Federated National Application Info Federated National Application Information 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?* Owner occupied Owner occupied, secondary residence Owner occupieid, seasonal residence Tenant occupied Vacant 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
