Homeowners Insurance Excess and Surplus Lines Basic Form

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Applicant Information
What is your first name? **
What is your first name? *
What is your middle name?
What is your middle name?
What is your last name? **
What is your last name? *
What is your email address? **
What is your email address? *
What is your phone number? **
What is your phone number? *
Select a description for this phone number?
Select a description for this phone number?
- Home
- Business
- Cellular
What is your date of birth? **
What is your date of birth? *
MM slash DD slash YYYY
This field is hidden when viewing the form
What is your social security number?
What is your social security number?
What is your gender?
What is your gender?
- Male
- Female
- Other
What is your marital status? **
What is your marital status? *
What is your occupation? (State the nature of your business if self-employed) **
What is your occupation? (State the nature of your business if self-employed) *
What is the name of your employer? **
What is the name of your employer? *
What is your mailing address? **
What is your mailing address? *

Street Address Address Line 2 City State ZIP Code
Is your mailing address also your primary home address? **
Is your mailing address also your primary home address? *
- Yes
- No
What is the address of your current residence? **
What is the address of your current residence? *

Street Address Address Line 2 City State ZIP Code
Do you own or rent your current residence? **
Do you own or rent your current residence? *
- Own
- Rent
Have you lived at your current residence for less than three years? **
Have you lived at your current residence for less than three years? *
- Yes
- No
What is the address of the residence you lived in prior to your current address? **
What is the address of the residence you lived in prior to your current address? *

Street Address Address Line 2 City State ZIP Code
How many years did you live at your previous address?
How many years did you live at your previous address?
Will there be a co-applicant for this policy? **
Will there be a co-applicant for this policy? *
- Yes
- No
Co-Applicant Information
What is the co-applicant's full name?
What is the co-applicant's full name?
What is their email address?
What is their email address?
What is their phone number?
What is their phone number?
Select a description for this phone number?
Select a description for this phone number?
- Home
- Business
- Cellular
What is their date of birth?
What is their date of birth?
MM slash DD slash YYYY
What is their gender?
What is their gender?
- Male
- Female
- Other
What is their marital status?
What is their marital status?
What is their occupation? (State the nature of their business if self-employed)
What is their occupation? (State the nature of their business if self-employed)
What is the name of their employer?
What is the name of their employer?
Application Sections
Agency Information
Click here to enter Agency information.

What is the date of this application?
What is the date of this application?
MM slash DD slash YYYY
What is the carrier name for this policy?
What is the carrier name for this policy?
What is the carrier’s NAIC code?
What is the carrier’s NAIC code?
What is the policy number?
What is the policy number?
What is the effective date of this policy?
What is the effective date of this policy?
MM slash DD slash YYYY
What is the expiration date of this policy?
What is the expiration date of this policy?
MM slash DD slash YYYY
What is the name of the agency?
What is the name of the agency?
What is the agency’s address?
What is the agency’s address?

Street Address Address Line 2 City State ZIP Code
What is the name of the agency contact?
What is the name of the agency contact?
What is the agency’s phone number?
What is the agency’s phone number?
What is the agency's fax number?
What is the agency's fax number?
What is the agency's email address?
What is the agency's email address?
This field is hidden when viewing the form
What is the agency's code?
What is the agency's code?
This field is hidden when viewing the form
What is the agency's subcode?
What is the agency's subcode?
This field is hidden when viewing the form
What is the agency customer ID?
What is the agency customer ID?
Location Schedule
Click here to enter Location Schedule information.

Please enter the address of the location(s) for which you are seeking coverage.
Please enter the address of the location(s) for which you are seeking coverage.
Location # Street City County State Zip
Property Information
Click here to enter Property information.

