Federated National Application Info - Dewey Insurance Agency

Name of all owners:*

Phone number:*

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

Yes
No

Email address(es) for all applicants:*

Property address:*

Applicant's mailing address:*

Occupation for all owners:*

Employer's name for all owners:*

Years employed w/ current employer:*

Years employed in this occupation:*

Marital status:*

Date of birth for all owners:*

What is the age of the roof?*

Who occupies the house?*

Does the home have any active polybutelene plumbing?*

No
Yes

Does applicant(s) or tenant(s) have any animals or pets? (If yes, please list the type, breed and if there is any attack history)*

Have you had any claims on this or any other property in the last 3 years? If yes, please give date(s) of loss, type of damage (theft, water etc) amount paid, if damage is repaired and if claim is closed:*

Is there a swimming pool on the property? 2) If yes, is it screened? fenced? 3) Is there a diving board or pool slide?*

Any prior sinkhole claims filed for this location?*

Yes
No

Any farming or other business conducted on the premises (including day/child care?*

Yes
No

Any existing or unrepaired damage to the insured location?*

Yes
No

Any uncorrected fire, building code violations or existing or unrepaired damage?*

Yes
No

During the last 25 years has any applicant been convicted of arson?*

Yes
No

Is there a skateboard/bike ramp or any other unusual liability exposure on the premises?*

Yes
No

Is there a trampoline on the premises?*

Yes
No

Purchase date:*

Purchase price:*

Any hazards including flooding, brush fire, forest fire, landslide etc?*

Yes
No

Any residence employees (employees that work and live in your home)?*

Yes
No

Is the property currently for sale?*

Yes
No
Yes, but I'm purchasing/new purchase

Any other residence owned, occupied or rented? If yes, give details:*

Any foreclosures, bankruptcy or repossessions in the past five years?*

Yes
No

Does the applicant own any recreational vehicles?*

Yes
No

Is the property within 300 feet or a commerical or non-residential property?*

Yes
No

Was the structure originally built for other than a private residence or converted?*

Yes
No

Is there a lead paint hazard?*

No
Yes

Is there a fuel/oil tank on premises?*

Yes
No

Have any applicants had any coverrage declined, canceled or non-renewed in the last three years?*

Yes
No

Is the building undergoing renovation or reconstruction? If yes, give details:*

If the building is under construction, is the applicant the general contractor?*

Yes
No
Property is not under construction

Is the electrical on circuit breakers?*

Yes
No

Mortgage company name, address and loan number:*

Does your mortgage escrow (pay for insurance)?*

Yes
No

Federated National Application Information