Dental Asst/ office. & Insurance Coordinator
Resume:
DATE (MM/DD/YYYY)
AGENCY NAIC CODE
NAMED INSURED(S)
CONTACT
NAME:
PHONE
(A/C, No, Ext):
FAX (A/C, No): POLICY NUMBER
ADDRESS:
CODE: SUBCODE: PLAN FACILITY CODE EFFECTIVE DATE EXPIRATION DATE AGENCY CUSTOMER ID:
POLICY CHANGE TIME DATE AGENT LAST INSPECTED PROPERTY EFFECTIVE DATE
HOW LONG HAVE YOU KNOWN THE APPLICANT
APPLICANT'S NAME (First, Middle, Last) APPLICANT'S MAILING ADDRESS DATE OF BIRTH SOCIAL SECURITY #
* This field may not be utilized for policyholders applying for residential property insurance in CA. PRIMARY E-MAIL ADDRESS: PRIMARY SECONDARY
PHONE # PHONE # SECONDARY E-MAIL ADDRESS:
CURRENT RESIDENCE Check if same as mailing address OWNED RENTED PREVIOUS ADDRESS YEARS AT PREVIOUS ADDRESS (if less than three years): DATE AT CURRENT RESIDENCE:
APPLICANT'S EMPLOYER NAME AND ADDRESS YRS WITH CURRENT EMPLOYER: APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed) YEARS IN CURRENT OCCUPATION: YEARS WITH PREVIOUS EMPLOYER: CO-APPLICANT'S NAME (First, Middle, Last) CO-APPLICANT'S ADDRESS Check if same as Applicant DATE OF BIRTH SOCIAL SECURITY #
* This field may not be utilized for policyholders applying for residential property insurance in CA. PRIMARY SECONDARY
PHONE # PHONE # PRIMARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
CO-APPLICANT'S EMPLOYER NAME AND ADDRESS YRS WITH CURRENT EMPLOYER: CO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed) YEARS IN CURRENT OCCUPATION: YEARS WITH PREVIOUS EMPLOYER: COVERAGE LIMIT PREMIUM COVERAGE OPTION LIMIT PREMIUM DEDUCTIBLE AMOUNT PERCENT TYPE DEDUCTIBLE AMOUNT PERCENT TYPE HO FORM #:
LOC # VEH # BOAT # ITEM# FORM NUMBER FORM NAME EDITION DATE COPYRIGHT OWNER CODE NEW AM
RENEW PM
POLICY CHANGE
DWELLING REPL COST - FULL VALUE INCLUDED
OTHER STRUCTURES REPL COST - DWELLING INCLUDED
PERSONAL PROPERTY REPL COST - CONTENTS INCLUDED
LOSS
BLANKET*
PERSONAL LIABILITY EA OCC BASE NAMED
HURRICANE*
MEDICAL PAYMENTS EA PER WIND / HAIL ANNUAL
HURRICANE**
THEFT
* Includes Dwelling, Other Structures, Personal Property, Loss of Use HOME BUS CELL HOME BUS CELL
HOME BUS CELL HOME BUS CELL
$ $ %MAX $
$ $ $
$ $ $
$
$ $
$ $ $ % $ %
$ $ $ % $ %
$ $ $ % $ %
$ % $ %
CARRIER
STATUS OF TRANSACTION
APPLICANT INFORMATION
COVERAGES / LIMITS OF LIABILITY LOC #:
FORMS AND ENDORSEMENTS (Attach ACORD 829, Forms and Endorsements Schedule, if more space is required) ACORD80(2016/11) © 1981-2016 ACORD CORPORATION. All rights reserved. HOMEOWNER APPLICATION
CIVIL UNION (if applicable)