Please select the applicable residence type.
Please select the applicable residence type.
- Dwelling
- Apartment
- Condominium
- Townhouse
- Rowhouse
- Cooperative
Please select the occupancy of this residence.
Please select the occupancy of this residence.
- Owner
- Tenant
- Unoccupied
- Vacant
How is this property used?
How is this property used?
- Primary home
- Secondary home
- Seasonal home
- Farm
- Other
Property Usage - Other (Write in)
Property Usage - Other (Write in)
Is there any construction underway or set to begin at this residence?
Is there any construction underway or set to begin at this residence?
- Yes
- No
Please select a description for the construction at this residence.
Please select a description for the construction at this residence.
- Builders Risk (Ground Up Construction)
- Renovation
- Reconstruction
What year was this residence built? (Ie. 2005) **
What year was this residence built? (Ie. 2005) *
Please select the areas of this residence that have been partially or completely renovated. (Select all that apply) **
Please select the areas of this residence that have been partially or completely renovated. (Select all that apply) *
- Wiring
- Plumbing
- Heating
- Roofing
- Exterior paint
Was the wiring renovation partial or complete?
Was the wiring renovation partial or complete?
- Partial
- Complete
What year did the wiring renovation take place?
What year did the wiring renovation take place?
Was the plumbing renovation partial or complete?
Was the plumbing renovation partial or complete?
- Partial
- Complete
What year did the plumbing renovation take place?
What year did the plumbing renovation take place?
Was the heating renovation partial or complete?
Was the heating renovation partial or complete?
- Partial
- Complete
What year did the heating renovation take place?
What year did the heating renovation take place?
Was the roofing renovation partial or complete?
Was the roofing renovation partial or complete?
- Partial
- Complete
What year did the roofing renovation take place?
What year did the roofing renovation take place?
What year did the exterior painting renovation take place?
What year did the exterior painting renovation take place?
Please select the areas of this residence that have been partially or completely renovated. (Select all that apply) **
Please select the areas of this residence that have been partially or completely renovated. (Select all that apply) *
- Wiring
- Plumbing
- Heating
- Roofing
- Exterior paint
Was the wiring renovation partial or complete? **
Was the wiring renovation partial or complete? *
- Partial
- Complete
What year did the wiring renovation take place? **
What year did the wiring renovation take place? *
Was the plumbing renovation partial or complete? **
Was the plumbing renovation partial or complete? *
- Partial
- Complete
What year did the plumbing renovation take place? **
What year did the plumbing renovation take place? *
Was the heating renovation partial or complete? **
Was the heating renovation partial or complete? *
- Partial
- Complete
What year did the heating renovation take place? **
What year did the heating renovation take place? *
Was the roofing renovation partial or complete? **
Was the roofing renovation partial or complete? *
- Partial
- Complete
What year did the roofing renovation take place? **
What year did the roofing renovation take place? *
What year did the exterior painting renovation take place? **
What year did the exterior painting renovation take place? *
What is the square footage of the total living area?
What is the square footage of the total living area?
Are there any known leaks at this residence?
Are there any known leaks at this residence?
- Yes
- No
What roof material was used at this residence? (Ie. Asphalt, Tile, etc.)
What roof material was used at this residence? (Ie. Asphalt, Tile, etc.)
Does this residence have a primary heating system?
Does this residence have a primary heating system?
- Yes
- No
Please describe the primary heating system. (Ie. Oil, propane)
Please describe the primary heating system. (Ie. Oil, propane)
Does this residence have a secondary heating system?
Does this residence have a secondary heating system?
- Yes
- No
Please describe the secondary heating system. (Ie. Oil, Propane, Etc.)
Please describe the secondary heating system. (Ie. Oil, Propane, Etc.)
What date was the heating system last serviced?
What date was the heating system last serviced?
What type of wiring does this residence have?
What type of wiring does this residence have?
- Copper
- Aluminum
- Knob & Tube
What date was the wiring last inspected?
What date was the wiring last inspected?
Does this residence have circuit breakers or fuses?
Does this residence have circuit breakers or fuses?
- Circuit Breakers
- Fuses
How many AMPS is this residence’s electrical service? (Ie. 100 AMPS, 200 AMPS, Etc.)
How many AMPS is this residence’s electrical service? (Ie. 100 AMPS, 200 AMPS, Etc.)
Please select the option that best describes the foundation.
Please select the option that best describes the foundation.
- Open
- Closed
- None
Does this residence have a fuel tank?
Does this residence have a fuel tank?
- Yes
- No
Please select the location of the fuel tank.
Please select the location of the fuel tank.
- Indoors Above Ground Masonry Floor
- Indoors Above Ground No Masonry Floor
- Outdoors Above Ground
- Outdoors Below Ground
What is the location of the fuel line?
What is the location of the fuel line?
- Under Ground
- Through Foundation
Please select the construction type of this residence.
Please select the construction type of this residence.
- Masonry Veneer
- Frame
- Masonry
- Other (Write in)
Enter a description of the other construction type.
Enter a description of the other construction type.
What percentage of the residence is masonry veneer?
What percentage of the residence is masonry veneer?
What percentage of the residence is frame?
What percentage of the residence is frame?
What percentage of the residence is masonry?
What percentage of the residence is masonry?
What percentage of the residence is the other construction type?
What percentage of the residence is the other construction type?
What material(s) were used for this residence’s siding?
What material(s) were used for this residence’s siding?
- Aluminum Siding
- Stucco
- Vinyl Siding/Plastic
- Cedar/Wood/Shingle
- EIFSCB (on cinder block)
- EIFSS (on studs)
- Other (Write in)
Enter a description for the other type of siding.
Enter a description for the other type of siding.
What percentage of this residence’s siding is aluminum siding?
What percentage of this residence’s siding is aluminum siding?
What percentage of this residence’s siding is stucco?
What percentage of this residence’s siding is stucco?
What percentage of this residence’s siding is vinyl siding/plastic?
What percentage of this residence’s siding is vinyl siding/plastic?
What percentage of this residence’s siding is cedar/wood/shingle?
What percentage of this residence’s siding is cedar/wood/shingle?
What percentage of this residence’s siding is EIFSCB (on cinder block)?
What percentage of this residence’s siding is EIFSCB (on cinder block)?
What percentage of this residence’s siding is EIFSS (on studs)?
What percentage of this residence’s siding is EIFSS (on studs)?
What year was the EIFS (Exterior Insulation and Finishing Systems) installed?
What year was the EIFS (Exterior Insulation and Finishing Systems) installed?
What percentage of this residence’s siding is the other type of siding?
What percentage of this residence’s siding is the other type of siding?
Does this residence have a fire suppression sprinkler system?
Does this residence have a fire suppression sprinkler system?
- Yes
- No
Is the fire suppression sprinkler system partial or complete?
Is the fire suppression sprinkler system partial or complete?
- Partial
- Complete
Please select the type of smoke alarm this residence has.
Please select the type of smoke alarm this residence has.
- Centrally Monitored
- Direct Reporting
- Local
- None
Please select the type of temperature alarm this residence has.
Please select the type of temperature alarm this residence has.
- Centrally Monitored
- Direct Reporting
- Local
- None
Please select the type of burglar alarm this residence has.
Please select the type of burglar alarm this residence has.
- Centrally Monitored
- Direct Reporting
- Local
- None
What is the distance to the nearest fire hydrant? (In feet)
What is the distance to the nearest fire hydrant? (In feet)
How many miles is it to the responding fire department?
How many miles is it to the responding fire department?
What protection class is this home located in?
What protection class is this home located in?
How would you measure this residence’s distance to tidal water?
How would you measure this residence’s distance to tidal water?
- Miles
- Feet
How many miles is this residence from tidal water?
How many miles is this residence from tidal water?
How many feet away from tidal water is this residence?
How many feet away from tidal water is this residence?
Does this residence have storm shutters?
Does this residence have storm shutters?
- Yes
- No
Select the type of storm shutters.
Select the type of storm shutters.
- Class A
- Class B
- Hurricane Resistive Glass
- Other
Enter a description for this residence's storm shutters.
Enter a description for this residence's storm shutters.
What is this residence’s wind class?
What is this residence’s wind class?
- Resistive
- Semi-Resistive
- Other
Enter a description for this residence's wind class.
Enter a description for this residence's wind class.
Are you in the process of purchasing this residence?
Are you in the process of purchasing this residence?
- Yes
- No
When date will you purchase this residence?
When date will you purchase this residence?
MM slash DD slash YYYY
What is the purchase price?
What is the purchase price?
When did you purchase this residence?
When did you purchase this residence?
MM slash DD slash YYYY
What was the purchase price?
What was the purchase price?
How many families can occupy this residence?
How many families can occupy this residence?
How many apartments does this residence have?
How many apartments does this residence have?
How many weeks out of the year is this residence rented?
How many weeks out of the year is this residence rented?
Select the items this residence has.
Select the items this residence has.
- Basement
- Garage
- Breezeway
- Fireplace(s)
- Swimming Pool
What is the square footage of the basement?
What is the square footage of the basement?
What is the square footage of the garage?
What is the square footage of the garage?
What is the square footage of the breezeway area?
What is the square footage of the breezeway area?
Select the type(s) of fireplaces at this residence.
Select the type(s) of fireplaces at this residence.
- Chimney
- Hearth
- Pre-fab
- Woodstove Insert
How many chimney fireplaces?
How many chimney fireplaces?
How many hearths?
How many hearths?
How many pre-fab fireplaces?
How many pre-fab fireplaces?
How many wood stove inserts?
How many wood stove inserts?
Select the option(s) that apply for the pool at this residence.
Select the option(s) that apply for the pool at this residence.
- Above Ground
- In Ground
- Approved Fence
- Diving Board
- Slide
Select the features present at this residence. (Select all that apply)
Select the features present at this residence. (Select all that apply)
- Non-Smoker
- Manned Security
- Lightning Protection
- Off Premises Theft Exclusion
Coverages/Limits of Liability
Click here to enter Coverages/Limits of Liability information.

