Citizens Clearinghouse Application Citizens Clearinghouse Application Information Name(s) of all owners*Date(s) of birth for all owners*Email address for all owners:*Occupation(s) for all owners:*Relationship of all owners:*Phone number:*Do we have permission to text you at this phone number?* Yes No Property address:*Is the property address different than your mailing address?* No Yes If yes, list the mailing address:*Credit report consent: IF YES: I consent to the obtaining or preparation of a credit report by a requesting Participating Insurer and my agent of record. I understand that these reports must be handled in the strictest confidence. Information as to the nature and scope of these reports will be provided to me upon request. A list of Participating Insurers can be found by requesting from Dewey Insurance Agency: IF NO, I do not consent to the obtaining or preparation of a credit report. I understand that declining to consent to a Participating Insurer obtaining a credit report may result in fewer quotes being made by Participating Insurers through the Clearinghouse:* Yes No Has the application had insurance on this property? (If yes, please provide name of company, expiration date and policy number)*Dwelling Occupancy? (Primary, Secondary, Seasonal, Unoccupied, or Vacant):*Date Purchased or leased:*Purchase price:*Is the home under construction or renovation?* No Yes Exterior Walls Construction? (Stucco, Siding, Wood shakes, etc.):*Is the dwelling built on a continuous masonry foundation?* No Yes Roof Condition:* Excellent Good Fair Poor Does the dwelling have a covered porch?* No Yes Is the property located within 1500 feet of salt water?* No Yes Is any part of the structure exposed to open seawater greater than ¼ mile in width?* No Yes Is the dwelling located within 300 feet of a commercial structure?* No Yes Is the property situated on more than 5 acres?* No Yes Is the dwelling currently for sale?* No Yes Yes, but it is a new purchase for me Is the home located inside city limits?* No Yes How far away is your home from a fire hydrant? (feet):*How far away is your home from a fire station? (miles):*Is the property readily accessible year round to the fire department and its equipment?* No Yes How many units or apartments?*Number of units in firewall?*Do you have any of the following protective devised in your home? (please note all that apply) smoke detector, fire extinguisher, fire detection, burglar alarm, dead bolt locks, indoor sprinkler system:*Number of families:*Primary Heat Source: (central, wall units etc)*Indicate Heating type (Electric, Gas, Oil, Etc.):*Is the heating device portable?* No Yes Is there any heating device with an open flame?* No Yes Has the Heating system been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:*Has the Plumbing been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:*What type of plumbing does the house have? (PVC, Copper, Polybutelene, galvanized etc, please note all types that are present in the house)*Has the roof been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:*Has the electrical wiring been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:*What type of electrical system: Circuit breakers Fuses Is the name brand of your electrical box any of the following: Federal Pacific, Challenger, Stab-Lok, Zinsco, Zinsco-Sylvania, GTE Sylvania or Kearney?*Indicate all that apply to the electrical system: knob & tube wiring, service less than 100 amps, aluminum branch wiring, cloth wiring:*Are all updates or renovations done by a Licensed Contractor?* No Yes Is there a swimming pool on the premises? If yes is it fenced or screened? Is there a diving board or pool slide?*Are any of the following located on the premises: Trampoline, Skateboard or Bicycle Ramp, Treehouse, Outdoor appliance, Inoperable motor vehicle(s) not secured in a garage or a structure, Vicious or exotic animals, animals with a history or biting, Horses or livestock for business, other unusual or dangerous conditions?*Is there a business on the premises? (including religious services and day care):* No Yes Have you made any claims on this, or any other property you own in the past 5 years? (If yes list type, amount paid and date of loss)*Are there any dogs on the property? If yes, advise of the breed(s):*Is the dwelling or any structure on the premises newly constructed, or rebuilt, repaired, restored, or remodeled to increase the total square footage of finished area by more than 25%, pursuant to a permit applied for after July 1, 2015?* No Yes Mortgage company name, address, loan number and phone number:*Does your mortgage company escrow?* No Yes How many months of the year is the dwelling unoccupied consecutively?*Is the property rented on a weekly or short term basis?