Tunit-Ca - Unit Renters Insurance Form (Page 2 of 2) in pdf

Please answer all questions then sign and date the application

1. Is there any business performed on the premises,

10. Is there a swimming pool with a diving board or

[ ]No [ ]Yes

including child care?

slide? If yes not eligible.

2. Is the dwelling in a brush area, forest, or landslide

11. Is the dwelling now, or has it been in the last 60

area or within 1300 feet of these areas? If yes, not

[ ]No [ ]Yes

days in foreclosure? If yes, not eligible.

[ ]No [ ]Yes

eligible.

3. Is the dwelling under construction? If yes not

12 Do you own or board any livestock, including

[ ]No [ ]Yes

eligible.

horses? If yes, not eligible.

4. Is the dwelling built on piers or piling? If yes, not

13. Do you own or board any dogs? If yes, complete

[ ]No [ ]Yes

eligible.

the dog information section below.

5. Has the roof been replaced in the past 25 years? If

[ ]No [ ]Yes

14. Are there circuit breakers? If no, risk ineligible.

[ ]No [ ]Yes

yes, when?

6. Is renter current with rent payment? If no, not

15. Is there a central fire alarm system? If yes, proof

[ ]No [ ]Yes

eligible.

of installation is required for credit.

7. Is the dwelling presently occupied? Vacant units

16. Is there a central burglary alarm system? If yes,

[ ]No [ ]Yes

are not eligible.

proof of installation is required for credit.

8. Are there any adjacent properties of a hazardous

17. Has applicant been refused insurance, been

[ ]No [ ]Yes

nature? If yes, explain on separate sheet of paper.

cancelled or non-renewed in the past 36 months?

9. Is unit rented out for less than 6 months at a time?

18. Is there a woodstove or propane heat? If yes, not

[ ]No [ ]Yes

If yes, not eligible.

eligible.

Animal Liability Warning: If there are any pure breed or mixed breed dogs that contain the following breeds: Rottweiler, dogs commonly

known as Pitbulls, Doberman Pincers, Chows, Akitas, Wolf hybrid, Staffordshire Terrier, Bull Mastiff, Presa Canarios, German Shepherd,

or any dog known by breed to be vicious or any risk with previous dog bite history then risk is not eligible.

MANDATORY ABSOLUTE ANIMAL EXCLUSION APPLIES TO ALL POLICIES.

List all dogs in the household or owned by your tenants:

IMPORTANT NOTICE: The policy that you are applying for does not provide coverage for the peril of water damage. Limited water

damage coverage is provided by endorsement for an additional premium charge.

Applicant acknowledges that he/she is aware of the policy’s water damage exclusion and has

[ ] Opted for water damage coverage with $5,000 limit.

[ ] Opted to increase limited water damage coverage to $10,000 limit.

Applicant’s initials_______________________

Public Law 91-508 requires that we advise you that as part of our underwriting procedure a routine inquiry may be made which will provide

applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request,

additional information as to the nature and scope of the report, if one is made, will be provided. We do inspect all insured locations and

verify the information you provided.

APPLICANT’S STATEMENT: I hereby declare to the best of my knowledge that the statements made on this application are material

and true and complete and that these statements are made as an inducement to Topa Insurance Company to issue the policy for which I am

applying. I further understand and agree that any material misrepresentation shall cause the policy, if issued, to be null and void. I

understand and agree that I am making these statements on behalf of all insureds under the policy.

Applicant’s Signature: ________________________________________ Date: ________________________ Time: ________________

I have personally reviewed this application with the applicant and explained the coverages, limitations and exclusions. I have also explained

to the applicant that I am not an insurance agent appointed by Topa Insurance Company and I am representing the applicant as his or her

agent in this matter.

Agent/Broker’s Signature: _____________________________________ Date: ________________________ Time: ________________

The effective date of coverage shall be either 12:01 A.M. on the date following the date the application was signed by the applicant,

provided the application and payment are received within 3 days of signature date OR if received after 3 days from the date of signature, the

effective date shall be the date received or the proposed effective date, whichever is later.

NO coverage shall be considered bound and the application will be rejected if ANY section is incomplete or the risk is ineligible.

TUNIT-CA (2/11)

Tunit-Ca - Unit Renters Insurance Form Page 2

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