PERSONAL LINES QUOTE PROPOSAL COVERAGES AND LIMITS OF LIABILITY. Notes
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1 PERSONAL LINES QUOTE PROPOSAL Applicant Name and Mailing Address 200 Fox glove COVINGTON GA Mortgagee Name, Mailing Address, Loan Number Type of Insurance Homeowners Company Essex Insurance Company Program/Form/Description 1125/HO3 Effective Date (from - to) 03/01/ /01/2014 Covered Risk Address (if different to Mailing Address) 200 Fox glove, COVINGTON, GA, COVERAGES AND LIMITS OF LIABILITY Coverage - Property Limit Loss Provision Deductible Dwelling - Coverage A $500,000 Replacement Cost Other Structures - Coverage B $50,000 $1,000 (All Other Perils) Personal Property - Coverage C $250,000 Replacement Cost Loss of Use/Rents - Coverage D $100,000 Optional Coverage - Liability Limit Personal Liability $100,000 Medical Payments to Others (Each Person) $1,000 Notes Basic Premium $2, Policy Fee $75.00 Filing Fee $0.00 Inspection Fee $0.00 Surplus Lines Tax $95.20 Total Premium $2, Minimum Earned Premium 25.0% at inception Date Prepared Agency GLOBAL INSURANCE SOLUTIONS This quote is a non-binding rate indication that is subject to a signed application and confirmation from our office. 1 of 5
2 PERSONAL LINES APPLICATION Applicant Name and Mailing Address 200 Fox glove COVINGTON GA Mortgagee Name, Mailing Address, Loan Number Type of Insurance Homeowners Company Essex Insurance Company Program/Form/Description 1125/HO3 Effective Date (from - to) 03/01/ /01/2014 Covered Risk Address (if different to Mailing Address) 200 Fox glove, COVINGTON, GA, COVERAGES AND LIMITS OF LIABILITY Coverage - Property Limit Loss Provision Deductible Dwelling - Coverage A $500,000 Replacement Cost Other Structures - Coverage B $50,000 $1,000 (All Other Perils) Personal Property - Coverage C $250,000 Replacement Cost Loss of Use/Rents - Coverage D $100,000 Wind/Hail Coverage Excluded? Yes No Optional Coverage - Liability Limit Personal Liability $100,000 Medical Payments to Others (Each Person) $1,000 DWELLING INFORMATION Year Built Construction Protection Sq.Ft. No. Rating Usage Market Distance To Type Class Stories Territory Value Fire Hydrant Fire Station 2004 Brick 4 3, Primary 100 feet # of Families Occupancy Primary Swimming Central Station Alarm Trampoline Hurricane Source of Heat Pool Fire Burglary Shutters 1 Owner Natural Gas No No No No No 2 of 5
3 Distance To Coastal Waters : 5+ miles If the dwelling is 1950 or earlier answer the following : - Has the wiring, heating, and plumbing been fully updated in the past 40 years? Yes No Wiring Heating Plumbing Year Roof Type : Architect What year was the roof fully updated? : 2004 Number of losses in prior 3 years? 0 PRIOR LOSS HISTORY Date Type of Loss Description Insurance Company Name Amount Paid or Reserved Is any child care business conducted on the premises? Yes No GENERAL INFORMATION Is any other business conducted on the premises? Yes No If yes, please explain the type of business conducted : Does any part of the premises consist of a mobile home or manufactured home? Yes No Are there any animals on premises? Yes No If yes, then describe (note type, breed and bite history) In the last five years has the applicant been involved with a Bankruptcy or Repossession or Foreclosure (open or closed) : Yes No AGENCY INFORMATION Agency GLOBAL INSURANCE SOLUTIONS Agency Address ABBOTTS WALK DRIVE, JOHNS CREEK, GA, Contact Name Phone # 1(678) Fax# 1(678) Address NOTICE OF INSURANCE INFORMATION PRACTICES : Personal information about you may be collected from persons other than you. Such information,as well as other personal and privileged information,collected by us or your agent may, in certain circumstances,be disclosed to third parties. 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/broker for instruction on how to submit a request to us. FL Residents Only : ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE ( ). NJ Residents Only : ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES (Bulletin 95-16, citing P.L.1995, c.132). VA Residents Only : IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCULDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS (52-40). Note to Agents : No binding or quoting authority! Please call or fax for same day binding and follow up with an application. Application must be signed by the Named Insured. Any incomplete applications received could jeopardize binding coverage! PRODUCER'S SIGNATURE : SIGNATUREFIELD_Signature_2027_10_1 TEXTFIELD_SignedDate_2027_10_1 Producer : How long have you known the applicant? Date agent last inspected property? Applicant's Statement: With respect to the lines of coverage selected above, I have read the attached application and I declare that, to the best of my knowledge and belief, all of the foregoing statements are true. APPLICANT'S SIGNATURE : SIGNATUREFIELD_Signature_2027_28_2 TEXTFIELD_SignedDate_2027_28_2 3 of 5
4 GEORGIA DILIGENT EFFORT STATEMENT Insured: Policy #: Effective: 03/01/2013 Diligent Effort made by Producing Agent: I, have made an effort to procure the desired insurance (Name) coverage or benefits from authorized insurers, but such effort has been unsuccessful in obtaining insurance coverage or benefits which are satisfactory to the insured. The contract is registered and delivered as a surplus line coverage under the Surplus Line Insurance Law O.C.G.A. Chapter (Signature of Producing Agent) (Date) 4 of 5
5 ATTACHED TO AND FORMING A PART OF POLICY NUMBER ENDORSEMENT EFFECTIVE (12.01 A.M STANDARD TIME) NAMED INSURED 03/01/2013 ENDORSEMENT NO. AGENT NO. SCHEDULE OF FORMS S.No Document Identifier - Version Date Document Name 1 ARF HOMEOWNERS POLICY DECLARATION 2 HD MINIMUM EARNED CANCELLATION 3 HD SCHEDULE OF FORMS 4 HD BIOLOGICAL OR CHEMICAL MATERIALS EXCLUSION 5 HS AMENDATORY ENDORSEMENT 6 HS BUSINESS PURSUITS EXCLUSION 7 HD SERVICE OF SUIT CLAUSE 8 BRP PRIVACY POLICY STATEMENT 9 HD WAR AND TERRORISM EXCLUSION ENDORSEMENT 10 HO HOMEOWNERS 3 - SPECIAL FORM 11 HO PERSONAL PROPERTY REPLACEMENT COST LOSS SETTLEMENT 12 HO GEORGIA CONSIDERATIONS 13 HS ANIMAL LIABILITY LIMITATION 14 HD TAINTED DRYWALL MATERIAL EXCLUSION HD AUTHORIZED REPRESENTATIVE / 5 of 5
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