PART COMP YEAR YEARS IN YEARS W/ YEARS W/
CURR OCC CURR EMPL PRIOR EMPL
YEARS IN YEARS W/ YEARS W/ CURR OCC CURR EMPL PRIOR EMPL
TM MANNED SECURITY OFF PREMISES THEFT EXCL OTHER: DATE (MM/DD/YYYY) PHONE
PRODUCER APPLICANT’S NAME AND MAILING ADDRESS (Include county & ZIP+4) (A/C, No, Ext):
FAX NAIC CODE FACILITY CODE
(A/C, No):
POLICY #
DATE AT CO/PLAN HOME PHONE #
CURR RES
EFFECTIVE DATE EXPIRATION DATE BUSINESS PHONE #
CODE: SUBCODE:
AGENCY CUSTOMER ID
PREVIOUS ADDRESS (If less than 3 years) YRS AT LOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP) PREV
ADDR
APPLICANT’S OCCUPATION APPLICANT’S EMPLOYER NAME AND ADDRESS MAR DATE OF BIRTH SOCIAL SECURITY #
(State nature of business if self-employed) STAT
CO-APPLICANT’S OCCUPATION CO-APPLICANT’S EMPLOYER NAME AND ADDRESS MAR DATE OF BIRTH SOCIAL SECURITY #
(State nature of business if self-employed) STAT
HO FORM DWELLING OTHER PERSONAL LOSS OF USE PERSONAL MEDICAL
STRUCTURES PROPERTY LIABILITY PAYMENTS
$ $ $ $ $ $
EST TOTAL PREMIUM $
DEPOSIT $
BALANCE $
MAIL POLICY TO: ACCOUNT #:
BILLING IF DIRECT BILL: IF APPLICANT BILL:
YR BUILT # ROOMS MARKET VALUE STRUCTURE TYPE USAGE TYPE # FAM- # PURCHASE ILIES HSEHLD DATE/PRICE
RES $
SQ FT # APTS REPLACEMENT COST
$ RENOVATION TYPE
NUMBER OF TERR PREM PROTECT DISTANCE TO PROTECTION DEVICE TYPE HEAT TYPE CODE GROUP CLASS
FIRE UNITS IN FIRE
HYDRANT
DIVS FIRE DIV STATION
FIRE/EC RATE FIRE DISTRICT/CODE NUMBER OIL STORAGE TANK LOCATION
DWELLING LOCATION OCCUPIED BY SWIMMING STORM SHUTTERS
POOL HOUSEKEEPING CONDITION
INSPECTED? TAX CODE FOUNDATION
BLDG CODE RATING OCCUPIED DAILY? # WKS WIND CLASS ROOF TYPE
GRADE RENTED
NO YES
SPRINKLER IF REPLACEMENT COST APPLIES:
BASEMENT GARAGE BREEZEWAY
DAY EVE DAY EVE
ALL PERIL EACH OCCURRENCE EACH PERSON WIND/HAIL
THEFT NAMED HURRICANE *
REPLACEMENT COST DWELLING REPLACEMENT COST CONTENTS ENTER OTHER ENDORSEMENT(S)
AGENT
DIRECT BILL BILL APPLICANT OTHER: FULL PAY APPLICANT
AGENCY BILL BILL MORTGAGEE OTHER: OTHER:
PLASTIC
FRAME SIDING FARM
ASBESTOS
MASONRY SIDING DWELLING TOWNHOUSE PRIMARY COC
MASONRY
FIRE RES APART ROWHOUSE SECONDARY UNOCC
VENEER ALUMINUM
CONDO CO-OP SEASONAL VACANT SIDING
NONE WIRING SYSTEM SMOKE TEMP BURGLAR PRIMARY: PLUMBING
FT MI CENTRAL SECONDARY: HEATING
DIRECT ROOFING
LOCAL EXTERIOR PAINT
DEADBOLT VISIBLE TO NEIGHBORS YES NO
YES HURR RES GLASS
YES
WITHIN WITHIN PROT APPROVED ABOVE
OWNER A
CITY LIMITS SUBURB FIRE EXTINGUISHER FENCE GROUND
IN-GROUND NO NO
WITHIN DIVING
TENANT B
FIRE DIST BOARD
SEMI-CLOSED RESISTIVE
YES NO RESISTIVE OTHER
CLASS SPEC OPEN NONE
ACORD 40 41 42 ATTACHED
NON-SMOKER CHIMNEYS PRE-FAB
