Homeowner Application
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1 Homeowner Application Applicant s Name: Mailing Agent Name: Agency Code: PROPOSED EFFECTIVE DATES: General Information: From To 12:01 A.M., Standard Time, at the address of the Applicant Billing Method: Insured Mortgagee Agent Type of Submission: New Business Renewal Rewrite Previous Policy No.: Requested Coverages: HO-3 HO-4 HO-6 HO-8 HO-A (TX Only) HO-B (TX Only) HO-BT (TX Only) HO-B-CON (TX Only) Deductible: All Perils Wind and Hail Theft Deductible Describe Location: Same as mailing address Street City County State Zip Underwriting Information: Year Built Square Footage Number of Families Number of Stories Type of Roof Territory Number Protection Class Miles from Fire Dept. Feet from Hydrant Fire District or Town Construction: Frame Masonry EIFS Brick Veneer (TX only) Mobile Home (TX only) Other Wood Stove?... Yes No If Yes, is this the Primary source of heat?... Yes No Submit two photos of wood stove along with wood stove questionnaire. Page 1 of 5
2 Rating Information: Property Coverage: Limits Premiums Liability Coverage: Limits Premiums Dwelling $ $ Personal Liability $ $ Other Structures $ $ Home Day Care /# of Children $ (Max of 5) Personal Property $ $ Medical Payments $ /Per Person $ Loss of Use $ $ In Home Business: Theft by Burglary (above $ $ Business Property $ $ $5,000 where applicable) Liability Aggregate $ $ (Policy Maximum) Satellite/Antenna $ $ Replacement Cost: Additional Charges/Credits: Dwelling Only $ $ Deductible Credits $ (not applicable to Liability) Dwelling & Contents $ $ Misc. Credit/Surcharges $ (wood stove, etc.) All Direct Causes of Loss $ $ State Tax (where applicable) $ (All Risk) Policy Fee (if applicable) $ Additional Interests Mortgagee/Loss Payees: Interest #1: Interest #2: Other Fees $ Total Premium: $ Name: Name: Loan Number: Type of Interest: Loan Number: Type of Interest: Miscellaneous Coverages (check box if applicable): Mine Subsidence (where applicable) Exclude Wind Earthquake (if available) Tenant Relocation (MA only) Offshore Island Zone: Claim free Renewal Credit Wind/Hail Deductible: EQ Additional Living (where applicable) Dollar Amount $ Expense Limit: $ Fire Alarm: Percent Amount % EQ Contents Limits: $ Central Local Distance to Coastal Waters: EQ Deductible: $ Burglar Alarm: Feet: Miles: Reconstruction Costs (CA only) Central Local Zone: Senior Citizen Credit (where applicable) Workers Compensation (CA only) Fire Station: miles Number of In-Servants: Fire District: Number of Out-Servants: Fire Hydrant: feet Page 2 of 5
3 Previous/Current Carrier and Loss History Information: Previous/Current Carrier: Policy Number: Expiration Any Previous/Current Carrier declined, canceled, or nonrenewed coverage within the last three years?... Yes No If Yes, give reason(s): (not applicable in Missouri and California) Any losses in the last three years?... Yes No If Yes, please provide the information requested below: Date of Loss Claim Type Description of Loss Amount Paid Amount Reserved Additional Information: Any bankruptcy or foreclosure proceedings filed? Reason: Discharged?... Is applicant delinquent on mortgage or tax payments?... Has anyone with a financial interest in the property been convicted of fraud, arson or other crime related to any loss on any property during the past five years?... Swimming pool, hot tub or spa on premises?... Pool fenced?... Automatic locking gate?... Steps have secured handrails?... Any lake, pond or dock on premises?... Trampoline on premises?... Is the dwelling set on land in excess of five acres?... Are there any animals kept on premises?... If Yes, list all: Animal Breed: Number: Bite History?... Animal Breed: Number: Bite History?... Other: Any businesses on premises?... Type of business (include Day Care): Other structures (garages, shed, etc.) on premises? If Yes, please list in comments. Yes No Yes No Electrical service on circuit breakers?... Is location primary residence of owner/ applicant?... Modular or farm dwelling?... Any existing fire, water or structural damage?... Working smoke detectors on premises?... Brush or landslide exposure?... Any dwelling or structure built on stilts?... Provide year of building updates (if over 20 years): Wiring: Plumbing: Roofing: Heating: Partial Partial Partial Partial Full Full Full Full Has property been seen by agent?... If Yes, date agent last inspected property: Please indicate the condition of the following as either good, fair, or poor: Good Fair Poor Dwelling... Outbuildings... Premises... Electrical... Housekeeping... Secondary Home... Roof... Plumbing... Page 3 of 5
4 Additional Applicant Information: Applicant s Social Security Number: Applicant s Occupation: Previous Address (if less than three years): Co-Applicant s Social Security Number: Co-Applicant s Occupation: (Street, City, County, State, Zip) Additional Comments: Additional Requirements: Photos of front and back of dwelling are required. Submit additional photo of: Any wood/coal/pellet stove Day care facility and play area Fenced pool, hot tub or spa Submit questionnaire form if: Wood/coal/pellet stove 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 our agents 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 or broker for instruction on how to submit a request to us. PRIVACY POLICY: I have received and read a copy of the Scottsdale Insurance Company Privacy Statement and Procedures. By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by Scottsdale Insurance Company and/or other members of the Scottsdale group of insurance companies. I understand and agree that any information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review, and renew the insurance for which I am applying. APPLICABLE IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties. Page 4 of 5
5 Applicant s Statement: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.) Application must be fully completed, signed and have required photos attached. Applicant s Signature: Co-Applicant s Signature: Producer s Signature: Agent Name: Agent License Number: (Applicable to Florida Agents Only) Page 5 of 5
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