AGENCY CUSTOMER ID:
DATE (MM/DD/YYYY):
AGENCY NAME:
CARRIER:
NAIC CODE:
POLICY NUMBER:
EFFECTIVE DATE:
NAMED INSURED(S):
BLKT #
AMOUNT
TYPE
PREMISES #:
STREET ADDRESS:
BUILDING #:
BLDG DESCRIPTION:
SUBJECT OF INSURANCE
COINS %
VALUATION
CAUSES OF LOSS
INFLATION GUARD %
DED
DED TYPE
FORMS AND CONDITIONS TO APPLY
ADDITIONAL INFORMATION:
BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810
VALUE REPORTING INFORMATION - Attach ACORD 811
SPOILAGE COVERAGE (Y / N):
DESCRIPTION OF PROPERTY COVERED:
LIMIT $:
DEDUCTIBLE $:
REFRIG MAINT AGREEMENT (Y / N):
OPTIONS:
BREAKDOWN OR CONTAMINATIONPOWER OUTAGESELLING PRICE
ACORD 45 attached for additional names
INTEREST:
LENDER'S LOSS PAYABLELOSS PAYEEMORTGAGEE
NAME AND ADDRESS:
RANK:
EVIDENCE:
CERTIFICATE:
REFERENCE / LOAN #:
LOCATION:
BUILDING:
ITEM CLASS:
ITEM:
ITEM DESCRIPTION:
SPOILAGE COVERAGE (Y/N):Y
LIMIT: $
DEDUCTIBLE: $
REFRIG MAINT AGREEMENT (Y/N):Y
SINKHOLE COVERAGE (Required in Florida):
ACCEPT COVERAGEREJECT COVERAGE
MINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV):
PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK:YES
# OF OPEN SIDES ON STRUCTURE:
CONSTRUCTION TYPE:
DISTANCE TO HYDRANT (FT):
DISTANCE TO FIRE STATION (MI):
FIRE DISTRICT:
CODE NUMBER:
PROT CL:
# STORIES:
# BASEMENTS:
YR BUILT:
TOTAL AREA:
WIRING, YR:
PLUMBING, YR:
ROOFING, YR:
HEATING, YR:
OTHER, YR:
BLDG CODE GRADE:
TAX CODE:
ROOF TYPE:
OTHER OCCUPANCIES:
WIND CLASS:RESISTIVESEMI-RESISTIVE
HEATING SOURCE (Woodburning Stove, etc):
DATE INSTALLED: MANUFACTURER:
PRIMARY HEAT:BOILERSOLID FUEL
IF BOILER, IS INSURANCE PLACED ELSEWHERE? Y
SECONDARY HEAT:BOILERSOLID FUEL
RIGHT EXPOSURE & DISTANCE:
LEFT EXPOSURE & DISTANCE:
FRONT EXPOSURE & DISTANCE:
REAR EXPOSURE & DISTANCE:
BURGLAR ALARM TYPE:
CERTIFICATE #:
EXPIRATION DATE:
INSTALLED AND SERVICED BY:
EXTENT:
GRADE:
# GUARDS / WATCHMEN:
WITH KEYS:YES
INTEREST
NAME AND ADDRESS
INTEREST IN ITEM NUMBER
(ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Signature: Date:
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or 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. *Applies in MD Only.
Applicable in CO
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.
Applicable in FL and OK
Any 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). *Applies in FL Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA
Any 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* (not to exceed five thousand dollars and the stated value of the claim for each such violation). *Applies in NY Only.
Applicable in ME, TN, VA and WA
It 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 and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.
Applicable in PR
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
PRODUCER’S SIGNATURE
PRODUCER’S NAME (Please Print)
STATE PRODUCER LICENSE NO (Required in Florida)
APPLICANT’S SIGNATURE
DATE
NATIONAL PRODUCER NUMBER