PARTIAL
LIGHTNING HEARTHS
SQ FT SQ FT SQ FT PROTECTION FULL
RATING CREDITS FIREPLACES
HOW LONG HAVE YOU KNOWN THE APPLICANT? DATE AGENT LAST INSPECTED PROPERTY:
* Not Applicable in NC APPLICANT INFORMATION
COVERAGES/LIMITS OF LIABILITY DED (Type & Amount)
ENDORSEMENTS PREMIUM
ACORD 610 Attached (NOT APPLICABLE IN NC) PAYMENT PLAN
RATING/UNDERWRITING
PLEASE COMPLETE REVERSE SIDE
ACORD 80 (2001/04) © ACORD CORPORATION 1981
ANY FARMING OR OTHER BUSINESS CONDUCTED ON PREMISES (Including day/child care)
EXPLAIN ALL "YES" RESPONSES IN REMARKS YES NO EXPLAIN ALL "YES" RESPONSES IN REMARKS (Except question 15, 16 and 17) YES NO
ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURING APPLICANT’S IF YES, INDICATE BELOW
THE LAST 3 YEARS, AT THIS OR AT ANY OTHER LOCATION? INITIALS:
DATE TYPE DESCRIPTION OF LOSS AMOUNT
PRIOR CARRIER PRIOR POLICY NUMBER EXPIRATION DATE RISK NEW TO AGENCY
INT # NAME AND ADDRESS LOAN NUMBER
INT # NAME AND ADDRESS LOAN NUMBER
FOR COMPANY USE ONLY INSURANCE BINDER EFFECTIVE DATE EXPIRATION DATE
TIME DATE APPLICANT’S PRODUCER’S SIGNATURE SIGNATURE YES NO YES NO MORTG’E ADDL INT MORTG’E ADDL INT
STATE SUPPLEMENT(S)(If applicable) PROTECTION DEVICE CERTIFICATE PERS EXCESS/UMBRELLA APP INLAND MARINE APPLICATION
REPLACEMENT COST ESTIMATE RECREATIONAL VEHICLE APP PHOTOGRAPH WATERCRAFT APPLICATION
LEAD FREE PAINT CERTIFICATION SOLID FUEL SUPPLEMENT
HOME BASED BUSINESS SUPP EARTHQUAKE APPLICATION
12:01 AM NOON COVERAGE IS NOT BOUND
IS PROPERTY SITUATED ON MORE THAN FIVE ACRES? (If yes, describe land use)
IF A FUEL OIL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (Give First Party and limit, and Third Party and limit) ANY RESIDENCE EMPLOYEES? (Number and type of full and part time employees)
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION AND SUBSEQUENT RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
ANY COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST 3 YEARS? NOT APPLICABLE IN MO HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION OR BANKRUPTCY DURING THE PAST FIVE YEARS?
ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES?
(Note breed and bite history) IS PROPERTY W/IN 300 FT OF A COMMERCIAL OR
NON-RESIDENTIAL PROPERTY?
WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED?
14. DURING THE LAST FIVE YEARS (TEN YEARS IN RHODE ISLAND), 1.
HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, failure to disclose the existence of an arson 2.
conviction is a misdemeanor punishable by a sentence of up to one 3. ANY FLOODING, BRUSH, FOREST FIRE HAZARD, LANDSLIDE, ETC? year of imprisonment.)
