Bass Application Information - Dewey Insurance Agency

Name(s) of all owners:*

Mailing address:*

Property address:*

Phone number*

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

Yes
No

Date(s) of birth for all owners:*

EMAIL ADDRESS(ES) 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.)*

Are there any plumbing or roof leaks?*

No
Yes

Is the insured currently or have in the past been in a high profile profession?*

No
Yes

Has Any Coverage Been Declined, Cancelled or Non-Renewed During the Last Three (3) Years?*

No
Yes

Has Applicant Had a Foreclosure, Repossession or Bankruptcy During the Past Five Years?*

No
Yes

Has Applicant Had a Judgement or Lien During the Past Five (5) Years:?*

No
Yes

During the Last Five (5) Years [Ten (10) Years in Rhode Island], Has Applicant Been Indicted For or Convicted of Any Degree of the Crime of Fraud, Bribery, Arson or Any Other Arson-Related Crime in Connection With This or Any Other Property?*

No
Yes

Any Uncorrected Fire or Building Code Violations?*

Yes
No

Does the building contain: Active knob & tube wiring, Active aluminum wiring, Galvanized plumbing or fuses boxes?*

Yes
No

Does the building have circuit breakers?*

Yes
No

Has the property been updated or fully renovated?*

Yes
No

Any prior losses? (if yes, please give the dates, type of loss, amount paid, if the claim is closed and if the damage is repaired)*

Any dogs or exotic pets on premises: (if yes, give type of pet including breed if it is a dog and if there is an attack history)*

Any Flooding, Brush, Forest Fire Hazard, Landslide ETC?*

No
Yes

Is Property Within 300 Feet of a Commercial Property?*

No
Yes

Was the Structure Originally Built for Other Than a Private Residence and Then Converted?*

No
Yes

Any Lead Paint Hazard?*

No
Yes

Is There a Manager on the Premises?*

No
Yes

Manager's name and phone # if manager is on premises:*

Is There a Security Attendant?*

No
Yes

Is the Building Entrance Locked?*

No
Yes

Please provide the year the ROOF has been updated:*

Please provide the year the WIRING has been updated:*

Please provide the year the PLUMBING has been updated:*

Please provide the year the HEATING has been updated:*

Is there a swimming pool? If yes, is it completely fenced? Is there a diving board or pool slide?*

Does Property Have Fire Extinguishers?*

Yes
No

Does the building contain the following: Active knob & tube wiring, Active aluminum wiring, Galvanized plumbing and/or Fuses boxes? (List all that are present)*

Does the building have Circuit Breakers?*

No
Yes