Insured Information
Desired Effective Date *
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Named Insured (2)
Marital Status *
Location Address
Mailing Address
Contact Info.
Current Insurance Information
# of Homes Owner Occupied *
# of Homes Rented to Others *
# of Familes of those Rented to Others *
# Owned or Leased *
# Furnished for Regular Use *
# of drivers *
# of Youthful Operators *
# of watercraft *
General
Are all underlying carriers rated B+ or better by A.M. Best? *
Has one or more of the risks been sued for libel, slander or discrimination? *
Has one or more of the risks had a liability claim(s) of $20k + in the past 5 yrs? *
Does one or more risk(s) handle, transport or store fireworks or ammunition? *
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? *
Has one or more driver(s) had a citation for driving under the influence of drugs or alcohol in the last two (2) years? *
Has one or more driver(s) had a citation for reckless driving, speed contest, vehicular manslaughter or homicide in the last two (2) years? *
Does one or more driver(s) own a high performance automobile and are under 30 years of age? *
Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle? *
Is one or more driver(s) covered in an assigned risk or similar plan or have restricted coverage under their primary insurance policy? *
Is one or more driver(s) under the age of 21 and have had an at-fault accident or two moving violations? *
Property
Does one or more insured(s) own a rental property larger than a four family dwelling? *
Does one or more insured(s) own more than four rental properties, including those that are four family dwellings? *
Does the risk(s) have an underground storage tank? *
Does the risk(s) have home daycare facilities on the residence premises? *
Are there animals of any type with a bite history on the premises? *
Watercraft
Is one or more driver(s) involved in the organized racing or speed contest of any motor vehicle? *
Does one or more insured(s) own any unusual watercraft including, but not limited to, a homemade boat, hydroplane, jet ski? *
Does one or more insured(s) own any watercraft that is more than 50 feet in length or has a total horsepower over 250? *
Pools/Tramplolines
Does the risk(s) have trampoline(s) including those with the safety nets? *
Does the risk(s) have a pool on the premises that is unfenced or has a sliding/diving board? *
Primary Policy Information
Type Of Policy *
Real Estate
LIST ALL OWNED, LEASED OR OCCUPIED RESIDENCES, BUILDINGS, FARMS, VACANT LAND, ETC.
Year built *
Automobiles
LIST ALL AUTOS OWNED, LEASED OR FURNISHED FOR REGULAR USE
Year built *
Recreational Vehicles
LIST MOTORCYCLES, SNOWMOBILES, DUNE BUGGIES, ETC.
Year built *
Watercraft
LIST ALL WATERCRAFT OWNED, LEASED, CHARTERED OR FURNISHED FOR REGULAR USE
Operator Information
LIST ALL MEMBERS OF THE HOUSEHOLD AND ALL OPERATORS OF VEHICLES/WATERCRAFT AS REQUIRED BY COMPANY
Date of Birth *
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Date Licensed *
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Percentage of Use *
Employment
Years Employed *
Other Policy Endorsemens Not Described Above
Agency/Agent Information