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?*

YesNo
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?*

YesNo
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.*

Wood StoveCoal StovePellet StoveFireplaceNone
Theft Protection:*

LocalCentralOtherNone
If other, please give details:
Fire Protection Features:*

LocalCentralOtherNone
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