What is the dwelling limit?
What is the dwelling limit?
What is the other structures limit?
What is the other structures limit?
What is the personal property limit?
What is the personal property limit?
Select the desired coverage option for loss of use?
Select the desired coverage option for loss of use?
- Actual Loss Sustained
- A Set Coverage Limit
What is the loss of use limit?
What is the loss of use limit?
What is the personal liability limit for each occurrence?
What is the personal liability limit for each occurrence?
What is the medical payments limit for each occurrence?
What is the medical payments limit for each occurrence?
Select the desired coverage options for dwelling and contents.
Select the desired coverage options for dwelling and contents.
- Replacement Cost - Full Value
- Replacement Cost - Dwelling
- Replacement Cost - Contents
Please enter the percentage you would like for extended replacement cost coverage. (Ie. 125%, 150%, 200%)
Please enter the percentage you would like for extended replacement cost coverage. (Ie. 125%, 150%, 200%)
Select the deductible type(s) to be used in this policy?
Select the deductible type(s) to be used in this policy?
- All Other Perils (AOP)
- Wind/Hail
- Theft
- Named Storm
- Annual Hurricane
- Other
Is the All Other Perils (AOP) deductible a dollar amount or percentage?
Is the All Other Perils (AOP) deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the All Other Perils (AOP) deductible?
What is the dollar amount of the All Other Perils (AOP) deductible?
What is the percentage used for the All Other Perils (AOP) deductible?
What is the percentage used for the All Other Perils (AOP) deductible?
Is the wind/hail deductible a dollar amount or percentage?
Is the wind/hail deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the wind/hail deductible?
What is the dollar amount of the wind/hail deductible?
What is the percentage used for the wind/hail deductible?
What is the percentage used for the wind/hail deductible?
Is the theft deductible a dollar amount or percentage?
Is the theft deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the theft deductible?
What is the dollar amount of the theft deductible?
What is the percentage used for the theft deductible?
What is the percentage used for the theft deductible?
Is the named storm deductible a dollar amount or percentage?
Is the named storm deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the named storm deductible?
What is the dollar amount of the named storm deductible?
What is the percentage used for the named storm deductible?
What is the percentage used for the named storm deductible?
Is the annual hurricane deductible a dollar amount or percentage?
Is the annual hurricane deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the annual hurricane deductible?
What is the dollar amount of the annual hurricane deductible?
What is the percentage used for the annual hurricane deductible?
What is the percentage used for the annual hurricane deductible?
What is the other deductible type?
What is the other deductible type?
Is the Other (Write in) deductible a dollar amount or percentage?
Is the Other (Write in) deductible a dollar amount or percentage?
- Dollar Amount
- Percentage
What is the dollar amount of the Other (Write in) deductible?
What is the dollar amount of the Other (Write in) deductible?
What is the percentage used for the Other (Write in) deductible?
What is the percentage used for the Other (Write in) deductible?
What homeowners form number is being requested?
What homeowners form number is being requested?
Optional Coverages - Endorsements
Click here to enter Optional Coverages (Endorsements) information.

