Quaker Special Risk
Homeowners/Dwelling Application

Today's Date: 12/16/2017
email
Applicant Occupation Employer
Co-Applicant Occupation Employer
Mailing Address
City/State/Zip
County
Insured Location (if different than mailing address)
City/State/Zip
County
Inspection Contact Phone Number
Producer Name Phone Number
Prior Carrier Expiration Date Expiring Premium Effective Date (of this policy)
If prior carrier, or a previous carrier, has cancelled or non-renewed, please explain why?
If the insured has not carried insurance within the last 12 months, please explain why?
Within the last 5 years has the applicant had a Foreclosure  Bankruptcy  Repossession 
Mortgagee (Name/Mailing Address Including Zip Code) Loan #
Mortgagee (Name/Mailing Address Including Zip Code) Loan #
Additional Insured (Name/Address/City/State/Zip) Describe Interest

COVERAGES/LIMITS OF LIABILITY
Policy Form Dwelling/(A&A HO-6)
Other Structures
Personal Property
Loss of Use
Personal Liability
Medical Payments
HO-3
HO-4
HO-6
DP-3
Loss Assessment
Ordinance of Law (10% provided)
5 % 15 % 25 %
AOP Deductible
Wind/Hail Deductible
% Exclude AOP
Other Deductible

RATING INFORMATION
Territory #
Protection Class #
if PC 9/10, please use supplemental questionnaire)
Distance to Fire Hydrant: Feet
Distance to Fire Station: Miles
Fire Department:
Paid Volunteer
Occupancy
Primary Secondary Rental Secondary Rental Builders Risk (requires supplemental questionnaire) Vacant
Construction
Frame/Stucco Masonry Masonry Veneer Superior EIFS Log (requires supplemental questionnaire)
Construction Style
Ranch Cape Colonial Victorian    Other
Year Built
Square Footage # of Stories # of Families
Roof Type
Comp Metal Shake Tile Slate    Other
Foundation Type
Concrete Slab Concrete Block Pilings/Stilts
Protective Alarm/Devices
Centrally Monitored Fire Centrally Monitored Burglar Local Fire Local Burglar Smoke Detector Interior Sprinklers
Market Value
Dwelling for Sale
Yes No
On Nat'l Historical Register
Yes No
Tours? Yes No
Vacant? (If yes, DP-3 Policy Form Applies)
Yes No
Since what date?
If HO4/6,
How many floors in the building?     On which floor is the unit?     How many units in the building?    
Update Information (required if home>25 years old) Was home completely gutted and remodeled?
Yes No    If yes, what Year?
Roof
Part Comp   
Year
Wiring
Part Comp   
Year
Heating
Part Comp   
Year
Plumbing
Part Comp   
Year

LOSS HISTORY
Note: Loss History includes all losses within the last 3 years regardless of location and
any loss greater than $1,000,000 regardless of location or date.
Date Type of Loss Cause Amount Preventative Measures

ADDITIONAL UNDERWRITING INFORMATION(check all applicable)
Eligible for Wind pool? Yes No Distance to Ocean/Bay Gulf:  Miles  Feet
Windstorm Mitigation
Hip Roof Roof Straps Protective Glass Metal Electronic Shutters Metal Manual Shutters Plywood Shutters
Earthquake Coverage Yes No
 If yes, Standard Deluxe
EQ Zone  EQ Territory
CALIFORNIA, OREGON AND WASHINGTON w/ earthquake                                              CALIFORNIA BRUSH
Soil Type:     Hard Rock  Soft Rock  Stiff Clay  Soft Soil          Other
Is Dwelling on tall walls or posts? Yes No Is the property located in a brush zone? Yes No
If built >1920 and <1950, full seismic retrofitting? Yes No Brush Density: Low Moderate Heavy Extreme
Is the Dwelling Located on a Hillside? Yes No
 Slope:    Degrees
Is there 150 feet of brush clearance around all structures? Yes No
 Distance to Brush:    Feet
Is there unrepaired earthquake damage? Yes No Automatic Exterior Sprinkler within the brush area? Yes No
Is there extensive un-reinforced masonry cladding? Yes No If Wood Shake roof,  1000 Feet of brush clearance? Yes No
                                        Fire Retardant Treatment? Yes No
Has anyone with financial interest in the property been convicted of arson, fraud, or other crime related to a loss on the property now or within the last 5 years? Yes No
Is there a a trampoline on premises? Yes No Daycare conducted on premises? Yes No
Is there a fuel tank on premises? Yes No
If yes, Underground Basement Above Ground
Is business conducted on premise? Yes No
If yes, explain:
Animals on Premises? Yes No
Type: Breed: Bite History:
Is the dwelling rented? Yes No
If yes, how many weeks? Rented to students? Yes No
Is there a swimming pool? Yes No
If yes, Fenced Unfenced Diving Board Slide
Is the dwelling undergoing any renovation or reconstruction?
Yes No  (if yes, requires supplemental questionnaire)
Gated Community? Yes No
Patrolled? Yes No
Is there a woodstove on premises? Yes No
 If yes, is it a primary heat source? Yes No
(supplemental questionnaire required for all wood burning stoves)
Caretaker? Yes No
Resident? Yes No