MARITAL STATUS* /
CIVIL UNION (if applicable)
MARITAL STATUS* /
OF USE
ACTUAL LOSS
SUSTAINED
* Named Storm Percentage Deductible in North Carolina
** Not Applicable in North Carolina
Page 1 of 6
The ACORD name and logo are registered marks of ACORD 03/08/2019
SELECTQUOTE AUTO & HOME INSURANCE
C/O TRAVELERS BUSINESS CENTER
P.O. BOX 59059
KNOXVILLE, TN 37950-9059
0M4897
THE PHOENIX INSURANCE COMPANY 25623
VERONICA GONZALEZ
Legacy 03/08/201903/08/2020
X
07/24/1980 Not Required
2113 21ST ST SE
HICKORY, NC 28602-3579
X
30,000
6,000
100,000
1,000
HO-4
500
adlsd6@r.postjobfree.com
$
BURG
BILLING ACCOUNT #: DEPOSIT AMOUNT: $ EST TOTAL PREMIUM: $ BILLING PAYMENT PLAN PAYMENTMETHOD MAIL POLICY TO: PAYOR PREMIUM FINANCED ? FINANCE COMPANY
Y/N
PROTECTION DEVICE TYPE DISTANCE TO
FIRE HYDRANT FIRE STATION
# FIRE DIVISIONS # UNITS FIRE DIV
PROT CLASS FIRE EXTINGUISHER
Y / N
TERRITORY
FIRE DISTRICT NAME FIRE DIST CODE
RENOVATIONS
STREET CITY COUNTY STATE ZIP+4
PRIOR CARRIER PRIOR POLICY NUMBER EXPIRATION DATE
THE LAST
APPLICANT'S
INITIALS:
IF YES, INDICATE BELOW
ENTERED BY IN
LOSS DATE LOSS TYPE DESCRIPTION OF LOSS CAT # AMOUNT PAID (A)GENT DISPUTE
(C)OMPANY (Y / N)
$
$
$
$
DIRECT BILL - POLICY FULL PAY BI-MONTHLY CASH EFT AGENT DIRECT BILL - ACCT ANNUAL MONTHLY CHECK PAYROLL DEDUCTION INSURED AGENCY BILL SEMI-ANNUAL CREDIT CARD PRE-AUTHORIZED DRAFT/CHECK (PAC) QUARTERLY
INSURED MORTGAGEE
MASONRY VENEER BUILDERS RISK EXCELLENT AVERAGE SYSTEM SMOKE TEMP FRAME RENOVATION GOOD BELOW AVG CENTRAL FT MI
MASONRY RECONSTRUCTION DIRECT
EXCELLENT AVERAGE LOCAL
OWNER GOOD BELOW AVG
ALUMINUMSIDING TENANT ANY KNOWN LEAKS? (Y/N) DEADBOLT PARTIAL STUCCO UNOCCUPIED SPRING FULL
VINYL SIDING / PLASTIC VACANT EXCELLENT AVERAGE
CEDAR, WOOD,
SHINGLE GOOD BELOW AVG
EIFSCB (on cinder block)
EIFSS (on studs) DWELLING NONE NONE
APARTMENT
YEAR EIFS INSTALLED: CONDOMINIUM
TOWNHOUSE
PRIMARY SEASONAL ROWHOUSE COPPER LAST INSPECTED DATE CIRCUIT BREAKERS SECONDARY FARM CO-OP ALUMINUM FUSES
VISIBLE FROM VISIBLE TO
ROAD NEIGHBORS KNOB & TUBE NUMBER OF AMPS
OCCUPIED DAILY
PART COMP YEAR
NON-SMOKER IN CITY LIMITS CLASS SPECIFIC WIRING
MANNED SECURITY IN FIRE DISTRICT NONE PLUMBING
LIGHTNING PROTECTION IN PROT SUBURB OPEN HEATING
OFF PREMISE THEFT EXCL CLOSED ROOFING
NONE EXTERIOR PAINT
INDOORS ABOVE GROUND MASONRY FLOOR
SQ FT NONE INDOORS ABOVE GROUND NO MASONRY FLOOR RESISTIVE SEMI-RESISTIVE ABOVE GROUND OUTDOORS ABOVE GROUND
SQ FT IN GROUND OUTDOORS BELOW GROUND
CHIMNEYS APPROVED FENCE STORM SHUTTERS