RENTERS AND CONDOS ONLY:
4. ANY OTHER RESIDENCE OWNED, OCCUPIED OR RENTED? 15. IS THERE A MANAGER ON THE PREMISES? 5. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) 16. IS THERE A SECURITY ATTENDANT? 6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? 17. IS THE BUILDING ENTRANCE LOCKED?
7. 18. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS?
IS BUILDING UNDERGOING RENOVATION OR RECONSTRUCTION? (Give estimated completion date and dollar value)
19. 8.
20. IS HOUSE FOR SALE? 9.
21. 10. IS PROPERTY LOCATED WITHIN TWO MILES OF TIDAL WATER?
22. IS THERE A TRAMPOLINE ON THE PREMISES?
11. 23.
12. DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGYS, MINI BIKES, ATVS, ETC)?
24. ANY LEAD PAINT HAZARD? (List year, type, make, model)
25. 13. IS BUILDING RETROFITTED FOR EARTHQUAKE (If applicable)
IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:
THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY.
THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE. THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.
GENERAL INFORMATION LOSS HISTORY PRIOR COVERAGE ADDITIONAL INTEREST REMARKS ATTACHMENTS BINDER/SIGNATURE ACORD 80 (2001/04)
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, and VA, insurance benefits may also be denied)
Applicant’s Statement: I have read the above application and any attachments. I declare that the information provided in them is true, complete and correct to the best of my knowledge and belief. This information is being offered to the company as an inducement to issue the policy for which I am applying.
Notice of Insurance Information Practices
SUTTER INSURANCE COMPANY
NOTICE: Homeowners 3 Special Rehabilitation Program - California
Coverage Statement
Name of Applicant/Insured:
I understand and agree that the Sutter Insurance Company offers standard Insurance Services Office, Inc. Homeowners 3 Special Coverage Homeowners insurance, and that the new or renewal policy being applied for excludes and/or limits the standard coverage as indicated below:
1. There is no coverage for damage to the insured premises or for liability to others arising out of any type of accident resulting from pollution or lead paint.
2. Total coverage on fine arts is limited to $5,000 in the aggregate.
3. Any ensuing rust, wet or dry rot, mold, fungi, or other microbes losses resulting from a covered peril, not otherwise excluded or excepted, is limited to $5,000 under Section I – Property and $10,000 under Section II – Liability.
4. Coverages E-Personal Liability and F-Medical Payments to Others do not apply to bodily injury or property damages which arise out of transmission of a communicable disease.
5. There are NO section II-Liability Coverages and LIMITED Section I-Property Coverages for Home Day Care Business. 6. If the policy is cancelled during the first 90 days the policy fees, if charged, plus a minimum of 25% of the annual premium,
is fully earned.
7. Coverage is limited to single and two family dwellings, where the insured resides in at least one family unit. 8. Punitive and exemplary damages are excluded from coverage.
9. Ordinance or Law Coverage has been deleted from coverage. 10. Animal Liability Coverage has been changed as indicated:
Excluded
Limited: Our total liability under coverages E-Personal Liability and F-Medical Payments to Others for all damages resulting from any one “occurrence” will not be more than $25,000.
11. Coverage for the following perils has been changed as indicated: Theft Coverage:
Unchanged Excluded
Limited: With respect to the peril of theft as specified in Section I-Perils Insured Against, we will pay only that part of the total loss payable under Section I that exceeds the following deductible (expressed as a percentage of Coverage A):
1% 2% 5% 10%
Specific Water Damage Coverage:
Unchanged
Excluded
Limited: With respect to the peril of specific water damage as specified by the policy, we will pay only that part of the total loss payable under Section I that exceeds the following deductible (expressed as a percentage of Coverage A):
1% 2% 5% 10%
Windstorm or Hail Coverage: Unchanged Excluded
Limited: With respect to the perils of windstorm or hail as specified by the policy, we will pay only that part of the total loss payable under Section I that exceeds the following deductible (expressed as a percentage of Coverage A):
1% 2% 5% 10%
Roof Coverage: Unchanged
This policy does not provide coverage for any loss or damage to the roof(s) at the location(s) covered by this policy resulting from the perils of windstorm and/or hail, nor to any damage resulting from water entering through the roof(s) of a covered structure at the insured location(s), or ensuing loss
By signing below I am verifying that I have read the above and understand and agree that this Coverage Statement accurately indicates the Homeowners 3 Special Program coverage that I have requested and received has been properly limited as indicated.
