ $ $ $ NAMED HURRICANE * FIRE FIRE & EC FIRE, EC & VMM BROAD SPECIAL ENDORSEMENTS PAYMENT PLAN EST TOTAL PREMIUM ACCOUNT #: BILLING IF DIRECT BILL: IF APPLICANT BILL: MAIL POLICY TO: AGENT DIRECT BILL BILL APPLICANT OTHER: FULL PAY APPLICANT AGENCY BILL BILL MORTGAGEE OTHER: OTHER: RATING/UNDERWRITING DATE AGENT LAST INSPECTED PROPERTY: FRAME MFG HOME YR BUILT # ROOMS MARKET VALUE STRUCTURE TYPE USAGE TYPE # FARM # FAM- PURCHASE ILIES HSEHLD DATE/PRICE MASONRY VINYL SIDING RES $ DWELLING TOWNHOUSE PRIMARY COC MASONRY ALUMINUM SQ FT # APTS REPLACEMENT COST COMP. DATE: VENEER SIDING APART ROWHOUSE SECONDARY FIRE RES $ CONDO CO-OP SEASONAL RENOVATION TYPE PART COMP YEAR NUMBER OF TERR PREM PROTECT DISTANCE TO PROTECTION DEVICE TYPE HEAT TYPE NONE WIRING CODE GROUP CLASS FIRE UNITS IN FIRE DIVS FIRE DIV HYDRANT STATION SYSTEM SMOKE TEMP BURGLAR PRIMARY: PLUMBING FT MI CENTRAL SECONDARY: HEATING FIRE/EC RATE FIRE DISTRICT/CODE NUMBER DIRECT HOUSEKEEPING CONDITION ROOFING LOCAL EXTERIOR PAINT DATE HEATING SYSTEM LAST SERVICED NUM OF AMPS (ELEC SYST) CIRCUIT BREAKERS FUSES KNOB & TUBE OR ALUMINUM WIRING PLUMBING SYSTEM CONDITION PLUMBING SYSTEM ANY KNOWN LEAKS FOUNDATION CLOSED YES NO YES NO YES NO YES NO OPEN NONE DWELLING LOCATION OCCUPANCY DEADBOLT OIL STORAGE TANK LOCATION SWIMMING POOL YES NO WINDSTORM LOSS MITIGATION FEATURES WITHIN UNOCC FIRE EXT INDOORS OUTDOORS APPROVED CITY LIMITS OWNER FENCE ABOVE GROUND ON ABOVE TENANT VACANT MASONRY FLOOR GROUND WITHIN FIRE DIST VISIBLE TO NEIGHBORS WITHIN PROT SUBURB ABOVE GROUND NOT ON MASONRY FLOOR BELOW GROUND DIVING BOARD SLIDE ABOVE GROUND IN - GROUND BLDG CODE GRADE INSPECTED? TAX CODE RATING OCCUPIED DAILY? # WKS RENTED WIND CLASS SEMI- RESISTIVE ROOF MATERIAL CONDITION OF ROOF YES NO CLASS SPEC YES NO RESISTIVE OTHER IF REPLACEMENT COST APPLIES, ACORD 42 ATTACHED: RATING CREDITS MANNED SECURITY SPRINKLER FIREPLACES (Enter Number) BASEMENT GARAGE BREEZEWAY OFF PREMISES NON-SMOKER THEFT EXCL PARTIAL CHIMNEYS PRE-FAB SQ FT SQ FT SQ FT LIGHTNING PROTECTION FULL HEARTHS WOOD STOVE INSERT ACORD 84 (2004/02) ACORD 610 Attached (NOT APPLICABLE IN NC) PREMIUM $ $ $ DED (Type & Amount) * Not Applicable in NC DEPOSIT BALANCE PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1981

2 GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS (Except question 15, 16 and 17) YES NO 1. ANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES? 14. DURING THE LAST FIVE YEARS (TEN YEARS IN RHODE ISLAND), (Including day/child care) If "Yes", list gross receipts: $ HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE 2. ANY RESIDENCE EMPLOYEES? CRIME OF ARSON? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (Number and type of full and part time employees) year of imprisonment.) 3. ANY FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC? 15. IS THERE A MANAGER ON THE PREMISES? RENTERS AND 4. ANY OTHER RESIDENCE OWNED, OCCUPIED OR RENTED? CONDOS ONLY: 16. IS THERE A SECURITY ATTENDANT? 5. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) 17. IS THE BUILDING ENTRANCE LOCKED? 6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? 18. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS? 7. ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST 3 YEARS? (Not applicable in MO) 8. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY, JUDGEMENT OR LIEN DURING THE PAST FIVE YEARS? 9. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES? (Note breed and bite history) 10. IS PROPERTY LOCATED WITHIN TWO MILES OF TIDAL WATER? 11. IS PROPERTY SITUATED ON MORE THAN FIVE ACRES? (If yes, describe land use) 12. DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATVS, ETC)? (List year, type, make, model) 13. IS BUILDING RETROFITTED FOR EARTHQUAKE? (If applicable) LOSS HISTORY ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURING THE LAST YEARS, AT THIS OR AT ANY OTHER LOCATION? IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTION? (Give estimated completion date and dollar value) IF YES, INDICATE BELOW APPLICANT S INITIALS: DATE TYPE DESCRIPTION OF LOSS CAT # AMOUNT IS HOUSE FOR SALE? 21. IS PROPERTY W/IN 300 FT OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY? 22. IS THERE A TRAMPOLINE ON THE PREMISES? 23. WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? 24. ANY LEAD PAINT HAZARD? 25. IF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (Give First Party and limit, and Third Party and limit) 26. IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR? YES NO PRIOR COVERAGE PRIOR CARRIER PRIOR POLICY NUMBER EXPIRATION DATE ADDITIONAL INTEREST INT # MORTG E NAME AND ADDRESS LOAN NUMBER ADDL INT REMARKS (Attach Additional Sheets if More Space is Required) FOR COMPANY USE ONLY BINDER/SIGNATURE INSURANCE BINDER EFFECTIVE DATE EXPIRATION DATE TIME 12:01 AM NOON COVERAGE IS NOT BOUND ATTACHMENTS STATE SUPPLEMENT(S) (If applicable) INLAND MARINE APPLICATION REPLACEMENT COST ESTIMATE PHOTOGRAPH SOLID FUEL SUPPLEMENT EARTHQUAKE APPLICATION PROTECTION DEVICE CERTIFICATE PERS EXCESS/UMBRELLA APP RECREATIONAL VEHICLE APP WATERCRAFT APPLICATION LEAD FREE PAINT CERTIFICATION HOME BASED BUSINESS SUPP IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY: THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY. THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY. PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. CREDIT SCORING INFORMATION MAY BE USED TO DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states) ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied) APPLICANT S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING. APPLICANT S SIGNATURE DATE PRODUCER S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 84 (2004/02)

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5 CALIFORNIA RESIDENTIAL PROPERTY INSURANCE DISCLOSURE FOR USE WITH ALL FORMS NOTICE TO CONSUMERS CALIFORNIA RESIDENTIAL INSURANCE DISCLOSURE This disclosure is required by Section of the California Insurance Code. This form provides general information related to residential property insurance and is not part of your residential property insurance policy. Only the specific provisions of your policy will determine whether a particular loss is covered and the amount payable. The information provided does not preempt existing California law. PRIMARY FORMS OF RESIDENTIAL DWELLING COVERAGE You have purchased the coverage(s) checked below. NOTE: Actual Cash Value Coverage is the most limited level of coverage listed. Guaranteed Replacement Cost is the broadest level of coverage. ACTUAL CASH VALUE COVERAGE pays the costs to repair the damaged dwelling minus a deduction for physical depreciation. If the dwelling is completely destroyed, this coverage pays the fair market value of the dwelling at time of loss. In either case, coverage only pays for costs up to the limits specified in your policy. REPLACEMENT COST COVERAGE is intended to provide for the cost to repair or replace the damaged or destroyed dwelling, without a deduction for physical depreciation. Many policies pay only the dwelling's actual cash value until the insured has actually begun or completed repairs or reconstruction on the dwelling. Coverage only pays for replacement costs up to the limits specified in your policy. EXTENDED REPLACEMENT COST COVERAGE is intended to provide for the cost to repair or replace the damaged or destroyed dwelling without a deduction for physical depreciation. Many policies pay only the dwelling's actual cash value until the insured has actually begun or completed repairs or reconstruction on the dwelling. Extended Replacement Cost provides additional coverage above the dwelling limits up to a stated percentage or specific dollar amount. See your policy for the additional coverage that applies. GUARANTEED REPLACEMENT COST COVERAGE covers the full cost to repair or replace the damaged or destroyed dwelling for a covered peril regardless of the dwelling limits shown on the policy declarations page. BUILDING CODE UPGRADE COVERAGE, also called Ordinance and Law coverage, is an important option that covers additional