Point O’Woods Association
Homeowner Insurance Application
Date Coverage is to be effective:
Applicant Information:
Name:
Insured Location:
Mailing Address:
City:
City:
State:
State:
Zip:
Zip:
County:
Telephone Number:
Occupation:
Has applicant had a foreclosure, repossession, or bankruptcy during the past 5 years:
Yes
No
Protection Information:
Distance to Fire Hydrant:
Distance to Fire Station:
Central Fire Alarm:
Yes
No
Central Burglar Alarm
Yes
No
Smoke Detectors:
Yes
No
Dead Bolts:
Yes
No
Sprinkler System:
Full
Partial
None
Contruction Information:
Material:
Brick
Stucco
Masonary
Wood Frame
Other
Other:
Type of Foundation:
Concrete Blocks
Piling/Stilts
Year Purchased:
Year Built:
Square Footage:
Type of Roof:
Market Value
$
Age of Roof:
Primary Flood Insurance Carried (NFIP):
Yes
No
Flood Zone:
Building Policy Limit:
Personal Property Policy Limit:
Limits / Deductibles:
Dwelling:
$
Other Structures:
$
Personal Property:
$
Loss of Use:
$
Personal Liability:
$
Medical Payments:
$
Deductible All Other Perils:
(min $2,500)
$
Deductible - Wind:
(3% of dwelling)
$
Eligible for Wind Pool:
Yes
No
Property Information:
Type:
Dwelling
Town House
Apartment
Condo
Row House
Co-Op
Occupancy:
Primary
Secondary
Rental
Is the home occupied daily:
Yes
No
Unoccupied > 30 consecutive days:
Yes
No
If home is rented, indicate number of weeks:
Is the Home Visbile to Others:
Yes
No
Is the Home for Sale:
Yes
No
Caretaker:
Yes
No
Gated Community:
Yes
No
Patrolled:
Yes
No
Building undergoing any renovations:
Yes
No
If yes, please provide details:
General Information:
Distance to Ocean,
Bay in Feet:
Distance to Ocean,
Bay in Miles:
Elevation above sea level in Feet:
Storm-shutters:
Yes
No
If yes, what type of
Storm-shutters:
Update Information - Required if home is over 25 years old, 20 years for roof:
Wiring:
Full
Partial
Year Complete:
Plumbing:
Full
Partial
Year Complete:
Heating:
Full
Partial
Year Complete:
Roof:
Full
Partial
Year Complete:
Additional Exposures:
(comment in remarks section)
Animals on Premises:
Yes
No
Type:
Training:
Number of Years Owned:
Swimming Pool on Premises:
Yes
No
Fenced/Screened:
Yes
No
Business Conducted on Premises:
Yes
No
Childcare/daycare on Premises:
Yes
No
Wood Stoves or Supplemental Heating on Premises:
Yes
No
Is Property within 300 ft of Any Commercial Structure:
Yes
No
List other structures & values on premises:
Remarks:
Prior Carrier and Loss Information:
Previous Carrier:
Expires:
Expiring or Renewal Premium:
Non-Renewing:
Yes
No
If Yes, Reason:
Have there been any losses in the past three years? If yes, please provide Loss details:
Loss Date(s), Type(s), Cause(s) and Amount(s)
Loss Details:
What preventative measures have been taken to prevent future losses? Please explain:
Declaration:
To the best of my knowledge and belief the information provided in this application, whether in my own hand or not, is true and I have not withheld any material facts. I understand that non-disclosures or misrepresentation of a material fact will entitle the company to void the insurance. I understand that signing the Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this application and the statements made therein shall form the basis of the insurance.
I Agree
I Disagree
Initials:
Date:
Questions:
Contact Jack Buttine (212) 697-1010 ext 21 or
jmb@buttine.com