HVH Application

Producer Information

Agency Name

Agency Code

Agent Name

Agency Email

Account Information

Effective Date

Insured Type

Entity Type

First Name Insured

First Last

Date of Birth

Occupation

Second Name Insured

First Last

Additional Insured

First Last

Mailing Address

Street Address Address Line 2 City State ZIP Code

Insured Phone Number

Insured Email

Risk Information

Risk Address same as mailing address?

Yes

No

If no, please provide additional information below

Address

Street Address Address Line 2 City State ZIP Code

Coverage Limits Information

Dwelling Limit

Minimum $300 per sq. ft

Mold Coverage Sublimit

Other Structures Limit

% of Dwelling Limit

Personal Property Limit

% of Dwelling Limit

Roof Settlement Schedule

Water Damage Limit

Additional Living Expense Limit

Per month subject to a maximum of 12 months

Personal Liability Limit

Medical Payments to Others Limit

Loss History

List

Loss Date

Loss Type

Description of Loss

Cat Loss (Yes/No)

Amount Paid

Claimed Closed? (Yes/No)

Legal Notice

This notice is given in compliance with the Federal Fair Credit Reporting Act (Public Law 91-508) and the Consumer Credit Reform Act of 1996. I understand that as a part of the Company's underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics, mode of living and driving record. Upon written request, additional information as to the scope of the report, if one is made, will be provided. I have read this application and the entries on it. The foregoing statements made and signed by the applicant represents the information set forth as correct and a true basis on which insurance may be granted but it in no way binds the applicant to accept the quotation or the insurer to accept the risk. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Your state may have specific warnings against filing false claim information. As explained in the Use of Credit Information Disclosure, many insurance companies, consider your insurance credit score in rating. Independent studies indicate that an insurance credit score is an extremely reliable predictor of insurance losses. Taking this information into consideration also helps us to provide you with the most accurate and fair rate.

Applicant's Name

First Last

Date

Applicant's Signature

Date

Signature of Authorized Representative

Date

Producer Information

Account Information

Risk Information

Coverage Limits Information

Deductible Information

Property Details

Eligibility Questions

Loss History

Legal Notice

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Contact Info