SQ FT HEARTHS DIVING BOARD FUEL LINE LOCATION A B
PRE-FAB SLIDE UNDER GROUND
SQ FT WOOD STOVE INSERT THROUGH FOUNDATION HURRICANE RESISTIVE GLASS CONSTRUCTION TYPE % COURSE OF CONSTRUCTION HOUSEKEEPING CONDITION PLUMBING CONDITION
OCCUPANCY
SIDING % DOOR LOCK SPRINKLER
ROOF CONDITION
RESIDENCE TYPE ROOF MATERIAL
PRIMARY HEAT SECONDARY HEAT
DISTANCE TO TIDAL WATER
DATE HEATING SYSTEM LAST SERVICED:
USAGE TYPE PURCHASE PRICE PURCHASE DATE WIRING ELECTRICAL SYSTEMS
$
SECURITY
YEAR BUILT # ROOMS # FAMILIES RATING CREDITS DWELLING LOCATION RATING MARKET VALUE # APARTMENTS # RESIDENTS HOUSEHOLD FOUNDATION
$
REPLACEMENT COST # WEEKS RENTED TAX CODE
$ FUEL STORAGE TANK LOCATION
TOTAL LIVING AREA BLDG CODE GRADE WIND CLASS
SWIMMING POOL
BASEMENT AREA INSPECTED (Y/N):
FIREPLACES (Enter # or 0 for none) WINDSTORM
GARAGE AREA
BREEZEWAY AREA
LOC #
Y / N
Miles Feet
AGENCY CUSTOMER ID:
PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required) RATING / UNDERWRITING LOC #:
NO PRIOR COVERAGE
ACORD80(2016/11)
LOCATION SCHEDULE
PRIOR COVERAGE
LOSS HISTORY
ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURING YEARS, AT THIS OR ANY LOCATION?
Page 2 of 6
178.00 178.00
X X
X
X
1
X
X
X
250 2
3 N
HICKORY
Central - Gas
X X
1 2113 21ST ST SE HICKORY NC 28602-3579
EXPLAIN ALL "YES" RESPONSES Y / N
ADDITIONAL
PREMISES
LIABILITY
EXTENSION
# PREMISES: INFLATION GUARD % INCREASE
LOC #: TERR: LOSS ASSESSMENT LIMIT
LOC #: TERR:
MINE SUBSIDENCE
LIMIT CONST MATERIAL:
# PREMISES: MED PAY (Y/N): PROP DESC:
ADDITIONAL
RESIDENCE
RENTED TO
OTHERS
LOC #: MED PAY (Y/N): # FAMILIES:
OFFICE,
PROFESSIONAL
PRIVATE SCHOOL,
STUDIO -
RESIDENCE
PREMISES
REQ INCR CONTENTS LIMIT
TERR:
INCR CONT NOT REQ MED PAY (Y/N) :
LOC #: MED PAY (Y/N): # FAMILIES:
OT. STRUCTS TERR:
TERR:
STRUCT TYPE:
BUILDERS RISK
THEFT BLDG
MATERIALS
LIMIT BUS/STRUCT DESC:
INCLUDED
OTHER
STRUCTURES-
INDIVIDUAL STRUC
LIMIT
COLLAPSE DUE TO
HYDRO-STATIC
PRESSURE
LIMIT STRUCTURE DESC:
INCLUDED
PLANTS, SHRUBS &
TREES
LIMIT
BUILDING ORD OR
LAW COVERAGE
AGG INCR INCLUDED
INCLUDED % REBUILD REFRIGERATED
FOOD PRODUCTS
INCLUDED LIMIT
BUS PROP AT HOME INCLUDED LIMIT
SINK HOLE
BUSINESS AWAY FROM PROP HOME INCLUDED LIMIT COLLAPSE INCLUDED DEBRIS REMOVAL INCLUDED LIMIT UNIT-OWNERS
ADDITIONS&
ALTERATIONS
SPECIAL COVERAGE
LIMIT
EARTHQUAKE
% DED TERR:
INCLUDED
RETROFIT TYPE:
DED
UNSCHEDULED
JEWELRY,
WATCHES, FURS
MAS VENEER: % AGG INCR
EMPLOYERS LIAB LIMIT # OF EMPLOYEES:
WATER BACKUP OF
SEWERS & DRAINS
EQUIP BREAKDOWN INCLUDED LIMIT
