Peoples Trust Application Info - Dewey Insurance Agency, Inc. Cooper City, FL

Names of all owners:*

Occupation for all owners:*

Dates of birth for all owners:*

Phone number:*

Do we have permission to text you at that phone number?*

Yes
No

Property address:*

Prior address for past 3 years:*

EMAIL ADDRESSES FOR ALL SIGNERS: (The application must be signed by all applicants. We will send the forms to you to sign electronically. If you do not want to sign electronically please note how you would like the application sent to you.)*

Mortgage company name, address and loan number:*

Is the insured location currently vacant or unoccupied?*

Do you expect the named insured to occupy the property within 30 days from the policy effective date?*

No
Yes

Has any applicant ever had insurance with People's Trust Insurance Company?*

Yes
No

Have you had any losses at this or any other location in the last three years, whether paid by insurance or not? (If yes, please give loss date, loss type, amount paid and if the claim is closed)*

Has any applicant ever had insurance declined, rescinded, canceled, or non-renewed within the last three (3) years for any of the following reasons: material misstatement or omission in first 90 days, Material Misrepresentation, Substantial change in risk, Fraud and/or Failure to mitigate loss or damage?*

Yes
No

During the last five (5) years, has any applicant been convicted of any degree of the crime of insurance related fraud, bribery, arson, or any arson-related crime in connection with this or any other property?*

Yes
No

Have you had any coverage declined, non-renewed or cancelled during the last twelve months for any of the following reasons: Incorrect Material Misstatement or Omission, Material Misstatement, or Fraud?*

Yes
No

Is the property location rented to others while not being occupied by an applicant for this insurance?*

Yes
No

Is the property location titled in the name of a LLC, corporation, association or trust?*

Yes
No

Have you had any liability or fire loss in the past three years? (If yes, please give loss date, loss type, amount paid and if the claim is open)*

Is this a secondary or seasonal property? If yes, is the location owner occupied for at least four months per year? Is the location rented to others while not being occupied by you?*

Does any applicant have more than two mortgages on the property location?*

Yes
No

Is the property location currently being purchase or has been purchased within the last twelve (12) months from a foreclosure or bank owned property?*

Yes
No

Is the location readily accessible year-round to the fire department and its equipment?*

Yes
No

Is the property situated on more than two (2) acres?*

Yes
No

Is the property situated on more than ten (10) acres?*

Yes
No

Is there business (including day care) coonducted on the premises?*

Yes
No

Does any applicant store on the property location any hazardous, flammable, or explosive chemicals or equipment as a result of any commercial or business operation conducted on or off the premises?*

Yes
No

Is the property located on a farm, ranch, orchard or grove or where farming activities or ranching operations take place?*

Yes
No

Is there any repair work, remodeling or renovations being performed at the property location? If yes, please explain:*

Yes
No

To your knowledge, has the property location sustained any damages prior to the date of this application, whether repaired or not repaired?*

Yes
No

Does the insured location have any pre-existing or existing damage?*

Yes
No

Has any applicant made any property or liability insurance claims with respect to this property location or any other location in the last three (3) years, whether paid by insurance or not?*

Yes
No

Have you sustained more than one non-weather related loss in the past three years?*

Yes
No

Does any applicant have knowledge of the property location ever experiencing known sinkhole or sinkhole activity, and/or cracking, movement, raveling, listing, leaning or buckling of a foundation, floor or wall or have you or any co-applicant ever filed a sinkhole claim related to this activity?*

Yes
No

Is any applicant presently involved or has ever been involved in a personal lines lawsuit against a homeowners insurance carrier? If yes, please explain:*

Is there any asbestos material in any part of the property location (i.e., siding, roofing, insulation, paint, vinyl flooring, etc.)?*

Is there any lead paint hazard at the property location?*

Does the property location contain any of the following plumbing attributes? Polybutylene tubing (branch or water supply), galvanized piping (branch, water supply, or drain), and/or Cast Iron drain?

Does the property location contain any of the following electrical attributes? Knob and tube wiring, aluminum wiring, Electrical service less than 100 AMPs or 220 volt electrical service, fuse box, Federal Pacific, Sylvania or Zinsco electrical panel and/or Sab-Lok breaker?*

Does the property location have an operable HVAC central air conditioning system?*

Does the property location contain a portable heater or open flame device used as a primary source of heat? Electrical, oil, or kerosene portable space heater, gas heater, Wood-burning stove and/or a fireplace?*

Does the property location have any of the following attributes? Trampoline or other rebounding device, Vicious or exotic animals kept on premises, Diving board or pool slide, Tree stand or tree house, Empty or non-operable in-ground swimming pool, Skateboard ramp(s), Fraternity or sorority usage, Home-sharing or short term vacation rental usage, Animals that have bitten previously, Vicious or exotic animals kept on premises, Porches or decks more than two (2) feet off the ground or have three (3) or more steps leading to them without handrails or guardrails?*

Does any applicant own any recreational vehicles designed for use off public roads and not subject to motor vehicle registration? If yes, please list year, make, and model:*

Does the property location have any of the following construction features: Dwelling constructed partially or entirely over water, Built on stilts, pilings, posts, piers or constructed with an open foundation, Historical home, Mobile or manufactured home, Dome home, log home, Do it yourself construction, Chinese drywall that is not compliant with the Drywall Safety Act of 2012 or any other drywall made with defective or hazardous material, Unpermitted additions or conversions and/or any other unusual construction features?*

Does the insured location have any commercial or business operations that involve the use of hazardous, flammable, or explosive chemicals or equipment?*

Does the insured location have a swimming pool?*

Is the swimming pool, spa, hot tub, or similar structure completely fenced, walled, or enclosed by a screen enclosure? Note: The pool’s fence or wall must be of a permanent installation with a minimum height of four feet and be constructed of material that provides a reasonable barrier (e.g., chain link, wood or metal construction).*

Is access to the swimming pool, spa, hot tub, or other similar structure controlled by a locking door, gate, or cover?*

Personal information about you may be collected from sources other than you in connection with this application and subsequent renewals. A credit report or score may be requested for underwriting or rating purposes. We may also obtain information about your credit history, your loss history and the loss history of the property proposed for coverage. Such information, as well as other personal and privileged information collected by us or our agents may, in certain circumstances, be disclosed to third parties, such as actuaries, underwriting consultants, and reinsurance brokers without your authorization, as permitted or required by law. A more detailed description of your rights regarding such information is available upon request.*

People's Trust Application Information