| Insured Information |
| Desired Effective Date
Required
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| First Name
Required
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| Last Name
Required
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| Named Insured (2) |
| Marital Status
Required
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| Location Address |
| ZIP / Postal Code
Required
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| Mailing Address |
| ZIP / Postal Code
Required
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| Contact Info. |
| Primary Phone Number
Required
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| E-Mail Address
Required
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| Current Insurance Information |
| Insurance Carrier
Required
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| Current Premium
Required
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| Policy No.
Required
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| Effective Dates
Required
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| Liability Limit
Required
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| Deductible
Required
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| # of Homes Owner Occupied
Required
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| # of Homes Rented to Others
Required
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| # of Familes of those Rented to Others
Required
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| # of vehicles
Required
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| # Owned or Leased
Required
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| # Furnished for Regular Use
Required
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| # of drivers
Required
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| # of Youthful Operators
Required
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| # of watercraft
Required
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| General |
| Are all underlying carriers rated B+ or better by A.M. Best?
Required
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| Has one or more of the risks been sued for libel, slander or discrimination?
Required
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| Has one or more of the risks had a liability claim(s) of $20k + in the past 5 yrs?
Required
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| Does one or more risk(s) handle, transport or store fireworks or ammunition?
Required
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| Automobile |
| Has one or more driver(s) had a license suspension, revocation or been refused a license for reasons related to the driving record of the driver in the last two (2) years?
Required
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| Has one or more driver(s) had a citation for driving under the influence of drugs or alcohol in the last two (2) years?
Required
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| Has one or more driver(s) had a citation for reckless driving, speed contest, vehicular manslaughter or homicide in the last two (2) years?
Required
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| Does one or more driver(s) own a high performance automobile and are under 30 years of age?
Required
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| Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle?
Required
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| Is one or more driver(s) covered in an assigned risk or similar plan or have restricted coverage under their primary insurance policy?
Required
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| Is one or more driver(s) under the age of 21 and have had an at-fault accident or two moving violations?
Required
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| Property |
| Does one or more insured(s) own a rental property larger than a four family dwelling?
Required
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| Does one or more insured(s) own more than four rental properties, including those that are four family dwellings?
Required
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| Does the risk(s) have an underground storage tank?
Required
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| Does the risk(s) have home daycare facilities on the residence premises?
Required
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| Are there animals of any type with a bite history on the premises?
Required
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| Watercraft |
| Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle?
Required
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| Does one or more insured(s) own any unusual watercraft including, but not limited to, a homemade boat, hydroplane, jet ski?
Required
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| Does one or more insured(s) own any watercraft that is more than 50 feet in length or has a total horsepower over 250?
Required
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| Pools/Tramplolines |
| Does the risk(s) have trampoline(s) including those with the safety nets?
Required
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| Does the risk(s) have a pool on the premises that is unfenced or has a sliding/diving board?
Required
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| Primary Policy Information |
| Type Of Policy
Required
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| Company Name/Policy Number
Required
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| Policy Period
Required
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| Limits of Liability: Single
Required
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| Limits of Liability: Bodily Injury
Required
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| Limits of Liability: Property Damage
Required
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| Real Estate |
| LIST ALL OWNED, LEASED OR OCCUPIED RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC. |
| Location
Required
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| Description
Required
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| Year built
Required
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| Interest
Required
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| Occupancy
Required
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| Automobiles |
| LIST ALL AUTOS OWNED, LEASED OR FURNISHED FOR REGULAR USE |
| Year built
Required
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| Make and Model
Required
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| Recreational Vehicles |
| LIST MOTORCYCLES, SNOWMOBILES, DUNE BUGGIES, ETC. |
| Year built
Required
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| Make and Model
Required
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| Watercraft |
| LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE |
| Motor Type, Make & Model
Required
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| Length, Horsepower & Max Speed
Required
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| Cost New & Current Value
Required
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| Waters Navigated
Required
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| Operator Information |
| LIST ALL MEMBERS OF THE HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED BY COMPANY |
| Name, Sex, Marital Status
Required
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| Date of Birth
Required
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| Date Licensed
Required
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| Drivers License # & Issuing State
Required
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| Vehicle/Craft
Optional
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| Percentage of Use
Required
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| Employment |
| Occupations Named Insured (1)
Required
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| Employer Name & Address
Required
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| Years Employed
Required
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| Occupations Named Insured (2)
Optional
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| Other Policy Endorsemens Not Described Above
Optional
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| Agency/Agent Information |
| Agency Number
Required
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| Agent Email Address
Required
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