Safepoint Application Information

Named insureds (please list all owners)*
Occupations (for all owners)*
Marital status
Date of birth (for all owners)*
Property address:*
Email address (for all owners):*
Phone number:*
Prior address for the last 3 years:*
Please list approximate dates that you lived at each address.
Do we have permission to run a prior loss report to show any losses you may have had?*
Mortgage company name and loan number (please list all mortgages):*
Does your mortgage company escrow (pay for insurance)?*
Do you have any pets? (If yes list the type of pet and breed of dog if applicable)*
Does the house have knob and tube wiring?*
Does the house have aluminum wiring?*
What type of plumbing pipe material? (Select one of the following: PVC/CPVC/PE/PEX, COPPER, POLYBUTELYNE, GALVANIZED STEEL)*
Number of amps for the electrical box:*
Is there a swimming pool at the location? (If yes, is the pool screened or fenced? Is there a diving board or pool slide?)*
IS the house located in a secured community? (If yes, is there 24 hour guard at the gate?*
Purchase price of the home:*
Have you had any claims at this or any other location in the last 3 years? (If yes, please list the type of claim, date of the claim, amount paid and whether the claim is open or closed)*
Is there any faming or other business conducted on the premises? (This includes day/child care)*
Any potentially hazardous electrical conditions (including Federal Pacific Electric, Challenger or Zinsko panels)?*
Any residence employees?*
Is the home for sale?*
If seasonal/secondary, is primary residence insured with Safepoint?*
Any coverage declined, cancelled or non-renewed during the last 3 years?*
Any prior or current sinkhole activity on the premises whether or not it results in a loss to the dwelling?*
Are there any animals or exotic pets kept on premises? (If yes, please note the type of animal, breed if applicable and any attack/bite history)*
Does applicant own any recreational vehicles (dune buggies, mini bikes, jet skis etc)?*
Is the building undergoing renovation or reconstruction? (If yes, give type of work, completion date and dollar value)*
Are there any Pit Bulls or Wolf/Wolf hybrid dogs on premises?*
Is there a trampoline on premises?*
Is there a skateboard or bicycle ramp on the premises?*
What heat source does the home have?*
Is the home protected by smoke detectors?*
Is the home rented for periods of less than two weeks at a time?*
Is the property located in a building where commercial or non-residential activity is present?*
Is the main dwelling or any other structure constructed partially or entirely over water?*
Is there a Family Home Day Care conducted on premises, which is defined as care for at least 2 children from unrelated families, for a payment or fee?*
Is the dwelling used, designed or constructed for non-habitational purposes?*
Is the dwelling a fraternity, sorority, or similar housing arrangement?*
Is the residence built over a landfill previously used for refuse?*
Is the property condemned or scheduled to be condemned?*
Existing damage or disrepair - have you been advised of or are you aware of any repairs or maintenance needed for any part of the structure, your roof, electrical, plumbing, and/or ac/heat systems? (If yes, please explain)*
Dwelling or any structures homemade, rebuilt, or extensively remodeled?*
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years?*
Has any applicant been canceled or non-renewed for material misrepresentation in the past seven (7) years or insurance fraud in the past fifteen (15) years or convicted of arson in the last twenty-five (25) years?*
Have you ever reported a sinkhole loss for the insured property - whether or not sinkhole activity was confirmed?*

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