Aplication for Personal Package

APLICATION FOR PERSONAL PACKAGE

APPLICANT INFORMATION
Applicants Name/Company: / Occupation: / For López Luna Use Only
Policy Number:______
Agency to Quote:______
Policy Period:______
Commission Requested:______
Comments:______
______
Social Security/SIC #: / Phone:
Fax:
Postal Address: / Physical Address:
PROPERTY COVERAGE
Type of Residence # 1 (Primary Residence): / Residence Location: / Residence Postal Address:
£ Personal
£ Commercial / £ Seasonal
£ Business
£ Other:______
Swelling Structure ($): / Personal Property-Unscheduled ($): / Personal Property (Include Schedule) ($):
Name of Mortgage (If Any): / Mortgage Address: / Is there any business pursuits conducted in premises? Specify
Mortgage Phone:
Inclusions
£ Theft coverage
£ Earthquake coverage
£ Special Deductible / Exclusions
£ Theft coverage
£ Earthquake coverage
£ Special Deductible / Comments:
Type of Residence # 2 (Secondary Residence): / Residence Location: / Residence Postal Address:
£ Personal
£ Commercial / £ Seasonal
£ Business
£ Other:______
Swelling Structure ($): / Personal Property-Unscheduled ($): / Personal Property (Include Schedule) ($):
Name of Mortgage (If Any): / Mortgage Address: / Is there any business pursuits conducted in premises? Specify
Mortgage Phone:
Inclusions
£ Theft coverage
£ Earthquake coverage
£ Special Deductible / Exclusions
£ Theft coverage
£ Earthquake coverage
£ Special Deductible / Comments:
PERSONAL LIABILITY AND MEDICAL PAYMENTS
Personal Liability:
Per occurrence $ / Medical Payments
Per Occurrence $ / YES:
£ Additional Residence Premises
£ Swimming Pools
£ Watercrafts / NO:
£ Additional Residence Premises
£ Swimming Pools
£ Watercrafts
Personal Injury:
Per Person$
If You Answer Yes to any questions you must provide, residence address, pool length and depth and watercraft information)
AUTOMOBILE
Coverage
£ Bodily Injury
£ Property Damage
£ BI-PD Combined Single Limit / Limits of Liability:
$______Per Person
$______Per Accident
$______Per Person
$______Per Accident / Medical Payments:
Per Person $
Vehicle is used for:
1. Miles to travel to work ______
2. Pleasure Use______
3. Farm Use______
4. Other Use______
5. Vehicle is garaged at:______
Other Than collision (Stated Amount)
Less Deductible / 1 / 2
Actual Cash Value Less Deductible / 1 / 2
Auto #`1: / Year: / Model: / Vehicle Identification Number: / Cost New: / Symbol Used:
Auto #`2: / Year: / Model: / Vehicle Identification Number: / Cost New: / Symbol Used:
Auto #`3: / Year: / Model: / Vehicle Identification Number: / Cost New: / Symbol Used:
Auto #`4: / Year: / Model: / Vehicle Identification Number: / Cost New: / Symbol Used:
Auto #`5: / Year: / Model: / Vehicle Identification Number: / Cost New: / Symbol Used:
Name of Main Lien holder (If Any): / Address:
Name of all Household Members / Relationship / Date of Birth / Sex / Occupation / Drivers License # / Year of first driver License / % of Use
QUESTIONNAIRE
Have any of the drivers any physical impairment?
£ YES £ NO / On the past three years, has applicant any insurance policy?
£ YES £ NO
Has applicant or any drivers been convicted for any vehicle violation?
£ YES £ NO / Reason for Policy Cancellation and previous insurance information:
Has applicant or any other driver license been suspended or revoked?
£ YES £ NO / Is any driver under 26 or over 65 years?
£ YES £ NO
Are other automobiles in the household? Are they insured?______
£ YES £ NO / £ YES £ NO
UMBRELLA
Liability:
£ $1MM
£ $2MM
£ $3MM
£ $4MM
£ $5MM / Self-retained limit:
£ $250
£ / Did you or any household member participate in any organized racing of any watercraft?
£ YES £ NO
Are any automobiles regular operated by person under 25
