Home owners Applicant's Name: Applicant DOB: Occupation: Prior Carrier: Target Premium: Current Carrier: Address: AGENCY: Prior Address: Location of Premises if different from Prior (unit #, city, state, zip): Our Markets allow us the flexibility to quote risks with non-traditional limits for Coverages B, C & D. Lowering any of these coverages will result in a lower premium, but will most likely not effect the replacement cost on contents. Please Select: HO3 HO4 HO6 DP1 DP3 Usage Type: Primary Secondary Secondary/Rental Tenant Occupied Vacant Builder's Risk (contact UW for supplement) of weeks rented: Dwelling Limit: Personal Property: Liability: Medical Payments: Other Structures: Loss of Use: AOP Deductible: Wind Deductible: Wind/Hail or Named Storm Deductible: Optional Endorsements (Check box for "Yes"): 125% ERC ID Fraud Limit Water Backup Limit Earthquake Replacement Cost on Contents Personal Injury Other (Please List) Construction: Construction: Frame Masonry ven. Masonry Other Log EIFS Year Built: Square Feet: # of Stories: # of Families: PC: Historical Registry: Gutted and Redone: Roof Type: Update Information: Roof: Partial: Complete:year Electric: Partial: Complete:year Plumbing: Partial: Complete:year Heating: Partial: Complete:year Additional Underwriting Info: Swimming Pool Yes no Any Bankruptcy or Foreclosure Yes no Animal on Premises Yes no Lapse in Coverage Yes no Available Credits: Central Station Alarm Gated Community Storm Shutters Roof Straps Hurricane Glass Pre-Cut Plywood Claims Information (past 3 years) Remarks: Effective Date Requested: Expiration Date: IF YOU HAVE NOT ALREADY, PLEASE INFORM YOUR CLIENT THAT PERSONAL INFORMATION ABOUT THEM, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN THE APPLICANT IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER ELIGIBILITY FOR INSURANCE OR THE PREMIUM TO BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF THE INSURANCE SCORE. Submit