| Download Word |
|
|
|
|
|
|
|
| |
|
Coverage |
Coverage |
| Exposure |
No Exposure |
Recommended |
Recommended |
| |
|
Accepted |
Not Accepted |
| AUTOMOBILE |
|
|
|
| Liability $ |
|
|
|
| PIP (Basic) |
|
|
|
| o Extended |
|
|
|
| o Additional |
|
|
|
| o Work Loss Exclusion $ |
|
|
|
| o Coordination Military |
|
|
|
| Ded: o Named Insured o Named Insured + Dep. Rel. $ |
|
|
|
| Medical Payments |
|
|
|
| Uninsured Motorists |
|
|
|
| o Stacked o Non-stacked o Lower limits |
|
|
|
| Comprehensive - Deductible $ |
|
|
|
| Collision - Deductible $ |
|
|
|
| Extended Non-Owned |
|
|
|
| CB, Phone, etc. $ |
|
|
|
| Tapes, etc. |
|
|
|
| Customizing Equipment $ |
|
|
|
| Extended Transportation Expense |
|
|
|
| Towing & Labor $ |
|
|
|
| Out of Territory (USA, Canada) |
|
|
|
| Other Owned Autos |
|
|
|
| |
|
|
|
| HOMEOWNERS Form: _______ Deductible: $ |
|
|
|
| Coverage A - Dwelling $ |
|
|
|
| Coverage B - Other Structures $ |
|
|
|
| Coverage C - Personal Property $ |
|
|
|
| Coverage D - Loss of Use $ |
|
|
|
| Coverage E - Liability $ |
|
|
|
| Coverage F - Medical Payments $ |
|
|
|
| |
|
|
|
| Condominium - Private Coverage A $ |
|
|
|
| Special Form - Coverage A |
|
|
|
| Loss Assessment - Increase or Addl. Location $ |
|
|
|
| |
|
|
|
| Primary Residence - Property Options |
|
|
|
| Guaranteed Replacement Cost |
|
|
|
| Coverage C Replacement Cost |
|
|
|
| Inflation Guard _______% |
|
|
|
| Increased Limits |
|
|
|
| Money, Coins, etc. $ |
|
|
|
| Securities, Tickets, Stamps $ |
|
|
|
| Jewelry, Furs, etc. - Theft $ |
|
|
|
| Firearms - Theft $ |
|
|
|
| Silverware, Goldware - Theft $ |
|
|
|
| Credit Card, Fund Transfer Card, Forgery $ |
|
|
|
| Scheduled Property: |
|
|
|
| Jewelry |
|
|
|
| Furs |
|
|
|
| Fine Arts |
|
|
|
| Cameras |
|
|
|
| Other Items (list here): |
|
|
|
| Primary Residence - Property Options (Continued) |
|
|
|
| Coverage C - Special Coverage |
|
|
|
| Computers - Special Coverage |
|
|
|
| Other Structures - Increase Coverage $ |
|
|
|
| Ordinance or Law Coverage |
|
|
|
| HO-4: Building Additions & Alterations $ |
|
|
|
| Earthquake Coverage |
|
|
|
| Windstorm Exclusion |
|
|
|
| |
|
|
|
| Primary Residence - Liability Options |
|
|
|
| Personal Injury |
|
|
|
| Watercraft, Jet Ski, Other |
|
|
|
| o Owned o Rent |
|
|
|
| Physical Damage |
|
|
|
| Liability, Medical Payments |
|
|
|
| Incidental Farming - Residence Premises |
|
|
|
| Owned Farm Elsewhere |
|
|
|
| Loss Assessment - Increase or Addl. Location $ |
|
|
|
| |
|
|
|
| BUSINESS ACTIVITIES |
|
|
|
| Conducted on Residence Premises |
|
|
|
| Other Structures $ |
|
|
|
| Furnishings, Supplies Equipment $ |
|
|
|
| Liability Medical Payments |
|
|
|
| Conducted at Secondary Residence |
|
|
|
| Merchandise $ |
|
|
|
| Other Business Property $ |
|
|
|
| Business Pursuits as Employee |
|
|
|
| Day Care in Home |
|
|
|
| Other Business Activities - Any Insured |
|
|
|
| |
|
|
|
| |
|
|
|
| Rental - Landlord |
|
|
|
| o In Dwelling - Residence Premises |
|
|
|
| o Condominium |
|
|
|
| o Other Structure - Residence Premises |
|
|
|
| o Other Location |
|
|
|
| Building or Structure $ |
|
|
|
| Contents $ |
|
|
|
| Loss of Rents $ |
|
|
|
| Liability, Medical Payments $ |
|
|
|
| Property Loss Assessment $ |
|
|
|
| Liability Loss Assessment $ |
|
|
|
| |
|
|
|
| |
|
|
|
| Private Secondary Residence - Own by / Rent to Insured |
|
|
|
| Building Coverage - Form: ______ $ |
|
|
|
| Other Structures $ |
|
|
|
| Contents $ |
|
|
|
| Loss of Use $ |
|
|
|
| Liability Medical Payments $ |
|
|
|
| Loss Assessment $ |
|
|
|
| Building Additions & Alterations (rented) |
|
|
|
| MISCELLANEOUS |
|
|
|
| Umbrella |
|
|
|
| Other Owned Locations (explain) |
|
|
|
| Inland Marine: Valuable Articles/Collectibles |
|
|
|
| Professional Services |
|
|
|
| Miscellaneous Land Vehicles or Watercraft |
|
|
|
| o Own o Rent |
|
|
|
| Golf Cart |
|
|
|
| Other: |
|
|
|
| Physical Damage |
|
|
|
| Liability, Medical Payments |
|
|
|
| |
|
|
|
| Mobile Home |
|
|
|
| o Own o Rent |
|
|
|
| Physical Damage |
|
|
|
| Contents |
|
|
|
| Auto Exposures |
|
|
|
| |
|
|
|
| Aircraft, Hang Glider, Hot Air Balloon, etc. |
|
|
|
| o Own o Rent |
|
|
|
| Physical Damage |
|
|
|
| Liability, Medical Payments |
|
|
|
| |
|
|
|
| FLOOD |
|
|
|
| Building |
|
|
|
| Contents |
|
|
|
| |
|
|
|
| LIFE INSURANCE |
|
|
|
| Last Expense Fund |
|
|
|
| Mortgage/Rent Fund |
|
|
|
| Educational Fund |
|
|
|
| Emergency Fund |
|
|
|
| Child Care Fund |
|
|
|
| Income Fund |
|
|
|
| Will |
|
|
|
| |
|
|
|
| ACCUMULATION ACCOUNT/RETIREMENT |
|
|
|
| Pensions |
|
|
|
| Annuities |
|
|
|
| Cash Value Life Insurance |
|
|
|
| Other |
|
|
|
| |
|
|
|
| HEALTH INSURANCE |
|
|
|
| Group Medical |
|
|
|
| Individual Medical |
|
|
|
| Dental |
|
|
|
| Vision |
|
|
|
| Disability Income |
|
|
|
|
|
|
|
| Prepared by: |
Date: |
|
|
|
|
|
|
| Agent: |
Date: |
|
|
|
|
|
|
| Insured: |
Date: |
|
|