Liability Application Step 1 of 3 33% Effective Date* Date Format: MM slash DD slash YYYY Policy NumberName of Insured* First Last Email* Phone*Birthdate* Date Format: MM slash DD slash YYYY Occupation*How do you prefer that we contact you?E-MailPhone callTextMailNo preferenceIs there another person insured?*YesNoSecond Named Insured First Last Email PhoneBirthdate Date Format: MM slash DD slash YYYY OccupationHow do you prefer that we contact you?E-MailPhone callTextMailNo preferenceInsured 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 AddressMailing 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?*YesNoName First Last Birthdate Date Format: MM slash DD slash YYYY Do you have other person to add?YesNoName First Last Birthdate Date Format: MM slash DD slash YYYY Do you have other person to add?YesNoAdditional Names & Dates of Births Liability Underwriting Questions:Liability coverage limitChoose one$300,000$500,000How is the insured premises used?Check all that apply Primary home Vacation home Long-term Rental Occasional rental Student housing Other Please specifyIs the premises located on 5 acres or more?*YesNoIs this property vacant?*YesNoDescribe 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?*YesNoWhere? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How is it used?Have you been denied insurance coverage in the last 3 years?*YesNoWhy were you denied insurance in the last 3 years? Are there animals on the property?*YesNoWhat kinds of animals and how many?If there are dogs, what breeds?Have any of your animals injured someone?YesNoAre there any pools or spas on the property?*YesNoWhat safety structures surround these?Does the pool have a diving board or slide?YesNoLights strung over the pool?YesNoAre there any trampolines on the property?*YesNoWhat 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?*YesNoAre there bars on the windows?*YesNoDo the bars have quick releases?YesNoDoes anyone in the household have an occupation with high visibility or high profile?*YesNoPlease explainHave you had any liability claims within the last 5 years?*YesNoProvide the insurance company & claim numberAre there any open claims?YesNoIs any portion of the property owned by a trust, LLC, partnership, corporation, or other entity other than an individual?*YesNoProvide the full legal name(s) and the portion it ownsSignature #1*Date* Date Format: MM slash DD slash YYYY Signature #2Date Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.