Please select the optional coverages and endorsements you would like to included in this policy.
Please select the optional coverages and endorsements you would like to included in this policy.
- Additional Premises Liability Extension
- Additional Residence Rented to Others
- Builders Risk Theft of Building Materials
- Builders Risk Collapse Due to Hydro-Static Pressure
- Building Ordinance or Law Coverage
- Business Property at Home
- Business Property Away from Home
- Debris Removal
- Earthquake
- Employers Liability
- Equipment Breakdown (Not applicable in NC)
- Fire Department Service Charge
- Flood
- Fungus and Mold
- Golf Carts - Liability
- Identity Fraud Expense
- Incidental Farming Personal Liability
- Increased Coverage C Special Liability Limits
- Inflation Guard
- Loss Assessment
- Mine Subsidence
- Office, Professional, Private School, Studio - Residence Premises
- Other Structures - Individual Structure
- Plants, Shrubs & Trees
- Refrigerated Food Products
- Sink Hole Collapse
- Unit-Owners Additions & Alterations Special Coverage
- Unscheduled Jewelry, Watches, Furs
- Water Backup of Sewers & Drains
- Watercraft Liability
- Watercraft Physical Damage
- Windstorm Exclusion
- Workers Compensation - Full Time Inservant
How many additional premises would you like to extend liability coverage to?
How many additional premises would you like to extend liability coverage to?
How many additional residences at this residence are rented to others?
How many additional residences at this residence are rented to others?
How many families can occupy the residence that is rented to others?
How many families can occupy the residence that is rented to others?
What limit of coverage do you want for builders risk theft of building materials?
What limit of coverage do you want for builders risk theft of building materials?
What limit of coverage do you want for builders risk collapse due to hydro-static pressure?
What limit of coverage do you want for builders risk collapse due to hydro-static pressure?
How much should the aggregate limit of coverage be for building ordinance or law coverage?
How much should the aggregate limit of coverage be for building ordinance or law coverage?
How much ($) would you like to increase the building ordinance or law coverage by?
How much ($) would you like to increase the building ordinance or law coverage by?
What percentage of the rebuild cost should the ordinance or law coverage be?
What percentage of the rebuild cost should the ordinance or law coverage be?
What limit of coverage do you want for business property at home?
What limit of coverage do you want for business property at home?
What limit of coverage do you want for business property away from home?
What limit of coverage do you want for business property away from home?
What limit of coverage do you want for debris removal?
What limit of coverage do you want for debris removal?
What do you want the percentage deductible for earthquake coverage to be?
What do you want the percentage deductible for earthquake coverage to be?
What do you want the dollar amount deductible for earthquake coverage to be?
What do you want the dollar amount deductible for earthquake coverage to be?
How many employees are there at this residence?
How many employees are there at this residence?
What limit of coverage do you want for employers liability coverage?
What limit of coverage do you want for employers liability coverage?
What do you want the deductible to be for equipment breakdown coverage?
What do you want the deductible to be for equipment breakdown coverage?
What limit of coverage do you want for equipment breakdown coverage?
What limit of coverage do you want for equipment breakdown coverage?
What limit of coverage do you want for flood damage to the building?
What limit of coverage do you want for flood damage to the building?
What limit of coverage do you want for flood damage to the contents?
What limit of coverage do you want for flood damage to the contents?
What limit of coverage do you want for fungus and mold property coverage?
What limit of coverage do you want for fungus and mold property coverage?
What limit of coverage do you want for fungus and mold liability coverage?
What limit of coverage do you want for fungus and mold liability coverage?
How many golf cart(s) do you have?
How many golf cart(s) do you have?
Enter a description of the golf cart. (Year, make, model)
Enter a description of the golf cart. (Year, make, model)
What limit of physical damage coverage do you want for your golf cart?
What limit of physical damage coverage do you want for your golf cart?
What limit of coverage do you want for identity fraud expenses?
What limit of coverage do you want for identity fraud expenses?
Do you want to include incidental farming personal liability coverage in this policy?
Do you want to include incidental farming personal liability coverage in this policy?
- Yes
- No
What percentage increase do you want for the inflation guard on this policy?
What percentage increase do you want for the inflation guard on this policy?
What limit of coverage do you want to loss assessment coverage?
What limit of coverage do you want to loss assessment coverage?
What limit of coverage do you want for mine subsidence coverage?
What limit of coverage do you want for mine subsidence coverage?
What limit of coverage do you want for other structures - individual structures coverage?
What limit of coverage do you want for other structures - individual structures coverage?
Enter a brief description of the other structure needing additional coverage?
Enter a brief description of the other structure needing additional coverage?
What limit of coverage do you want for plants, shrubs & trees?
What limit of coverage do you want for plants, shrubs & trees?
What limit of coverage do you want for refrigerated food products coverage?
What limit of coverage do you want for refrigerated food products coverage?
What limit of coverage do you want for unit-owners additions & alterations special coverage?
What limit of coverage do you want for unit-owners additions & alterations special coverage?
What limit of coverage in aggregate do you want for unscheduled jewelry, watches, and furs?
What limit of coverage in aggregate do you want for unscheduled jewelry, watches, and furs?
What limit of coverage do you want for water backup of sewers & drains coverage?
What limit of coverage do you want for water backup of sewers & drains coverage?
What limit of coverage do you want for watercraft liability coverage?
What limit of coverage do you want for watercraft liability coverage?
What limit of coverage do you want for watercraft physical damage coverage?
What limit of coverage do you want for watercraft physical damage coverage?
How many full-time employees are there at this residence?
How many full-time employees are there at this residence?
Loss History
Click here to enter Loss History information.