INC DED LIMIT
WATERCRAFT
LIABILITY
FIRE DEPARTMENT LIMIT
SERVICE CHARGE INCLUDED
WATERCRAFT
PHYSICAL DAMAGE
FLOOD BLDG CONTENTS LIMIT
FUNGUS AND MOLD
EXCL LIABILITY PROPERTY WINDSTORM EXCL YES
EXCL PROP DAMAGE LIABILITY WORKERS
COMPENSATION-
FULL TIME
INSERVANT
GOLF CARTS -
LIABILITY
INCLUDED # GOLF CARTS:
# OF EMPLOYEES:
DESCRIPTION:
GOLF CARTS -
PHYSICAL DAMAGE
LIMIT
IDENTITY FRAUD EXP INCLUDED LIMIT
INCIDENTAL
FARMING PERS LIAB MEDICAL PAYMENTS (Y/N):
INCR COV C
SPECIAL LIAB LIMIT
ELECTRONIC APP
IN AND OUT OF
VEHICLE
TOTAL INCR
ELECTRONIC
APP IN VEHICLE
TOTAL INCR
GUNS TOTAL INCR
MONEY TOTAL INCR
SECURITIES TOTAL INCR
SILVERWARE TOTAL INCR
COVERAGE TYPE COVERAGE INFORMATION PREMIUM COVERAGE TYPE COVERAGE INFORMATION PREMIUM
$ $
$ $ $
$ $
$ $
$ $
$ $ $
$ $
$
$
$ $
$ $ $ $
$
$ $
$ $
$ $ $
$ $
$ $
$
$ $ $ $
$ $
$ $
(Not applicable in NC) $ $ $
$ $
$
$ $ $ $ $
$
$
(Not applicable in Arkansas) $
$ (Applicable only in CA, MT, NV, NH, NJ, NY, ND, OH, OR, WA, WV and WY)
$ $
$ $ COVERAGE TYPE OPTS LIMIT APPL TO DEDUCTIBLE PREMIUM CODE $ $
$ $
DESCRIPTION $ TYPE: $
$ TERR: Y / N:
CODE $ $
DESCRIPTION $ TYPE: $
$ $ $ TERR: Y / N:
CODE $ $
$ $ $ DESCRIPTION $ TYPE: $
$ $ $ TERR: Y / N:
$ $ $ CODE $ $
$ $ $ DESCRIPTION $ TYPE: $
$ $ $ TERR: Y / N:
LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER 1. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) 2. HAS ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS?
(Missouri Applicants - Do not answer this question) 3. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS? 4. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS? 5. ANY OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION, OWNED, OCCUPIED OR RENTED? AGENCY CUSTOMER ID:
OPTIONAL COVERAGES - ENDORSEMENTS LOC #:
GENERAL INFORMATION
ACORD80(2016/11) Page 3 of 6
$ LIMIT
Y
Automobile - Personal 604******-*** 1 Automobile - Personal N 604******-*** 1
EXPLAIN ALL "YES" RESPONSES Y / N
EXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISE Y / N EXPLAIN ALL "NO" RESPONSES Y / N
YEAR MAKE MODEL BODY TYPE
ANIMAL TYPE BREED BITE HISTORY (Y/N) ANIMAL TYPE BREED BITE HISTORY (Y/N) START DATE COMP DATE INT EXT ADDITION ADD LEVEL STRUC CHANGES MATERIALS UNATTACHED OCC DURING REN COST OF PROJECT
% % sq. ft. sq. ft. Y / N INCL EXCL Y / N
FARMING TELECOMMUTER DAY CARE # OF CHILDREN:
HOME OFFICE/BUSINESS
INSURANCE COMPANY: LIMIT: CLEANUP/SUBLIMIT:
NAME OFCOMMUNITY:
OWNER'SNAME:
PHONE (A/C,No):
6. HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY?
7.
8. DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?
(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) 1. ANY BUSINESS CONDUCTED ON PREMISES?
2. ANY RESIDENCE EMPLOYEES? # FULL TIME: DESCRIPTION: # PART TIME: DESCRIPTION: 3. ANY FLOODING, BRUSH, FOREST FIRE OR LANDSLIDE HAZARD? 4. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES? 5. IS PROPERTY SITUATED ON MORE THAN ONE ACRE? # OF ACRES: LAND USED FOR: 6. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS? 7. IS THE DWELLING / HOME FOR SALE? (no explanation required) 8. IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY? (If "YES", describe in detail) 9. IS THERE A TRAMPOLINE ON THE PREMISES?
a. IF "YES", IS THERE A SAFETY NET? (no explanation needed) 10. WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? ORIGINAL OCCUPANCY:
11. ANY LEAD PAINT?
12. IF A FUEL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK?
(If "YES", provide the name of the insurance company, the applicable limit and thecleanupsublimit) 13. IS THE RESIDENCE IN A GATED COMMUNITY?
14. IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR?
$
15. IS THERE AN APPROVED CARBON MONOXIDE ALARM IN OPERATING CONDITION WITHIN THE MANDATED NUMBER OF FEET OF EVERY ROOM USED FOR SLEEPING PURPOSES? (IL - 15 FT) (no explanation needed) 16. IS THE NAMED INSURED THE OWNER OF THE PROPERTY? (If "NO", provide the name of the owner) 1.
2. IS THERE A SECURITY ATTENDANT?
3. IS THE BUILDING ENTRANCE LOCKED?
AGENCY CUSTOMER ID:
GENERAL INFORMATION (continued)
GENERAL INFORMATION - RESIDENTIAL LOC #:
GENERAL INFORMATION - RENTERS AND CONDOS ONLY LOC #: ACORD 80 (2016/11) Page 4 of 6
DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGIES, MINI BIKES, ATVS, etc), NOT SCHEDULED ON THIS POLICY? IS THERE A MANAGER ON THE PREMISES? MANAGER'S NAME: N
N
BINDER / NOTICE OF INFORMATION PRACTICES
INSURANCE BINDER IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY: EFFECTIVE DATE EXPIRATION DATE 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 TIME 12:01 AM CURRENT USE BY THE COMPANY.
NOON THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY COVERAGE IS NOT BOUND WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE.
(Applicant's Initials):
ACORD 80 (2016/11) Page 5 of 6
or broker for your state's requirements.)
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, please contact your agent EARTHQUAKE APPLICATION PERSONAL INLAND MARINE SECTION REPLACEMENT COST ESTIMATE WATERCRAFT SECTION FLOOD EXCLUSION NOTICE PERS UMBRELLA APPLICATION SECTION RESIDENCE BASED BUSINESS SUPP WINDSTORM LOSS MITIGATION LEAD FREE PAINT CERTIFICATION PHOTOGRAPH SOLID FUEL SUPPLEMENT MOBILE HOME SUPPLEMENT PROTECTION DEVICE CERTIFICATE STATE SUPPLEMENT(S) (If applicable) AGENCY CUSTOMER ID:
INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE SEND BILL INTEREST IN ITEM NUMBER LOCATION: BUILDING:
LIENHOLDER
VEHICLE: BOAT:
ITEM:
ITEM
CLASS:
MORTGAGEE
ITEM DESCRIPTION
TRUSTEE
REFERENCE / LOAN #:
ADDITIONAL INTEREST (Attach ACORD 45, Additional Interest Schedule, if more space is required) INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION: BUILDING:
LENDER'S LOSS PAYABLE VEHICLE: BOAT:
ITEM:
ITEM
CLASS:
LOSS PAYEE ITEM DESCRIPTION
MORTGAGEE
REFERENCE / LOAN #:
REMARKS / ATTACHMENTS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) BINDER / NOTICE OF INFORMATION PRACTICES
LOSS PAYEE
ADDITIONAL INSURED
LENDER'S LOSS PAYABLE
TRUSTEE
LIENHOLDER
APPLICABLE IN ARIZONA: Binders are effective for no more than 90 days. APPLICABLE IN COLORADO: The insurer has thirty (30) business days, commencing from the effective date of coverage, to evaluate the issuance of the insurance policy. APPLICABLE IN MARYLAND: The insurer has 45 business days, commencing from the effective date of coverage, to confirm eligibility for coverage under the insurance policy. APPLICABLE IN MICHIGAN: The policy may be cancelled at any time at the request of the insured. APPLICABLE IN MONTANA: No binder shall be valid beyond the issuance of the policy with respect to which it was given or beyond 90 days from its effective date, whichever period is the shorter. If the policy has not been issued, a binder may be extended or renewed beyond such 90 days with the written approval of the insurer. APPLICABLE IN OKLAHOMA: All policies shall expire at 12:01 AM standard time on the expiration date stated in the policy. APPLICABLE IN OREGON: Binders are effective for no more than ninety
