Citizens Clearinghouse Application - Dewey Insurance Agency

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

Citizens Clearinghouse Application Information