costs to repair or replace a dwelling to comply with the building codes and zoning laws in effect at the time of loss or rebuilding. These costs may otherwise be excluded by your policy. Meeting current building code requirements can add significant costs to rebuilding your home. Refer to your policy or endorsement for the specific coverage provided and coverage limits that apply. READ YOUR POLICY AND POLICY DECLARATIONS PAGE CAREFULLY: The policy declarations page shows the specific coverage limits you have purchased for your dwelling, personal property, separate structures such as detached garages, and additional living expenses. The actual policy and endorsements provide the details on extensions of coverage, limitations of coverage, and coverage conditions and exclusions. The amount of any claim payment made to you will be reduced by any applicable deductibles shown on your policy declarations page. It is important to take the time to consider whether the limits and limitations of your policy meet your needs. Contact your agent, broker, or insurance company if you have questions about what is covered or if you want to discuss your coverage options. INFORMATION YOU SHOULD KNOW ABOUT RESIDENTIAL DWELLING INSURANCE AVOID BEING UNDERINSURED: Insuring your home for less than its replacement cost may result in your having to pay thousands of dollars out of your own pocket to rebuild your home if it is completely destroyed. Contact your agent, broker, or insurance company immediately if you believe your policy limits may be inadequate. THE RESIDENTIAL DWELLING COVERAGE LIMIT: The coverage limit on the dwelling structure should be high enough so you can rebuild your home if it is completely destroyed. Please note: The cost to rebuild your home is almost always different from the market value. Dwelling coverage limits do not cover the value of your land. The estimate to rebuild your home should be based on construction costs in your area and should be adjusted to account for the features of your home. These features include but are not limited to the square footage, type of foundation, number of stories, and the quality of the materials used for items such as flooring, countertops, windows, cabinetry, lighting and plumbing. The cost to rebuild your home should be adjusted each year to account for inflation. Coverage limits for contents, separate structures, additional living expenses and debris removal are usually based on a percentage of the limit for the dwelling. If your dwelling limit is too low, these coverage limits may also be too low. SI 3286 (6-11) SUTTER INSURANCE COMPANY Page 1 of 2

6 You are encouraged to obtain a current estimate of the cost to rebuild your home from your insurance agent, broker, or insurance company or an independent appraisal from a local contractor, architect, or real estate appraiser. If you do obtain an estimate of replacement value, and wish to change your policy limits, contact your insurance company. While not a guarantee, a current estimate can help protect you against being underinsured. DEMAND SURGE: After a widespread disaster, the cost of construction can increase dramatically as a result of the unusually high demand for contractors, building supplies and construction labor. This effect is known as demand surge. Demand surge can increase the cost of rebuilding your home. Consider increasing your coverage limits or purchasing Extended Replacement Cost coverage to prepare for this possibility. CHANGES TO PROPERTY: Changes to your property may increase its replacement cost. These changes may include the building of additions, customizing your kitchen or bathrooms, or otherwise remodeling your home. Failure to advise your insurance company of any significant changes to your property may result in your home being underinsured. EXCLUSIONS: Not all causes of damage are covered by common homeowners or residential fire policies. You need to read your policy to see what causes of loss or perils are not covered. Coverage for landslide is typically