(90) days. A binder extension or renewal beyond such 90 days would require the written approval by the Director of the Department of Consumer and Business Services.
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. PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND 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 WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA or WV. Specific ACORD 38s are available for applicants in these states.) SEE ADDITIONAL REMARKS SCHEDULE FOR MORE INFORMATION (ACORD 101-********* 634 1
AGENCY CUSTOMER ID:
FRAUD STATEMENTS / SIGNATURE
PRODUCER'S SIGNATURE PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO
(Required in Florida)
APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER ACORD80(2016/11) Page 6 of 6
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. Applicable in AL, AR, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
Applicable in CO
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. Applicable in FL and OK
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)*. *Applies in FL Only. Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA
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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA
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 and denial of insurance benefits. *Applies in ME Only. Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents,helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Endorsements and Coverages
HO-300NC Special Provisions
HO-19 Inflation Guard
HO-208NC Water Backup and Sump Overflow
HO-290NC Personal Property Replacement Cost
AGENCY NAMED INSURED
POLICY NUMBER
CARRIER NAIC CODE
EFFECTIVE DATE:
AGENCY CUSTOMER ID:
LOC #:
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE:
ADDITIONAL REMARKS
ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL REMARKS SCHEDULE Page 1 of 1
SELECTQUOTE AUTO & HOME INS
THE PHOENIX INSURANCE COMPANY 25623
VERONICA GONZALEZ
03/08/2019
ACORD 80 Homeowner Application
Important Notice about Billing Options and Disclosures This notice contains important information about our billing options and charges. You have chosen to pay your insurance premium in full and will be billed by mail / email. Other charges that may apply include a $10.00 late charge and a $20.00 fee for payments returned by your bank. If your billing needs change, you may pay your premium by: Bill Plan Monthly Pay in Full
Electronic Funds Transfer (EFT) $2.00 No Charge
Recurring Credit Card (RCC) $2.00 No Charge
Bill by Mail / Email $3.00 No Charge
Late Charge: $10.00 per occurrence
Payments returned by your bank: $20.00 per occurrence In the event two payments are returned during a 12 month period you will be required to pay with guaranteed funds for 182 days from the date of the last returned payment. Guaranteed funds are credit card, bank check, money order or home banking payments. Other forms of payment will be returned. You will not be eligible to use our Electronic Funds Transfer (EFT) or Recurring Credit Card (RCC) payment plans. Visit www.amp.travelers.com if you would like to enroll in our Electronic Funds Transfer (EFT) or Recurring Credit Card (RCC) payment plan.
When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. If you have multiple policies with us you may be able to combine those policies into a single billing account. If you have selected one of our monthly billing options, and you combine your policies into a single billing account, you will be charged just one service charge per installment, and not per individual account. To add this policy to an existing billing account or if you have other questions about this notice, please call your insurance representative at 1-800-***-****.
QCN501 11-17
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