OPTIONAL COVERAGES/ENDORSEMENTS
Personal Property Replacement Cost Yes No Directors & Officers Coverage Yes No
Special Personal Property Coverage Yes No Extending Liability Yes No
 no. of properties   occupancy 
 if rental, how long (weekly, annual, etc.) 
 address  
Special Computer Coverage Yes No
Extended Replacement Cost Dwelling Yes No
125% 150%
Upgrade to Green Residential Endorsement Yes No Watercraft Liability
 Engine Type:  Inboard Outboard Sailboat
 Length    feet
LexElite Eco-Homeowner Yes No
Personal Injury Yes No
Increased Special Limits (Jewelry/Watches/Furs) Yes No Increased Limits on Business Property Yes No
 If yes, $10,000 $25,000
Increased Special Limits (all) Yes No Golf Cart Coverage Yes No
 no. of carts:    value   year 
 make    model   serial no. 
Water Back Up and Sump Pump Overflow Yes No
$5,000 $10,000 $25,000
Family Security Endorsement Yes No Include Liability for Golf Carts Yes No
Identity Fraud Yes No HO6 All Risk Coverage A Yes No

ADDITIONAL COMMENTS

NOTICE OF INSURANCE INFORMATION PRACTICES: Personal information about you may be collected from persons other than you. Such information, as well as other personal and privileged information, collected by us or your agent 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/broker for instruction on how to submit a request to us.

NOTICE TO ARKANSAS APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."

NOTICE TO COLORADO APPLICANTS: "IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES."

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: "WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT."

NOTICE TO FLORIDA APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE."

NOTICE TO KENTUCKY APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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."

NOTICE TO LOUISIANA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."

NOTICE TO MAINE APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS."

NOTICE TO MINNESOTA APPLICANTS: "A PERSON WHO SUBMITS AN APPLICATION OR FILES CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME."

NOTICE TO NEW JERSEY APPLICANTS: "ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."

NOTICE TO NEW MEXICO APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES."

NOTICE TO NEW YORK APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION."

NOTICE TO OHIO APPLICANTS: "ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD."

NOTICE TO OKLAHOMA APPLICANTS: "WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY."

NOTICE TO PENNSYLVANIA APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES."

NOTICE TO VIRGINIA APPLICANTS: "IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS."

NOTICE TO WEST VIRGINIA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."

IMPORTANT ADDITIONAL NOTICE: This application does not bind the applicant to buy, or the insurer to issue the insurance, but it is agreed that this application shall be the basis of the insurance policy.

PRODUCER'S SIGNATURE: ________________________________________ DATE: ______________________

Applicant's Statement: The undersigned applicant declares that if the information supplied on this application changes between the date of this application and the time when the insurance policy is issued, the applicant will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorizations or agreement to bind this insurance.

The undersigned applicant further declares that I have read and understand the entire application including the applicable fraud warning, if any, and that the statements set forth in this application are true and complete.

APPLICANT'S SIGNATURE: ______________________________________ DATE: ______________________

Validation Code: 35278
Enter Validation Code:  (Required)

Please submit to my following underwriter


V20140626