Have you had any losses, whether or not paid by insurance, during the last seven years, at this or any location?
Have you had any losses, whether or not paid by insurance, during the last seven years, at this or any location?
- Yes
- No
Please select the loss type.
Please select the loss type.
Enter the loss type for the first loss.
Enter the loss type for the first loss.
What was the date of loss?
What was the date of loss?
MM slash DD slash YYYY
Please enter a brief description of the loss.
Please enter a brief description of the loss.
How much was paid?
How much was paid?
Is this loss being disputed?
Is this loss being disputed?
- Yes
- No
Is there another claim? 2
Is there another claim?
- Yes
- No
Please select the loss type.
Please select the loss type.
Enter the loss type for the second loss. 2
Enter the loss type for the second loss.
What was the date of loss?
What was the date of loss?
MM slash DD slash YYYY
Please enter a brief description of the loss.
Please enter a brief description of the loss.
How much was paid?
How much was paid?
Is this loss being disputed?
Is this loss being disputed?
- Yes
- No
Is there another claim?
Is there another claim?
- Yes
- No
Please select the loss type.
Please select the loss type.
Enter the loss type for the third loss.
Enter the loss type for the third loss.
What was the date of loss?
What was the date of loss?
MM slash DD slash YYYY
Please enter a brief description of the loss.
Please enter a brief description of the loss.
How much was paid?
How much was paid?
Is this loss being disputed?
Is this loss being disputed?
- Yes
- No
Is there another claim?
Is there another claim?
- Yes
- No
Please select the loss type.
Please select the loss type.
Enter the loss type for the fourth loss.
Enter the loss type for the fourth loss.
What was the date of loss?
What was the date of loss?
MM slash DD slash YYYY
Please enter a brief description of the loss.
Please enter a brief description of the loss.
How much was paid?
How much was paid?
Is this loss being disputed?
Is this loss being disputed?
- Yes
- No
Please enter your initials for the Loss History section.
Please enter your initials for the Loss History section.
Prior Coverage
Click here to enter Private Coverage information.