excluded. Some excluded perils such as earthquake or flood can be purchased as an endorsement to your policy or as a separate policy. Contact your agent, broker, or insurance company if you have a concern about any of the exclusions in your policy. CONTENTS (PERSONAL PROPERTY) COVERAGE DISCLOSURE: This disclosure form does not explain the types of contents coverage provided by your policy for items such as your furniture or clothing. Contents may be covered on either an actual cash value or replacement cost basis depending on the contract. Almost all policies include specific dollar limitations on certain property that is particularly valuable such as jewelry, art, or silverware. Contact your agent, broker or insurance company if you have any questions about your contents coverage. You should create a list of all personal property in and around your home. Pictures and video recordings also help you document your property. The list, photos, and video should be stored away from your home. CONSUMER ASSISTANCE If you have any concerns or questions, contact your agent, broker, or insurance company. You are also encouraged to contact the California Department of Insurance consumer information line at (800) 927-HELP (4357) or at for free insurance assistance. ACKNOWLEDGEMENT OF DISCLOSURE I have read this CALIFORNIA RESIDENTIAL PROPERTY INSURANCE DISCLOSURE, which I received within 60 days of my application, and I have selected the option(s) indicated below: Actual Cash Value Replacement Cost Coverage Extended Replacement Cost Coverage Guaranteed Replacement Cost Coverage Building Code Upgrade Coverage I acknowledge that I have been provided a copy of this California Residential Property Insurance Disclosure. Applicant s Name (Please Print): Applicant s Signature: Date: (Original Signature of Applicant is Required) Note: RETURN THIS ACKNOWLEDGEMENT OF DISCLOSURE. If the submission has two or more applicants on the application, only one original signature is needed. Please make a copy for your records. SI 3286 (6-11) SUTTER INSURANCE COMPANY Page 2 of 2

7 CALIFORNIA RESIDENTIAL PROPERTY INSURANCE BILL OF RIGHTS FOR USE WITH ALL FORMS California Residential Property Insurance Bill of Rights A consumer is entitled to receive information regarding homeowner s insurance. The following is a limited overview of information that your insurance company can provide: The insurance company s customer service telephone number for underwriting, rating, and claims inquiries. A written explanation for any cancellation or nonrenewal of your policy. A copy of the insurance policy. An explanation of how your policy limits were established. In the event of a claim, an itemized, written scope of loss report prepared by the insurer or its adjuster within a reasonable time period. In the event of a claim, a copy of the Unfair Practices Act and, if requested, a copy of the Fair Claims Settlement Practices Regulations. In the event of a claim, notification of a consumer s rights with respect to the appraisal process for resolving claims disputes. An offer of coverage and premium quote for earthquake coverage, if eligible. A consumer is also entitled to select a licensed contractor or vendor to repair, replace, or rebuild damaged property covered by the insurance policy. The information provided herein is not all inclusive and does not negate or preempt existing California law. If you have any concerns or questions, contact your agent, broker, insurance company, or the California Department of Insurance consumer information line at (800) 927-HELP (4357) or at for free insurance assistance. This insurer reports claim information to one or more claims information databases. The claim information is used to furnish loss history reports to insurers. If you are interested in obtaining a report from a claims information database, you may do so by contacting: A- Plus at to request a free A-Plus Loss-History Report SI 3422 (6-11) SUTTER INSURANCE COMPANY Page 1 of 1

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