ASC - HOMEOWNERS INSURANCE APPLICATION

ASC - HOMEOWNERS INSURANCE APPLICATION
Agency Name:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
POLICY INFORMATION
Rating State:
Policy Form:
Agent Number Safeco
Agent Number Travelers
Effective Date:

MonthDayYear
Date
APPLICANT INFORMATION
Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Marital Status:
Is there a co-applicant for this policy?
Primary Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
CO-APPLICANT INFORMATION
Full Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Marital Status:
Relationship to Applicant:
ADDRESS
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the policy address the same as the mailing address?
If no, please provide:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UNDERWRITING
Do you or any household member have any pets or animals that have bitten or injured anyone or a dog that has been declared dangerous/vicious by a law enforcement agency?
If yes, please provide details:
Is the home under construction?
Is there a business on the premises?
Will the residence be rented to others on a short-term basis?
Are horses and/or livestock kept on the premises?
Dwelling Status:
If vacant, how long has the home been vacant?
Do you currently have property insurance coverage?
Current property insurance carrier:
Maintenance condition of the dwelling:
HISTORY VERIFICATION
Has the property insurance been cancelled, declined, or non-renewed in the last 5 years?
Number of losses in the last 5 years to the insured's home or personal possessions at this or another location:
Date the applicant became owner of the residence:

MonthDayYear
Date
DWELLING INFORMATION
Year Built:
Square Footage:
Basement:
If yes, % finished:
Central Air:
Garage:
If yes, attached or detached:
Number of garage spaces:
Construction:
Dwelling Style:
Roof Material:
Roof Renovations:
Roof Renovation Year:
Plumbing Renovation:
Heating:
Exterior Walls:
Foundation Type:
Do you have any of the following? Select all that apply.
Theft Protection:
If other, please give details:
Fire Protection Features:
If other, please give details:
Smoke Detectors:
Swimming Pool:
If yes, is there a fence surrounding the pool?
If yes, what is the height of the fence?
Trampoline:
Total Number of Full Baths:
Total Number of Half Baths:
Fire Station Type:
Distance to Fire Station:
Distance to nearest Fire Hydrant:
Are there any solar panels on the dwelling?
If yes, # of panels:
Personal Property Limit of Insurance:
Loss of Use:
Flood Insurance:
Is the home located in a designated high-risk flood zone?
Earthquake Insurance:
Scheduled Personal Property (for high-value items such as jewelry, art, firearms, collectibles, etc.) Information:
Service Line Coverage (covers underground or overhead utility lines for water, gas, electric, sewer, internet, etc. that run from the street to your home):
Identity Theft Protection:
Home Business Endorsement (covers equipment and liability for small home-based businesses, which aren't covered under standard personal property):
Mortgagee?:
Mortgagee Name:
Mortgagee Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Loan Number:
DISCOUNTS & SURCHARGES
Fire Sprinkler:
Hail Resistant Roof:
DWELLING
Dwelling Limit of Insurance:
All Perils Deductible:
Hail Deductible:
Liability Limit:
Medical Payments Limit:
Sewer & Water Backup Limit:
Notes:
After submitting your application, please follow the instructions shown on the confirmation page.
Should be Empty:

ASC - HOMEOWNERS INSURANCE APPLICATION

POLICY INFORMATION

APPLICANT INFORMATION

CO-APPLICANT INFORMATION

ADDRESS

UNDERWRITING

HISTORY VERIFICATION

DWELLING INFORMATION

DISCOUNTS & SURCHARGES

DWELLING