Southern Oak Application Information - Dewey Insurance Agency, Inc. Cooper City, FL

Name(s) of all owners:*

Property address:*

Email address(es) for all signers:*

Phone number(s):*

Please provide a phone number so we can call you to obtain social security numbers for all applicants:

Date(s) of birth for all applicants:*

Marital status for all applicants:*

Occupation(s) for all applicants:*

Do we have your permission to run credit/loss history reports? (The Federal Fair Credit Reporting Act imposes criminal penalties, including a fine, up to two years in prison, or both against anyone who knowingly and willfully obtains information on a consumer reporting agency under false pretenses and other penalties for anyone who obtains such consumer information without permissible acceptance of these terms.)*

No
Yes

Is the property address the same as the mailing address? If no, give the mailing address:*

Mortgage company name, phone number and loan number:*

Does your mortgage escrow?*

No
Yes

Purchase date*

Purchase price*

Number of electrical amps:*

Plumbing material (PVC, Copper, galvanized, polybutelyne etc)*

Electrical type:*

Circuit breakers
Fuses

Any losses, whether or not paid by insurance, during the last five years at this or any other location? Please list any loss whether or not reported to and/or paid by an insurance company at this or any other location. List the type of loss (water, wind etc), amount paid, are repairs made?, is the claim closed? and date of loss.*

Has any applicant been previously canceled or nonrenewed for insurance for reasons other than reduction of hurricane exposure?*

Yes
No

Is the dwelling vacant or unoccupied?*

Yes
No

Is building undergoing renovation or reconstruction? (Give estimated completion date and dollar value)*

Is the dwelling, or other structure homemade, of unconventional construction (e.g. log home) or constructed with extensive remodeling or "Do-it-yourself" basis?*

Yes
No

Is the roof damaged or does the roof have any visible signs of leaks?*

Yes
No

Is the roof covering WOOD shingle?*

No
Yes

Does the risk utilize space heaters, fireplaces or wood burning stoves as the primary source of heat?*

No
Yes

Is the main structure partially or entirely over water?*

No
Yes

Is the property located on 5 or more acres?*

No
Yes

Any farming or other business conducted on premises (Including day/child care, religious services etc)?*

No
Yes

Does any resident smoke tobacco products?*

No
Yes

Is there a trampoline on the premises?*

No
Yes

Is there a Swimming Pool / Hot Tub on the premises?*

No
Yes

Are there any animals or exotic pets kept on the premises?*

No
Yes

If you have pets please list the breed, bite history, age and weight (list for each pet):*

Any saddle, hoofed, exotic animal or ineligible breed of dog or mix thereof?*

No
Yes

Are there any roomers or boarders on premises?*

No
Yes

Previous address for the past five years:*

Is risk constructed in whole or in part with EIFS (Enhanced Insulation and Finishing System: a general class of non-load bearing building cladding systems that provides exterior walls with an insulated, water-resistant, finished surface in an integrated composite material system)?*

No
Yes

Has applicant(s) ever been convicted of a felony?*

No
Yes

Has applicant(s) ever been involved in a first party lawsuit against an auto or homeowners insurance company?*

No
Yes

Is the risk within 700 feet of tidal water?*

No
Yes

Distance to the closest fire hydrant:*

Distance to the closest fire station:*

Number of units in the building: (single family, duplex, etc)*

Number of units in fire division/fire wall? (n/a for single family home)*

Is the property located within city limits?*

No
Yes

Any Residence Employees?*

No
Yes

Any flooding, brush, forest fire hazard, landslide, etc.?*

No
Yes

Has applicant had a foreclosure, repossession, bankruptcy, judgment, or lien during the last five years?*

No
Yes

During the last five years, has any applicant been indicted for, or convicted of any degree of the crime of fraud, bribery, arson, or any arson-related crime in connection with this or any other property?*

No
Yes

Any uncorrected fire or building code violations?*

No
Yes

Is house for sale?*

No
Yes
Yes, it is a new purchase for me

Is property within 300 ft. of a commercial or non-residential 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 property occupied by three or more unrelated individuals?*

No
Yes

Is there a child and/or adult/senior daycare on the premises?*

No
Yes

Does the property have any existing damage/disrepair?*

No
Yes

Has the insured location ever experienced damage or loss resulting from sinkhole activity or any other earth movement, that you are aware of?*

No
Yes

Does the insured location have, or has it ever had, sinkhole activity or any other earth movement, that you are aware of?*

No
Yes

Has any applicant to be insured under the policy ever submitted a claim for sinkhole loss, sinkhole investigation, or any other earth movement at the insured location?*

No
Yes

Please check all that apply:*

diving board
pool slide
pool/spa is full of water
fence is lockable and permanent
fence has self-latching gate
pool/spa surrounded by complete fence, wall or screen
fence height is minimum of 4 feet

Does the dwelling have a foundation other than a continuous masonry construction?*

No
Yes

Is the dwelling built on a landfill previously used for refuse?*

No
Yes

Is the dwelling retrofitted with a solar heating system(other than pool heating)?*

No
Yes

Has the insured ever been cancelled or non renewed for material misrepresentation or insurance fraud, or ever convicted of arson?*

No
Yes

Structure constructed partially or entirely over water?*

No
Yes

Is the property readily accessible year-round to fire department equipment?*

No
Yes

Seasonal or Secondary dwelling?*

No
Yes

Is the property ever rented?*

No
Yes

Number of consecutive months unoccupied*

Secured community or professionally managed?*

No
Yes

Overseen by a reputable party within 50 miles of risk?*

No
Yes

Are there any wood-burning stoves or portable space heaters used as either a primary or secondary source of heat?*

No
Yes