B&W APP

Applicant's Name
Applicant DOB
Address
Agency
Occupation
Prior Carrier
Expiration date of prior coverage

MonthDayYear
Date
Prior Address
Location of Premises
Our Markets allow us the flexibility to quote risks with non-traditional

limits for Coverages B, C & D. Lowering any of these coverages will result

in a lower premium, but will most likely not effect the replacement cost
Usage Type

Please Select:Primary
of weeks rented
Dwelling Limit
Other Structures
HO3

HO4Secondary
HO3

HO6Secondary/Rental
HO3

DP1Tenant Occupied
HO3

DP3Vacant
Personal Property
Loss of Use
Liability
AOP Deductible
Wind/Hail or Named Storm Deductible
Wind/Hail or Named Storm Deductible
Wind/Hail or Named Storm Deductible
Optional Endorsements (Check box for "Yes"):
Construction
125% ERC

Optional Endorsements (Check box for "Yes"):
125% ERC

ID Fraud Limit:Water Backup Limit:Earthquake:
125% ERC

Replacement Cost on Contents:
125% ERC

Personal Injury:Other (Please List):
ID fraud limit field
Year Built
Roof

Complete:Partial:
Electric

Complete:Partial:
Square Feet
# of Stories
Year
Year
# of Families
PC
Partial:

Partial:Complete:
Historical Registry
Gutted and Redone
Year
Year
Roof Type:

Fuses: Yes No# of Amps:
Fuses: Yes No

Knob & Tube: Yes NoAdditional Underwriting Info:
# of Amps
Galvanized Plumbing
Galvanized Plumbing:

Yes NoAvailable Credits:
Additional Underwriting Info:

IF YOU HAVE NOT ALREADY, PLEASE INFORM YOUR CLIENT THAT PERSONAL INFORMATION ABOUT THEM, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN THE APPLICANT IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. 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 AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER ELIGIBILITY FOR INSURANCE OR THE PREMIUM TO BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF THE INSURANCE SCORE.Complete:
Claims Information (past 3 years): 4.

Central Station Alarm:
Claims Information (past 3 years): 4.

Gated Community:Storm Shutters:Roof Straps:Hurricane Glass:Pre-Cut Plywood:
Yes

Yes3.Animal on Premises
No

1.Swimming Pool2.Any Bankruptcy or ForeclosureNo
No

YesNo
Remarks
Effective Date Requested

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Should be Empty: