Residential Earthquake Application

Residential Earthquake Application

Applicant’s Name:Agent Name:

Mailing Address:Address:

Agency Code:

PROPOSED EFFECTIVE DATES:

FromTo

General Information:12:01 A.M., Standard Time at the address of the Applicant

Location #:
Mailing Address:
Suite/Building #:
City: / State: / ZIP:
ConstructionClass: (Check one)
Wood Frame / Non-Combustible
Brick Veneer / Masonry Non-Combustible
Joisted Masonry-Tilt Up / Modified Fire Resistive
Joisted Masonry-Reinforced Masonry / FireResistive
Joisted Masonry-Un-reinforced Masonry / Modular
ParkingClass: (Check one)
None / Tuckunder-2-Sides
Detached / Full Subterranean
Attached-No structure above / Partial Subterranean
HabitationalOverGarage(HOG) / FirstFloor Parking
Tuckunder-1-Side / Soft First Floor
Age of house: / Square footage: / Number of Stories:
Pool / Yes / No
Type of Pool: / concrete inground / above ground
Setback or overhangs: / Yes / No / Unknown
Building Shape: / Regular / Irregular / Unknown
Bolted to foundation / Yes / No
Coverage Requested:
Building / $
Pool / $
Contents / $
Outbuilding / $
Extension Coverage / $
Additional Living Expense / $
Fair Rental Value / $
Deductible Option / 3% / 5% / 10% / 15% / 20%

Notice of Insurance Information Practices:

Personal information about you may be collected from persons other than you. 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. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instruction on how to submit a request to us.

Application must be fully completed, signed and have required photos attached.

NOTICES, FRAUD WARNINGS AND ATTESTATION

FRAUD WARNING:

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.

APPLICANT’S STATEMENT:

I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: This does not constitute a warranty.)

APPLICANT’S SIGNATURE: ______DATE:

CO-APPLICANT’S SIGNATURE:______DATE:

PRODUCER’S SIGNATURE: ______DATE:

AGENT NAME: AGENT LICENSE NUMBER:

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