Did you previously have insurance for this residence?
Did you previously have insurance for this residence?
- Yes
- No
What is the name of the insurance company that previously insured this residence?
What is the name of the insurance company that previously insured this residence?
What is the previous insurance carrier’s policy number?
What is the previous insurance carrier’s policy number?
What is the expiration date of the previous insurance policy?
What is the expiration date of the previous insurance policy?
General Information
Click here to enter General information.

Do you have any other insurance with this company/agency?
Do you have any other insurance with this company/agency?
- Yes
- No
Please enter the line of business for the first policy type you have. (Ie. Homeowners, Automobile, etc.)
Please enter the line of business for the first policy type you have. (Ie. Homeowners, Automobile, etc.)
Please enter the policy number for the first policy type you have.
Please enter the policy number for the first policy type you have.
Please enter the line of business for the second policy type you have. (Ie. Homeowners, Automobile, etc.) (Skip if no other policy exists)
Please enter the line of business for the second policy type you have. (Ie. Homeowners, Automobile, etc.) (Skip if no other policy exists)
Please enter the policy number for the second policy type you have. (Skip if no other policy exists)
Please enter the policy number for the second policy type you have. (Skip if no other policy exists)
Has any coverage been declined, canceled or non-renewed during the last three (3) years? (Missouri Applicants - Do not answer this question)
Has any coverage been declined, canceled or non-renewed during the last three (3) years? (Missouri Applicants - Do not answer this question)
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Have you (the Applicant) had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years?
Have you (the Applicant) had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Have you (the Applicant) had a judgement or lien during the past (5) years?
Have you (the Applicant) had a judgement or lien during the past (5) years?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Is any other residence, not listed on any application, owned, occupied or rented?
Is any other residence, not listed on any application, owned, occupied or rented?
- Yes
- No
Please enter the address of your other residence(s).
Please enter the address of your other residence(s).
Has insurance been transferred within the agency?
Has insurance been transferred within the agency?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Do you (the Applicant) own any recreational vehicles (Snow mobiles, dune buggies, mini bikes, ATVs, etc.) not scheduled on this policy?
Do you (the Applicant) own any recreational vehicles (Snow mobiles, dune buggies, mini bikes, ATVs, etc.) not scheduled on this policy?
- Yes
- No
How many recreational vehicles do you (the Applicant) own? (Please enter a numeral)
How many recreational vehicles do you (the Applicant) own? (Please enter a numeral)
Please enter the year, make, model and body type of the recreational vehicles you own.
Please enter the year, make, model and body type of the recreational vehicles you own.
Year Make Model Body Type
During the last five (5) years [Ten (10) years in Rhode Island], have you (any Applicant) been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with the or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)
During the last five (5) years [Ten (10) years in Rhode Island], have you (any Applicant) been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with the or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
General Information - Residential
Click here to enter General information (Residential).