X___________________________________________________________________________ __________
Applicant’s Signature (Required) Date (Required)
SI 3286 (6-11) SUTTER INSURANCE COMPANY Page 1 of 2
CALIFORNIA RESIDENTIAL PROPERTY INSURANCE DISCLOSURE
FOR USE WITH ALL FORMS
NOTICE TO CONSUMERS — CALIFORNIA RESIDENTIAL INSURANCE DISCLOSURE
This disclosure is required by Section 10102 of the California Insurance Code. This form provides general information related to residential property insurance and is not part of your residential property insurance policy. Only the specific provisions of your policy will determine whether a particular loss is covered and the amount payable. The information provided does not preempt existing California law.
PRIMARY FORMS OF RESIDENTIAL DWELLING COVERAGE
You have purchased the coverage(s) checked below. NOTE: Actual Cash Value Coverage is the most limited level of coverage listed. Guaranteed Replacement Cost is the broadest level of coverage.
ACTUAL CASH VALUE COVERAGE pays the costs to repair the damaged dwelling minus a deduction for physical
depreciation. If the dwelling is completely destroyed, this coverage pays the fair market value of the dwelling at time of loss. In either case, coverage only pays for costs up to the limits specified in your policy.
REPLACEMENT COST COVERAGE is intended to provide for the cost to repair or replace the damaged or
destroyed dwelling, without a deduction for physical depreciation. Many policies pay only the dwelling's actual cash value until the insured has actually begun or completed repairs or reconstruction on the dwelling. Coverage only pays for replacement costs up to the limits specified in your policy.
EXTENDED REPLACEMENT COST COVERAGE is intended to provide for the cost to repair or replace the
damaged or destroyed dwelling without a deduction for physical depreciation. Many policies pay only the dwelling's actual cash value until the insured has actually begun or completed repairs or reconstruction on the dwelling. Extended Replacement Cost provides additional coverage above the dwelling limits up to a stated percentage or specific dollar amount. See your policy for the additional coverage that applies.
GUARANTEED REPLACEMENT COST COVERAGE covers the full cost to repair or replace the damaged or
destroyed dwelling for a covered peril regardless of the dwelling limits shown on the policy declarations page.
BUILDING CODE UPGRADE COVERAGE, also called Ordinance and Law coverage, is an important option that
covers additional costs to repair or replace a dwelling to comply with the building codes and zoning laws in effect at the time of loss or rebuilding. These costs may otherwise be excluded by your policy. Meeting current building code requirements can add significant costs to rebuilding your home. Refer to your policy or endorsement for the specific coverage provided and coverage limits that apply.
READ YOUR POLICY AND POLICY DECLARATIONS PAGE CAREFULLY: The policy declarations page shows
the specific coverage limits you have purchased for your dwelling, personal property, separate structures such as detached garages, and additional living expenses. The actual policy and endorsements provide the details on extensions of coverage, limitations of coverage, and coverage conditions and exclusions. The amount of any claim payment made to you will be reduced by any applicable deductibles shown on your policy declarations page. It is important to take the time to consider whether the limits and limitations of your policy meet your needs. Contact your agent, broker, or insurance company if you have questions about what is covered or if you want to discuss your coverage options.
INFORMATION YOU SHOULD KNOW ABOUT RESIDENTIAL DWELLING INSURANCE
AVOID BEING UNDERINSURED: Insuring your home for less than its replacement cost may result in your having to pay
thousands of dollars out of your own pocket to rebuild your home if it is completely destroyed. Contact your agent, broker, or insurance company immediately if you believe your policy limits may be inadequate.
