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:
*
Please Select
Homeowners
Renters
Condominium
Agent Number Safeco
Agent Number Travelers
Effective Date:
*
-
Month
-
Day
Year
Date
APPLICANT INFORMATION
Name:
*
First Name
Last Name
Birthdate:
*
-
Month
-
Day
Year
Date
Marital Status:
*
Please Select
Married
Single
Divorced
Widowed
Is there a co-applicant for this policy?
*
Yes
No
Primary Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
*
example@example.com
CO-APPLICANT INFORMATION
Full Name:
First Name
Last Name
Birthdate:
-
Month
-
Day
Year
Date
Marital Status:
Please Select
Married
Single
Divorced
Widowed
Relationship to Applicant:
Please Select
Spouse
Domestic Partner
Child
Relative
Roommate
Other
ADDRESS
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the policy address the same as the mailing address?
*
Yes
No
If no, please provide:
Street Address
Street Address Line 2
City
State / 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?
*
Please Select
Yes
No
If yes, please provide details:
Is the home under construction?
*
Please Select
Yes
No
Is there a business on the premises?
*
Please Select
Yes
No
Will the residence be rented to others on a short-term basis?
*
Please Select
Yes
No
Are horses and/or livestock kept on the premises?
*
Please Select
Yes
No
Dwelling Status:
*
Please Select
Owner Occupied - Primary
Owner Occupied - Secondary
Vacant or Unoccupied
Primarily Rented to Others
If vacant, how long has the home been vacant?
Do you currently have property insurance coverage?
*
Please Select
Yes
No
Current property insurance carrier:
*
Maintenance condition of the dwelling:
*
Please Select
Excellent
Very Good
Good
Average
Fair
Poor
HISTORY VERIFICATION
Has the property insurance been cancelled, declined, or non-renewed in the last 5 years?
*
Please Select
Yes
No
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:
*
-
Month
-
Day
Year
Date
DWELLING INFORMATION
Year Built:
*
Square Footage:
*
Basement:
*
Please Select
Yes
No
If yes, % finished:
Central Air:
*
Please Select
Yes
No
Garage:
*
Please Select
Yes
No
If yes, attached or detached:
Number of garage spaces:
Construction:
*
Please Select
Frame
Joisted Masonry
Masonry
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Dwelling Style:
*
Please Select
1 Story
2 Story
Bi-Level Raised Ranch
Tri-Split Level
Manufactured Home
Mobile Home
Victorian
Row-Townhouse
Condo
Duplex
Triplex
Fourplex
Roof Material:
*
Please Select
Asphalt Shingles
Architectural Shingles
Shakes
Tar & Gravel
Steel
Wood Shingles
Tile/Clay
Slate
Rolled Rubber
Tin
Aluminum
Hail Proof
Copper
Foam
Plexiglass
Roof Renovations:
Please Select
Full
Partial
Roof Renovation Year:
Plumbing Renovation:
Heating:
*
Please Select
Gas/Forced Air
Electric/Baseboard
Oil
Radiant Floor
Freestanding Wood/Pellet/Coal Stove
Wood Furnace
Space Heaters
Propane
Hot Water/Baseboard
Exterior Walls:
*
Please Select
Wood Siding
Brick Veneer
Stucco on Frame
Vinyl Siding
Stone on Frame
Siding/Cement Fiber/Clapboard
Aluminum Siding
Brick/Solid Brick on Masonry
Concrete Block
Siding Log
Solid Log
Cinder Block
Foundation Type:
*
Please Select
Slab
Basement
Crawl Space
Daylight Basement
Piers/Pilings/Stilts
Suspended Over Hillside
Do you have any of the following? Select all that apply.
*
Wood Stove
Coal Stove
Pellet Stove
Fireplace
None
Theft Protection:
*
Local
Central
Other
None
If other, please give details:
Fire Protection Features:
*
Local
Central
Other
None
If other, please give details:
Smoke Detectors:
*
Please Select
Battery
Hard-Wired
None
Swimming Pool:
*
Please Select
Yes
No
If yes, is there a fence surrounding the pool?
Please Select
Yes
No
If yes, what is the height of the fence?
Trampoline:
*
Please Select
Yes
No
Total Number of Full Baths:
*
Total Number of Half Baths:
*
Fire Station Type:
*
Please Select
Career
Volunteer
Distance to Fire Station:
*
Distance to nearest Fire Hydrant:
*
Are there any solar panels on the dwelling?
*
Please Select
Yes
No
If yes, # of panels:
Personal Property Limit of Insurance:
*
Loss of Use:
*
Please Select
12 months
24 months
Flood Insurance:
*
Please Select
Yes
No
Is the home located in a designated high-risk flood zone?
*
Please Select
Yes
No
Earthquake Insurance:
*
Please Select
Yes
No
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):
*
Please Select
Yes
No
Identity Theft Protection:
*
Please Select
Yes
No
Home Business Endorsement (covers equipment and liability for small home-based businesses, which aren't covered under standard personal property):
*
Please Select
Yes
No
Mortgagee?:
*
Please Select
Yes
No
Mortgagee Name:
Mortgagee Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Loan Number:
DISCOUNTS & SURCHARGES
Fire Sprinkler:
*
Please Select
Yes
No
Hail Resistant Roof:
*
Please Select
Yes
No
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.
Submit
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