Is any business conducted on the premises?
Is any business conducted on the premises?
- Yes
- No
Please select the business type(s) conducted on premises.
Please select the business type(s) conducted on premises.
- Farming
- Telecommuter
- Day Care
- Home Office/Business
- Other
Enter the Other business type conducted on premises.
Enter the Other business type conducted on premises.
How my children attend the day care?
How my children attend the day care?
Do you (the Applicant) have any residence employees?
Do you (the Applicant) have any residence employees?
- Yes
- No
How many full-time employees?
How many full-time employees?
Enter a brief job description for the full-time residence employee(s).
Enter a brief job description for the full-time residence employee(s).
How many part-time employees?
How many part-time employees?
Enter a brief job description for the part-time residence employee(s).
Enter a brief job description for the part-time residence employee(s).
Is there any flooding, brush, forest fire or landslide hazard at this residence?
Is there any flooding, brush, forest fire or landslide hazard at this residence?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Are there any animals or exotic pets kept on premises?
Are there any animals or exotic pets kept on premises?
- Yes
- No
How many animals or exotic pets are kept on premises? (Please enter a numeral)
How many animals or exotic pets are kept on premises? (Please enter a numeral)
Please enter the Animal Type, Breed, and if there is a bite history (Y/N).
Please enter the Animal Type, Breed, and if there is a bite history (Y/N).
Animal Type Breed Bite History (Y/N)
Is the property situated on more than one acre?
Is the property situated on more than one acre?
- Yes
- No
How many acres are there?
How many acres are there?
What is the land used for?
What is the land used for?
Are there any uncorrected fire or building code violations?
Are there any uncorrected fire or building code violations?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Is the dwelling/home for sale?
Is the dwelling/home for sale?
- Yes
- No
Is the property within 300 feet of a commercial or non-residential property?
Is the property within 300 feet of a commercial or non-residential property?
- Yes
- No
Please provide a detailed explanation.
Please provide a detailed explanation.
Is there a trampoline on premises?
Is there a trampoline on premises?
- Yes
- No
Does the trampoline have a safety net?
Does the trampoline have a safety net?
- Yes
- No
Was the structure originally built to be other than a private residence and then converted to a private residence?
Was the structure originally built to be other than a private residence and then converted to a private residence?
- Yes
- No
What was the original occupancy?
What was the original occupancy?
Is there any lead paint?
Is there any lead paint?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
If a fuel tank is on premises, has other insurance been obtained for the tank?
If a fuel tank is on premises, has other insurance been obtained for the tank?
- Yes
- No
What is the name of the insurance company for the tank?
What is the name of the insurance company for the tank?
What is the limit of coverage for the fuel tank on that policy?
What is the limit of coverage for the fuel tank on that policy?
What is the cleanup coverage sublimit on that policy?
What is the cleanup coverage sublimit on that policy?
Is the residence in a gated community?
Is the residence in a gated community?
- Yes
- No
What is the name of the gated community?
What is the name of the gated community?
If the building is under construction, are you (the Applicant) the general contractor?
If the building is under construction, are you (the Applicant) the general contractor?
- Yes
- No
What is the construction start date?
What is the construction start date?
MM slash DD slash YYYY
What is the construction estimated completion date?
What is the construction estimated completion date?
MM slash DD slash YYYY
What percentage of the construction project will be done on the interior of the residence?
What percentage of the construction project will be done on the interior of the residence?
What percentage of the construction project will be done on the exterior of the residence?
What percentage of the construction project will be done on the exterior of the residence?
If there will be an addition, how many additional square feet are being added?
If there will be an addition, how many additional square feet are being added?
If another level is being added to the residence, how many additional square feet will the additional level add to the residence?
If another level is being added to the residence, how many additional square feet will the additional level add to the residence?
Will the construction include any structural changes to the residence?
Will the construction include any structural changes to the residence?
- Yes
- No
Do you (the Applicant) want to include or exclude coverage for building materials that are not yet attached to the residence?
Do you (the Applicant) want to include or exclude coverage for building materials that are not yet attached to the residence?
- Include
- Exclude
Will the residence be occupied during the construction?
Will the residence be occupied during the construction?
- Yes
- No
What is the total cost of the construction project?
What is the total cost of the construction project?
Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes? (Illinois - 15ft)
Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes? (Illinois - 15ft)
- Yes
- No
Are you (the Applicant) the owner of the property?
Are you (the Applicant) the owner of the property?
- Yes
- No
What is the name of the owner of this residence?
What is the name of the owner of this residence?
General Information - Renters and Condos Only
Click here to enter General information (Renters & Condos).