* No Yes Do you live in a limited access/ gated community?* No Yes Do any of the residents smoke?* No Yes Is your home visible to neighbors?* No Yes Is there manned security on premises?* No Yes Are there any residence employees?* No Yes Do you own any recreational vehicles? (golf carts, ATV, etc)*Was dwelling originally built for purposes other than a residence and later converted for residential use?* No Yes Is risk constructed in whole or in part with EIFS (Enhanced Insulation and Finishing System)?* No Yes Is the dwelling currently for sale?* No Yes Yes, but this is a new purchase for me Are there any uncorrected fires or building code violations?* No Yes Does the number of Roof overlays exceed 1?* No Yes Is the roof damaged or does the roof have visible signs of leaks?* No Yes Does any person who will be insured under the policy have knowledge that repairs have been made to the dwelling and/or property relating to sinkhole activity?* No Yes Does the dwelling or screen enclosure have any existing damage? (Including but not limited to cracking, settlement or sinkhole damage)* No Yes Has the applicant ever requested a sinkhole investigation or submitted a claim for sinkhole loss?* No Yes Are you or any person who will be an insured under this policy aware of any loss assessment or special assessment on the “residence premises” in the past 5 years?* No Yes Is there any sinkhole damage without proper remediation action taken to stabilize the home?* No Yes Do you have any knowledge of any prior repairs made to structures on premises for cracking damage?* No Yes Has any named insured had a foreclosure, repossession or bankruptcy during the past 5 years?* No Yes Is the risk a foreclosed property?* No Yes Has applicant(s) ever been convicted of a felony?* No Yes During the last 15 years has any applicant been convicted of insurance fraud?* No Yes During the last 25 years has any applicant been convicted of any degrees of a crime of arson?* No Yes Has the insured ever been cancelled, non-renewed or declined for insurance coverage? (Other than non-payment)* No Yes Has applicant(s) ever been involved in a first party lawsuit against an auto of homeowners insurance company?* No Yes Are there any assisted living activities or any other form of in-home care on the premises?* No Yes Do you have any open claims?* No Yes Is the dwelling subject to brush or forest fires?* No Yes Is there an underground fuel tank on the premises?* No Yes Is structure constructed partially or entirely over water? No Yes Are there any porches or decks more than 2ft off the ground or that have more than 3 steps without handrails or guardrails?* No Yes Are all spas/hot tubs covered and locked?* No Yes N/A - no spas or hot tubs Indicate the number of dogs on premises:*Has any applicant been canceled for material misrepresentation on an application for insurance or on a claim in the past 7 years?* No Yes Is the dwelling used as a fraternity or sorority house or any similar housing arrangement?* No Yes Does the dwelling show signs of settlement or cracking of the walls, floor or foundations?* No Yes Are there any signs of sinkhole activity on the property such as shifting, or bulging of a foundation, wall or roof?* No Yes Does any person who will be an insured under this policy have knowledge of any sinkhole investigation, ground study, structural evaluation, and/or sinkhole inspection performed due to a sinkhole claim or for any reason other than an inspection to request sinkhole insurance for the property?* No Yes Does any person who will be an insured under this policy have knowledge that repairs have been made to the dwelling and/or property relating to sinkhole activity?* No Yes Does the dwelling have any existing damage?* No Yes Is the property in a state of disrepair?* No Yes Is the dwelling, or other structure homemade, rebuilt or constructed with extensive remodeling on a "do-it-yourself" basis?* No Yes Was the dwelling orignally built for purposes other than a residence and later converted for residential use?* No Yes Is the property located on a landfill previously used for refuse?* No Yes Is the dwelling rented for periods of 30 days or less?* No Yes Not rented ever Is the dwelling advertised or held out for rental to guests for short term rental periods?* No Yes Not rented ever Was the dwelling ever moved from its original foundation?* No Yes Is home currently condemned?* No Yes Is the dwelling vacant or unoccupied (new purchases or buildings nearing completion are considered vacant if they are not occupied within 30 days of the requested effective date)?* No Yes Does the property have any polybutylene piping?* No Yes Does dwelling have a flat roof (pitch less than 1 ft per 12 ft)?* No Yes Does dwelling have utility service?* No Yes