THE RESIDENTIAL DWELLING COVERAGE LIMIT: The coverage limit on the dwelling structure should be high
enough so you can rebuild your home if it is completely destroyed. Please note:
The cost to rebuild your home is almost always different from the market value. Dwelling coverage limits do not cover the value of your land.
The estimate to rebuild your home should be based on construction costs in your area and should be adjusted to account for the features of your home. These features include but are not limited to the square footage, type of foundation, number of stories, and the quality of the materials used for items such as flooring, countertops, windows, cabinetry, lighting and plumbing.
The cost to rebuild your home should be adjusted each year to account for inflation.
Coverage limits for contents, separate structures, additional living expenses and debris removal are usually based on a percentage of the limit for the dwelling. If your dwelling limit is too low, these coverage limits may also be too low.
SI 3286 (6-11) SUTTER INSURANCE COMPANY Page 2 of 2
You are encouraged to obtain a current estimate of the cost to rebuild your home from your insurance agent, broker, or insurance company or an independent appraisal from a local contractor, architect, or real estate appraiser. If you do obtain an estimate of replacement value, and wish to change your policy limits, contact your insurance company. While not a guarantee, a current estimate can help protect you against being underinsured.
DEMAND SURGE: After a widespread disaster, the cost of construction can increase dramatically as a result of the
unusually high demand for contractors, building supplies and construction labor. This effect is known as demand surge. Demand surge can increase the cost of rebuilding your home. Consider increasing your coverage limits or purchasing Extended Replacement Cost coverage to prepare for this possibility.
CHANGES TO PROPERTY: Changes to your property may increase its replacement cost. These changes may include the
building of additions, customizing your kitchen or bathrooms, or otherwise remodeling your home. Failure to advise your insurance company of any significant changes to your property may result in your home being underinsured.
EXCLUSIONS: Not all causes of damage are covered by common homeowners or residential fire policies. You need to read
your policy to see what causes of loss or perils are not covered. Coverage for landslide is typically excluded. Some excluded perils such as earthquake or flood can be purchased as an endorsement to your policy or as a separate policy. Contact your agent, broker, or insurance company if you have a concern about any of the exclusions in your policy.
CONTENTS (PERSONAL PROPERTY) COVERAGE DISCLOSURE:
This disclosure form does not explain the types of contents coverage provided by your policy for items such as your furniture or clothing. Contents may be covered on either an actual cash value or replacement cost basis depending on the contract. Almost all policies include specific dollar limitations on certain property that is particularly valuable such as jewelry, art, or silverware. Contact your agent, broker or insurance company if you have any questions about your contents coverage. You should create a list of all personal property in and around your home. Pictures and video recordings also help you document your property. The list, photos, and video should be stored away from your home.
CONSUMER ASSISTANCE
If you have any concerns or questions, contact your agent, broker, or insurance company. You are also encouraged to contact the California Department of Insurance consumer information line at (800) 927-HELP (4357) or at www.insurance.ca.gov for free insurance assistance.
ACKNOWLEDGEMENT OF DISCLOSURE
I have read this CALIFORNIA RESIDENTIAL PROPERTY INSURANCE DISCLOSURE, which I received within 60 days of my application, and I have selected the option(s) indicated below:
Actual Cash Value
Replacement Cost Coverage
Extended Replacement Cost Coverage Guaranteed Replacement Cost Coverage Building Code Upgrade Coverage
I acknowledge that I have been provided a copy of this California Residential Property Insurance Disclosure. Applicant’s Name (Please Print):
Applicant’s Signature:
(Original Signature of Applicant is Required) Date:
Note: RETURN THIS ACKNOWLEDGEMENT OF DISCLOSURE. If the submission has two or more applicants on the application, only one original signature is needed. Please make a copy for your records.
SI 3422 (6-11) SUTTER INSURANCE COMPANY Page 1 of 1
“CALIFORNIA RESIDENTIAL PROPERTY INSURANCE BILL OF RIGHTS”
FOR USE WITH ALL FORMS
