Liability Application

"*" indicates required fields

Step 1 of 3

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This field is for validation purposes and should be left unchanged.

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

Second Named Insured

First Last

Phone

Birthdate

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 State Zip Code

Mailing Address is the Same as Insured Premises Address

Mailing Address

Street Address Address Line 2 City State Zip Code

Do you have other persons who reside on the premises?*

Yes

Name

First Last

Birthdate

MM slash DD slash YYYY

Do you have other person to add?

Yes

Name

First Last

Birthdate

MM slash DD slash YYYY

Do you have other person to add?

Yes

Additional Names & Dates of Births

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

Is this property vacant?*

Yes

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

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

Why were you denied insurance in the last 3 years?

Are there animals on the property?*

Yes

What kinds of animals and how many?

If there are dogs, what breeds?

Have any of your animals injured someone?

Yes

Are there any pools or spas on the property?*

Yes

What safety structures surround these?

Does the pool have a diving board or slide?

Yes

Lights strung over the pool?

Yes

Are there any trampolines on the property?*

Yes

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

Are there bars on the windows?*

Yes

Do the bars have quick releases?

Yes

Does anyone in the household have an occupation with high visibility or high profile?*

Yes

Please explain

Have you had any liability claims within the last 5 years?*

Yes

Provide the insurance company & claim number

Are there any open claims?

Yes

Is any portion of the property owned by a trust, LLC, partnership, corporation, or other entity other than an individual?*

Yes

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

"*" indicates required fields

Step 1 of 3

33%

This field is for validation purposes and should be left unchanged.

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

Second Named Insured

First Last

Phone

Birthdate

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 State Zip Code

Mailing Address is the Same as Insured Premises Address

Mailing Address

Street Address Address Line 2 City State Zip Code

Do you have other persons who reside on the premises?*

Yes

Name

First Last

Birthdate

MM slash DD slash YYYY

Do you have other person to add?

Yes

Name

First Last

Birthdate

MM slash DD slash YYYY

Do you have other person to add?

Yes

Additional Names & Dates of Births

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

Is this property vacant?*

Yes

Describe all business activity on the premises.

Do you own other property?*

Yes

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

Why were you denied insurance in the last 3 years?

Are there animals on the property?*

Yes

What kinds of animals and how many?

If there are dogs, what breeds?

Have any of your animals injured someone?

Yes

Are there any pools or spas on the property?*

Yes

What safety structures surround these?

Does the pool have a diving board or slide?

Yes

Lights strung over the pool?

Yes

Are there any trampolines on the property?*

Yes

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

Are there bars on the windows?*

Yes

Do the bars have quick releases?

Yes

Does anyone in the household have an occupation with high visibility or high profile?*

Yes

Please explain

Have you had any liability claims within the last 5 years?*

Yes

Provide the insurance company & claim number

Are there any open claims?

Yes

Is any portion of the property owned by a trust, LLC, partnership, corporation, or other entity other than an individual?*

Yes

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

Liability Application

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