Is there a manager on the premises?
Is there a manager on the premises?
- Yes
- No
What is the manager’s name?
What is the manager’s name?
What is the manager's phone number?
What is the manager's phone number?
Is there a security attendant?
Is there a security attendant?
- Yes
- No
Please provide a brief explanation.
Please provide a brief explanation.
Is the building entrance locked?
Is the building entrance locked?
- Yes
- No
Additional Interest(s)
Click here to enter Additional Interest(s) information.

Is there an additional interest to be added to this policy?
Is there an additional interest to be added to this policy?
- Yes
- No
Please select the type of additional interest?
Please select the type of additional interest?
- Additional Insured
- Lender's Loss Payable
- Lienholder
- Loss Payee
- Mortgagee
- Trustee
What is the name of the additional interest?
What is the name of the additional interest?
What is the additional interest’s address?
What is the additional interest’s address?

Street Address Address Line 2 City State ZIP Code
What is the reference/loan #?
What is the reference/loan #?
What is the rank of this additional interest relative to other additional interests?
What is the rank of this additional interest relative to other additional interests?
Is there a second additional interest?
Is there a second additional interest?
- Yes
- No
Please select the type of additional interest?
Please select the type of additional interest?
- Additional Insured
- Lender's Loss Payable
- Lienholder
- Loss Payee
- Mortgagee
- Trustee
What is the name of the additional interest?
What is the name of the additional interest?
What is the additional interest’s address?
What is the additional interest’s address?

Street Address Address Line 2 City State ZIP Code
What is the reference/loan #?
What is the reference/loan #?
What is the rank of this additional interest relative to other additional interests?
What is the rank of this additional interest relative to other additional interests?
Remarks/Attachments
Click here to add Remarks/Attachments.

Please enter additional remarks regarding the insurance for this residence in the space below.
Please enter additional remarks regarding the insurance for this residence in the space below.
Please select the supplemental applications/notices you would like to include with this application.
Please select the supplemental applications/notices you would like to include with this application.
- Earthquake Application
- Flood Exclusion Notice
- Lead Free Paint Certification
- Mobile Home Supplement
- Personal Inland Marine Section
- Personal Umbrella Application Section
- Photograph
- Protection Device Certificate
- Replacement Cost Estimate
- Residence Based Business Supplemental
- Solid Fuel Supplemental
- State Supplement(s) (if applicable)
- Watercraft Section
- Windstorm Loss Mitigation
Payment Plan
Click here to enter Payment Plan information.

What is the deposit amount for this policy?
What is the deposit amount for this policy?
What is the estimated total premium?
What is the estimated total premium?
Select the billing set up for this policy.
Select the billing set up for this policy.
- Direct Bill - Policy
- Direct Bill - Account
- Agency Bill
Select the payment plan for this policy.
Select the payment plan for this policy.
- Full Pay
- Annual
- Semi-Annual
- Quarterly
- Bi-Monthly
- Monthly
Select the payment method for this policy.
Select the payment method for this policy.
- Cash
- Check
- Credit Card
- EFT
- Payroll Deduction
- Pre-Authorized Draft/Check (PAC)
Who will the policy be mailed to?
Who will the policy be mailed to?
- Agent
- Insured
Who is the payor?
Who is the payor?
- Insured
- Mortgagee
- Other
Enter who will pay the bill for this policy.
Enter who will pay the bill for this policy.
Will this policy use premium financing?
Will this policy use premium financing?
- Yes
- No
What is the name of the premium finance company?
What is the name of the premium finance company?
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form. Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. **
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
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Veronica Benson

Veronica is an experienced personal insurance professional with over 25 years of experience.

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Homeowners Insurance Excess and Surplus Lines Basic Form

Applicant Information

Co-Applicant Information

Application Sections

Agency Information

Location Schedule

Property Information

Coverages/Limits of Liability

Optional Coverages - Endorsements

Loss History

Prior Coverage

General Information

General Information - Residential

General Information - Renters and Condos Only

Additional Interest(s)

Remarks/Attachments

Payment Plan

Veronica Benson

RiskRevu^TM Newsletter

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Location #	Street	City	County	State	Zip

Year	Make	Model	Body Type

Animal Type	Breed	Bite History (Y/N)

Homeowners Insurance Excess and Surplus Lines Basic Form

Applicant Information

Co-Applicant Information

Application Sections

Agency Information

Location Schedule

Property Information

Coverages/Limits of Liability

Optional Coverages - Endorsements

Loss History

Prior Coverage

General Information

General Information - Residential

General Information - Renters and Condos Only

Additional Interest(s)

Remarks/Attachments

Payment Plan

Veronica Benson

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RiskRevu^TM Newsletter