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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
Are there any alternative heating sources (i.e. wood/coal/gas/pellet stoves)?
Yes
No
Professional installed:
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
MM slash DD slash YYYY
Description
Paid
Reserved
Date
MM slash DD slash YYYY
Description
Paid
Reserved
Date
MM slash DD slash YYYY
Description
Paid
Reserved
Date
MM slash DD slash YYYY
Description
Paid
Reserved
Date
MM slash DD slash YYYY
Description
Paid
Reserved
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