Citizens application information

Name(s) of all owners*

Date(s) of birth for all owners*

Email address for each listed 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

Roof Condition:*

Excellent
Good
Fair
Poor

Is the dwelling located within 300 feet of a commercial structure?*

No
Yes

Is the dwelling currently for sale?*

No
Yes
Yes, but it is a new purchase for me

Do you have any of the following protective devises 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)*

Is the heating device portable or have 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:*

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, assisted living, fraternity/sorority house and/or 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):*

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
Not rented ever

Do you live in a limited access/ gated community?*

No
Yes

Are there any residence employees?*

No
Yes

Do you own any recreational vehicles? (golf carts, ATV, etc)*

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 of any of the following: 1) Repairs have been made to the dwelling and/or property relating to sinkhole activity 2) ever requested a sinkhole investigation or submitted a claim for sinkhole loss 3) Sinkhole damage without proper remediation action taken to stabilize the home 4) Knowledge of any prior repairs made to structures on premises for cracking damage 5) 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

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

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

Do you have any open claims?*

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

Has any applicant been canceled for material misrepresentation on an application for insurance or on a claim in the past 7 years?*

No
Yes

Does the dwelling have any existing damage?*

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