RENTAL DWELLING POLICY APPLICATION ... - Deans & Homer

DATE APPLICATION COMPLETED: ___________ INCEPTION DATE: _________ SPECIAL FORM POLICY IS: □ NEW □ RENEWAL OF __________ □ REWRITE OF ___________ NAMED PERIL FORM

PRODUCER: (NAME AND ADDRESS) INSURED: (NAME AND ADDRESS)

MORTGAGEE: (NAME AND ADDRESS) PROPERTY ADDRESS:

REPLACEMENT COST: YES NO OWNERS, LANDLORDS AND TENANTS LIABILITY: A) DWELLING $__________

ATTACHED GARAGE $__________ DETACHED GARAGE $__________

B) DESCRIBE APPURTENANT STRUCTURESGUEST HOUSE $__________ BARN $__________ SWIMMING POOL $__________ OTHER $__________

C) DECLARED PERSONAL PROPERTY $___________

$100,000 $300,000 $500,000 $1,000,000

PERSONAL INJURY COVERAGE: YES NO COVERAGE FOR PERSONAL INJURY SUBJECT TO ACCEPTABLE UNDERWRITING

GREEN BUILDING COVERAGE: YES NO

DEDUCTIBLES: $ 250 $ 500 $ 1,000 $__________ (OTHER – PLEASE ENTER AMOUNT) INSTALLMENT OPTION: □ SEMI-ANNUAL □ QUARTERLYPAYMENT OPTION: □ ANNUAL BILL OR

BILL AGENCY OR DIRECT BILL: □ BILL INSURED □ BILL MORTGAGEE

YESINCREASED BUILDING ORDINANCE COVERAGE: NO INCREASED LIMIT $______________ INCREASED LIMIT FOR DEBRIS REMOVAL: $________________ OPTIONAL EARTHQUAKE COVERAGE (THIS OPTION IS ONLY AVAILABLE IN CALIFORNIA): YES NO

DISTANCE APPROVED HYDRANT: _________________ PROTECTION CLASS: ____________ DISTANCE TO RESPONDING FIRE STATION:___________ VALUE COMPUTATION:

LIVING AREA:____________________________ SQ. FT BASEMENT: ____________________________ SQ. FT APPURTENANT STRUCTURE: ________________ SQ. FT

PORCHES, DECKS, UNFINISHED AREA: _________SQ. FT ATTACHED GARAGE: ______________________ SQ. FT DETACHED GARAGE: ______________________ SQ. FT

DESCRIBE THE APPURTENANT STRUCTURE(S): ____________________________________________________BUILDING INFORMATION

1) YEAR BUILT _______ 2) AGE OF ROOF ______ AND CONDITION __________________ TILE ______%

METAL ______ % OTHER ______% 3) ROOF COVER: COMPOSITION SHINGLE _____ %

WOOD SHINGLE/SHAKE ______%

4) YEAR THE FOLLOWING WERE BROUGHT UP TO CODE: WIRING _______ HEATING ______ PLUMBING ______ 5) PLUMBING TYPE: PEX GALVANIZED PIPE COPPER PIPE OTHER

6) IS WIRING ON 100% CIRCUIT BREAKERS? YES

7) PERCENT OF TOTAL LIVING AREA ABOVE GARAGE: NONE 25% 50% 75% 100% 8) IS BUILDING BOLTED TO FOUNDATION? YES NO

9) IF BASEMENT, AMOUNT OF AREA THAT IS FINISHED: _____ %10) EXTERIOR WALL MATERIAL: WOOD FRAME ___% FRAME STUCCO___% BRICK___% OTHER: __________ ___% 11) USE: SINGLE FAMILY DETACHED 2-FAMILY DUPLEX 3-FAMILY TRIPLEX 4-FAMILY FOUR-PLEX

12) DWELLING FURNISHED? YES NO IF YES, # OF UNITS ______ OR ALL UNITS

13) NUMBER OF STORIES: _____ (PLEASE INDICATE IF THERE ARE HALF STORIES)

: : TAR & GRAVEL ______%

NO

DH 25-10 (09-19) of 4 This product is provided by Deans & Homer on behalf of Aspen American Insurance Company and Fidelity & Deposit Company of Maryland.Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

Insurance Managing Underwriters

RENTAL DWELLINGPOLICY APPLICATION

:

14) PROTECTIVE SYSTEMS: NONE ULOCAL ALARM:U UREMOTELY MONITORED ALARM: □ BURGLARY □ CENTRAL STATION BURGLAR ALARM

□ FIRE □ CENTRAL STATION FIRE ALARM

□ CARBON MONOXIDE □ INTERIOR BUILDING MONITORED SPRINKLER SYSTEM

ADDITIONAL UNDERWRITING INFORMATION

OUR ACCEPTANCE OF THIS RISK WILL DEPEND ON THE COMPLETENESS AND ACCURACY OF THE FOLLOWING ANSWERS. 1. PREVIOUS CARRIER __________________________________________ POLICY NO. ______________________2. HAS ANY CARRIER CANCELLED, REQUESTED REPLACEMENT OR REFUSED RENEWAL? YES NO

