Application Forms

APPLICANT'S INFORMATION
Name Insured
Effective Date
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Insured Phone #
Email Address
PROPERTY/LIABILITY CORE COVERAGES
Dwelling Personal Liability Limits: $500,000 Appuranant Structures (10% of Dwelling Limit) Medical Payments: $500 Personal Property (70% of Dwelling Limit) Replacement Cost Dwelling and Contents Loss of Use (20% of Dwelling Limit) HO-3 Special Form Perils (Dwelling)
PROPERTY INFORMATION
Year Built:
If over 25 years old, please list all updates:
Dwelling Limit: $    Dwelling Deductible: $500   $1,500   $2,500
Dwelling Construction: Frame   Joisted Masonry   Metal   Masonry N-C/Fire Resistive   Manufactured Home   Trailer
If Manufactured Home, is it on a permanent foundation? Yes No
Dwelling Roof Material:
Dwelling Sq Ft Area:   # of Stories:
Deadbolts? Yes No    Sprinklered? Yes No    Percentage:
Alarms? Yes No    Type of Alarms:
Number of Families:
Basement? Yes No    If Yes: Full   Partial    Basement Sq Ft:
Attached Garage? Yes No    If Yes, Sq Ft:
Fireplaces? Yes No    If Yes, Explain:
Mortgagee:
PROPERTY/LIABILITY UNDERWRITING
Are there any alternative heating sources (i.e. wood/coal/gas/pellet stoves)? Yes No If Yes, Explain: Professional installed: Yes No
Swimming Pool? Yes No If Yes: Above Ground In-ground Approved Fence Diving Board Sliding Board
Any farming or other business conducted on the premises other than that of the Kennel operation? Yes No If Yes, Explain:
Number of Acres? If more than five acres, explain land use:
Any residence employees? Yes No If Yes, Number of Full-Time: Part-Time:
Any other residences owned, occupied or rented? Yes No If Yes, Explain:
Any coverage Declined, cancelled or non-renewed within the past three years? Yes No If Yes, Explain:
Are there any animals or exotic pets kept on the premises? Yes No If Yes, Explain:
Do you own any recreation vehicles (snow mobiles, dune buggies, mini bikes, motorcycles, atvs, watercraft, etc.)? Yes No If Yes, Explain:
Is building undergoing renovations or reconstruction? Yes No If Yes, Explain: Estimated Completion Date:   Estimated Value:
Is house for sale? Yes No If Yes, Explain:
Is there any known lead paint exposure? Yes No If Yes, Explain:
Are there any physical defects that need to be corrected? Yes No If Yes, Explain:
LOSSES IN THE PAST 3 YEARS
Date Description Paid Reserved
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