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: Other:
Type of Foundation:    
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: Occupancy:
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