IF YES, EXPLAIN: _____________________________________________________________________________________________________________________________________________________________________

3. LIST CLAIMS OR LOSSES FOR LAST 3 YEARS AND, IF ANY, PRIOR TO THAT: ____________________________________________________________________________________________________________________________

4. PRODUCER, HOW LONG HAVE YOU KNOWN THE INSURED? ___________ YEARS 5. PRODUCER, HOW LONG HAVE YOU WRITTEN INSURED’S INSURANCE? ___________ YEARS

6. IF CORPORATE OWNED, DOES THE CORPORATION CONDUCT OPERATIONS OTHER THAN OWNERSHIP OF RENTAL DWELLINGS?IF SO, EXPLAIN ______________________________________________________________________________

7. DWELLING PURCHASE PRICE: $__________________ DATE OF PURCHASE: ____________________ 8. IF TENANT OCCUPIED:

a. WHAT IS THE ANNUAL RENTAL INCOME? $_______________b. DOES THE INSURED EMPLOY A PROPERTY MANAGEMENT FIRM? YES NO

IF THE ANSWER TO 8.B. IS YES, PROVIDE THE NAME OF THE MANAGEMENT COMPANY:_________________________________________________________________________________

c. DOES THE INSURED REQUIRE A SECURITY/DAMAGE DEPOSIT FROM TENANTS? YES $_______ NO 9. IS DWELLING VACANT OR UNOCCUPIED? YES NO

IF YES, A) ON WHAT DATE DID THE DWELLING BECOME VACANT:_________________________________B) IS BUYBACK COVERAGE DESIRED FOR VANDALISM, MALICIOUS MISCHIEF, THEFT, ATTEMPTED

THEFT IF DWELLING IS VACANT FOR MORE THAN 60 DAYS: YES NO 10. IS DWELLING IN OR NEAR A WOODED AREA? YES NO IF YES, DISTANCE TO AREA: __________ 11. IS DWELLING IN OR NEAR A DESIGNATED BRUSH AREA? YES NO IF YES, DISTANCE TO BRUSH: ________

12. ARE THERE ANY UNUSUAL EXPOSURES WE SHOULD KNOW ABOUT? YES NO IF YES, EXPLAIN: ____________________________________________________________________________

13. QUALITY GRADE OF CONSTRUCTION? ECONOMY STANDARD ABOVE AVERAGE CUSTOM PREMIUM

14. PROPERTY SLOPE? NONE (0-15O) MODERATE (16-30 O) STEEP (OVER 30 O) YES NO YES NO YES NO

15. IS DWELLING NEAR A BODY OF WATER?16. ANY DOCKS OR PIERS ON PREMISES?17. DOES DWELLING HAVE A WOOD BURNING HEATING DEVICE?18. PHOTOGRAPH OF DWELLING – PLEASE ATTACH




FRAUD WARNING: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. (Not applicable in AK, AR, AZ, CA, CO, DE, DC, FL, ID, IN, KY, LA, MD, ME, MN, NH NJ, NM, NY, OH, OK, OR, PA, RI, TN, TX, WA and WV.)

STATE FRAUD STATEMENTS

ALASKAAny person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.

ARIZONAFor your protection Arizona state law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

ARKANSASAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIAFor your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADOFor your protection Colorado law requires the following to appear on this form. It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DELAWAREAny person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

DISTRICT OF COLUMBIAWarning: It is a crime to provide false or misleading information to any insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

FLORIDAAny person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

IDAHOAny person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading information is guilty of a felony.

INDIANAAny person who knowingly and with intent to defrauds an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.

KENTUCKYAny person who, knowingly and with intent to defraud any insurance company or other person, files a statement of claim containing any materially false information or conceals, for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

LOUISIANAAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MAINEIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.




MARYLANDAny person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MINNESOTAA person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NEW HAMPSHIREAny person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NEW JERSEYAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICOAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NEW YORKAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

OHIOAny person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OKLAHOMAWARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

OREGONAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

PENNSYLVANIAAny person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

RHODE ISLANDAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

TENNESSEEIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

TEXASAny person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

VIRGINIAIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WASHINGTONIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WEST VIRGINIAAny person who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of crime and may be subject to fines and confinement in prison.

______________________________________________ Signature of Insured or Agent




RENTAL DWELLING POLICY APPLICATION ... - Deans & Homer

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