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Liability Application

33%

Liability Underwriting Questions:
Liability coverage limit
Choose 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?
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How is it used?
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 Property
List 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 explain
Have 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 #2
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Δ

33%

Liability Underwriting Questions:
Liability coverage limit
Choose 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?
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How is it used?
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 Property
List 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 explain
Have 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 #2
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

Δ

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PO Box 878
1110 J St., Reedley, Ca 93654
559.638.2327
[email protected]

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