Liability Application Step 1 of 3 33% Effective Date* MM slash DD slash YYYY Policy Number Name of Insured* First Last Email* Phone*Birthdate* MM slash DD slash YYYY Occupation* How do you prefer that we contact you? E-Mail Phone call Text Mail No preference Is there another person insured?* Yes No Second Named Insured First Last Email PhoneBirthdate MM slash DD slash YYYY Occupation How do you prefer that we contact you? E-Mail Phone call Text Mail No preference Insured Premises Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address is the Same as Insured Premises Address Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have other persons who reside on the premises?* Yes No Name First Last Birthdate MM slash DD slash YYYY Do you have other person to add? Yes No Name First Last Birthdate MM slash DD slash YYYY Do you have other person to add? Yes No Additional Names & Dates of Births Liability Underwriting Questions:Liability coverage limitChoose one $300,000 $500,000 How is the insured premises used?Check all that apply Primary home Vacation home Long-term Rental Occasional rental Student housing Other Please specify Is the premises located on 5 acres or more?* Yes No Is this property vacant?* Yes No Describe all business activity on the premises.Some examples include: piano lessons, home day care, product sales, electronic or mechanical repairs, arts & crafts, consulting, home maintenance or cleaning, food preparation and sales, tutoring or teaching, and animal boarding.Do you own other property?* Yes No Where? 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Have you been denied insurance coverage in the last 3 years?* Yes No Why were you denied insurance in the last 3 years? Are there animals on the property?* Yes No What kinds of animals and how many?If there are dogs, what breeds?Have any of your animals injured someone? Yes No Are there any pools or spas on the property?* Yes No What safety structures surround these? Does the pool have a diving board or slide? Yes No Lights strung over the pool? Yes No Are there any trampolines on the property?* Yes No What safety structures surround these? Additional PropertyList all the aircraft, watercraft, personal watercraft, ATV’s or other powered vehicles you own.Does the property have a floor furnace?* Yes No Are there bars on the windows?* Yes No Do the bars have quick releases? Yes No Does anyone in the household have an occupation with high visibility or high profile?* Yes No Please explainHave you had any liability claims within the last 5 years?* Yes No Provide the insurance company & claim number Are there any open claims? Yes No Is any portion of the property owned by a trust, LLC, partnership, corporation, or other entity other than an individual?* Yes No Provide the full legal name(s) and the portion it owns Signature #1*Date* MM slash DD slash YYYY Signature #2Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.