HVH Application

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Producer Information

Agency Name

Agency Code

Agent Name

Agency Email

Account Information

Effective Date

MM slash DD slash YYYY

Insured Type

Entity Type

First Name Insured

First Last

Date of Birth

MM slash DD slash YYYY

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

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

Deductible Information

All Other Perils:

Wind/Hail:

Freeze:

Water Damage:

(Non-Weather)

Theft:

Property Details

Residence Type:

Single Family Home:

Year Built:

Protection Class:

Total Living Area soft:

Number of Stories:

Garage Area sqft:

Attached or Detached Garage:

Basement:

Construction Type:

Foundation Type:

Year Roof Installed/Replaced:

Roof Composition/Type:

Roof Shape:

Central Burglar & Fire Alarm System?

Yes

Is there a trampoline on premise?

Yes

Swimming Pool

Yes

Diving Board?

Yes

Slide?

Yes

Pool fenced to code?

Yes

Self Locking Gate?

Yes

Central AC/Heat?

Yes

Months Used per Annum (by Owner)

Rented/Short Term Rental or other Source

Yes

Eligibility Questions

Has the applicant experienced a foreclosure, repossession, or declared bankruptcy within the past five years?

Yes

Has the applicant been convicted or indicted for fraud, bribery, arson, or any property-relatedcrime in the past five years?

Yes

Has there been a lapse in coverage in the past 12 months?

Yes

Are there more than two mortgages on the property, or any mortgage that is not held by a financial institution?

Yes

Is the dwelling currently listed for sale?

Yes

Is the dwelling designated as a historic property?

Yes

Is the property located within 300 feet of a commercial or non-residential building thatrepresents an increased hazard to the dwelling?

Yes

If yes, provide details:

Does the home have Exterior Insulated Finish System (EIFS) installed prior to 1998 without aweep or drainage system?

Yes

Is there any presence or history of "Chinese drywall," lead-based paint, or asbestos?

Yes

Are there any unresolved mold issues that were not professionally remediated?

Yes

Is the residence used as student housing?

Yes

Is the residence a multi-family dwelling (two or more units)?

Yes

Is the home equipped with any of the following electrical components: fuses, knob-and-tubewiring, aluminum wiring, circuit breakers under 100 amps, or panels by Federal Pacific, Stab-Lok, Zinsco, Sylvania, or Challenger?

Yes

Are the supply lines made from galvanized, polybutylene, cast iron, or lead piping?

Yes

Are the waste or drain pipes made from galvanized, polybutylene, cast iron, or lead?

Yes

Are any portable heating devices used in the home?

Yes

Does the home include a wood-burning stove (including pellet stoves)?

Yes

Are there any major renovations to the property currently in progress?

Yes

Does the dwelling contain unconventional materials, unique construction, or structuralconversions not originally intended as residential?

Yes

Are there any animals or livestock on the premises?

Yes

If Yes, specify the type and breed:

Is the property used to conduct any type of business, including minor or externally insuredoperations?

Yes

Does the residence have solar panels installed?

Yes

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

MM slash DD slash YYYY

Applicant's Signature

Date

MM slash DD slash YYYY

Signature of Authorized Representative

Date

MM slash DD slash YYYY

Producer Information

Account Information

Risk Information

Coverage Limits Information

Deductible Information

Property Details

Eligibility Questions

Loss History

Legal Notice

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