Insured Information

Name:
Mailing Address:
City:
State:	Zip:
Phone Number:
Insured Location:
City:
State:	Zip:
(1)SSN #:	DOB:
(2)SSN #:	DOB:
Occupation:
Name of Employer:
Address of Employer:
Position Held:

Agent Information

Producer:
Address:
City:
State:	Zip:
Phone:
Fax:

Mortgagee(s) Information/Additional Interests

Loan Number 1:
Name:
Address:
City:
State:	Zip:
Loan Number 2:
Name:
Address:
City:
State:	Zip:

Protection Information

Distance To Fire Hydrant:	Fire Station:
Is the Fire Department:	Paid Volunteer
Fire Dept. Response Time:	min. (For PC 9/10 only)
Distance to the nearest water source:
Type of water source:
Central Alarm
Fire: Burglar:
Sprinkler System:	Full Partial None
Protection Class:
Smoke Detectors:	Y N
Dead Bolts:	Y N

Limits of Policy

Dwelling:	$
Other Structures:	$
Personal Property:	$
Loss of Use/Fair Rental:	$
Personal Liability:	$
Medical Payments:	$
Loss Assessment Coverage:	$

Optional Coverages

Replacement Cost on Contents:	Y N
Increased Limits - Jewelry, Watches, Furs:	Y N
Extending Liability: #locations	State:
Earthquake Coverage: Y N	EQ Zone:
(HO6 Only): All Risk Coverage Dwelling	Y N

Deductibles (subject to company guidelines)

Requested Deductible:	AOP:$ Wind: % EQ: %
Eligible for Windpool	Y N
Exclude Wind	Y N
(NC Only) Wind Deductible Buyback	Y N %

Property Information:

Occupancy:	Primary Secondary/Seasonal Rental
Is the home occupied daily:	Y N
Unoccupied more than 30 consecutive days:	Y N
If home is rented, number of weeks:
Is the home visible to neighbors:	Y N
Home up for sale:	Y N
Caretaker/Property Manager:	Y N
Resident Paid Non Resident Paid
Has applicant had a foreclosure, repossession, or bankruptcy during the past five years:	Y N
Describe:
Gated Community: Patrolled:	Y N Y N
Building undergoing any renovation:	Y N
Builders Risk/Renovation: Est. date of completion
Estimated Replacement cost upon completion:
ISO Territory #: BCEGS#:

Type of Foundation:

List other structures and values on the premises:

Remarks:

Three year loss history - Must be filled out Completely

Date	Type of Loss	Cause	Amount

What preventative measures have been taken to prevent future losses? Explain:

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 your agent may in certain surcomstances 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/broker for instruction on how to submit a request to us.

NOTE TO AGENTS: No binding or quoting authority! Please call or fax for same day binding and follow up with an application. Application must be signed by the named insured. Any incomplete applications recieved could jeopardize binding coverage!