Additional Location Supplemental Application

Scottsdale Insurance Company National Casualty Company

Scottsdale Indemnity Company Scottsdale Surplus Lines Insurance Company

1-800-423-7675 • Fax (480) 483-6752

ADDITIONAL LOCATION SUPPLEMENTAL APPLICATION

(To be used in conjunction with Company application DFS-APP or an ACORD Dwelling Fire Application)

Location No.: / Address:
City: State: Zip:
Limits: / Dwelling / Other Structures / Personal Property / ALE/Fair Rental Value / Premises Liability / Med Pay
$ / $ / $ / $ / $ / $
Rating /
Underwriting: / Year Built / Square Feet / PC / Construction Type / Usage Type / Occupancy / No. Families
Updates: / Wiring / Type: / Partial
Complete / Year:
/ Plumbing / Type: / Partial
Complete / Year:
Heating / Type: / Partial
Complete / Year:
/ Roofing / Type: / Partial
Complete / Year:
Location-Specific Remarks:
Location No.: / Address:
City: State: Zip:
Limits: / Dwelling / Other Structures / Personal Property / ALE/Fair Rental Value / Premises Liability / Med Pay
$ / $ / $ / $ / $ / $
Rating /
Underwriting: / Year Built / Square Feet / PC / Construction Type / Usage Type / Occupancy / No. Families
Updates: / Wiring / Type: / Partial
Complete / Year:
/ Plumbing / Type: / Partial
Complete / Year:
Heating / Type: / Partial
Complete / Year:
/ Roofing / Type: / Partial
Complete / Year:
Location-Specific Remarks:
Location No.: / Address:
City: State: Zip:
Limits: / Dwelling / Other Structures / Personal Property / ALE/Fair Rental Value / Premises Liability / Med Pay
$ / $ / $ / $ / $ / $
Rating /
Underwriting: / Year Built / Square Feet / PC / Construction Type / Usage Type / Occupancy / No. Families
Updates: / Wiring / Type: / Partial
Complete / Year:
/ Plumbing / Type: / Partial
Complete / Year:
Heating / Type: / Partial
Complete / Year:
/ Roofing / Type: / Partial
Complete / Year:
Location-Specific Remarks:

This supplement does not bind YOU nor US to complete the insurance, but it is agreed that the information herein shall be the basis of the contract should a policy be issued.

APPLICANT’S SIGNATURE: DATE:

PRODUCER’S SIGNATURE: DATE:

IMPORTANT NOTICE: As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

DFZ-APP-1 (11-16)