£ YES £ NO / Are any under laying auto policies reduced or restricts with respect to any driver?
£ YES £ NO
Are any auto in assigned risk pool?
£ YES £ NO / Are any auto subject to financial responsibility laws?
£ YES £ NO
If you answer yes to any of the previows questions, plese explain:
UMBRELLA CONT.
Has applicant been held responsible for a third party liability loss in excess of $10,000?
£ YES £ NO / If Yes, please explain amount of loss, place ands when:
Has the applicant any property, vehicle or watercraft out of Puerto Rico?
£ YES £ NO / If Yes, please explain
REAL ESTATE
List all Owned, Leased or Occupied residence, buildings, farms, land, etc.
#`1: / Location: / Description: / Years Built: / Interest: / Occupancy:
#`2: / Location: / Description: / Years Built: / Interest: / Occupancy:
#`3: / Location: / Description: / Years Built: / Interest: / Occupancy:
#4: / Location: / Description: / Years Built: / Interest: / Occupancy:
#51: / Location: / Description: / Years Built: / Interest: / Occupancy:
Automobiles/motorcycles, dune buggies, minibikes, etc.(all Recreational Vehicles)
#`1: / Year: / Motor type, Model:
#`2: / Year: / Motor type, Model:
#`3: / Year: / Motor type, Model:
#`4: / Year: / Motor type, Model:
#`5: / Year: / Motor type, Model:
Watercraft (owned, lease, chartered or furnished for regular use)
#`1: / Year: / Motor type, Model: / Length: / Horse Power: / Maximum Speed: / Value:
New______
Current______ / Waters Navigated:
#`1: / Year: / Motor type, Model: / Length: / Horse Power: / Maximum Speed: / Value:
New______
Current______ / Waters Navigated:
Schedule of Underlying Insurance
Coverage:
Personal Liab. / Policy No: / Policy Period: / Carrier: / Limits of Liability: / Premium:
Coverage:
Automobile Liab. / Policy No: / Policy Period: / Carrier: / Limits of Liability: / Premium:
Coverage:
Watercraft Liab. / Policy No: / Policy Period: / Carrier: / Limits of Liability: / Premium:
YACHT COVERAGE
#`1: / Year: / Motor type, Model: / Length: / Horse Power: / Maximum Speed: / Value:
New______
Current______ / Waters Navigated:
#`1: / Year: / Motor type, Model: / Length: / Horse Power: / Maximum Speed: / Value:
New______
Current______ / Waters Navigated:
Type of Hull:
£ Cabin Cruiser
£ Runabout / £ Houseboat
£ Sailboat / Construction:
£ Fiberglass
£ Wood / £ Steel
£ Aluminum / £ Ferro Cement
£ Other______/ Maximum Design Speed:
Power Type:
£ Inboard
£ Inboard-Outdrive / £ Sail
£ Aux Sail / £ Outboard
£ Jet / Trailer Year: / Trailer Model: / Serial Number:
Trailer Number of Axies: / Trailer Capacity: / Date of Purchase: / Purchase Price: / Current Market Value
UMBRELLA CONT.
Insurance Coverage Requested
Coverage: / Amount of Insurance ($) / Deductible:
Yacht Hull and Equipment:
Liability (P&I):
Medical Payments:
Explain all Responses in Remarks
Is yacht ever charted to others?
£ YES £ NO / Is yacht used for any other business purpose?
£ YES £ NO
Do you employee a paid captain or crew?
£ YES £ NO / Is yacht used for water skiing?
£ YES £ NO
Has any insurance company cancelled or refuse yacht insurance to you?
£ YES £ NO / If yes, please explain:
LOSS HISTORY
Loss Past 3 Years: / Date: / Insurance Company: / Type: / Amount:
Property
Liability
Automobile
Yacht
Other
CLAUSE
I hereby warrant that the information submitted is true and that I have not withheld any information required in this application, and that I am a duly authorize motor vehicle operator:
Date: / Signature:
FOR LÓPEZ LUNA INSURANCE USE ONLY
Service Executive: / Comments
Date: / Signature:

The information submitted is intended only for the person or entity to which it is addressed and may contain confidential information or material. Please, if you receive this information/material in error, please contact the sender and/or delete or destroy it