Universal P C Application Information Universal P & C Application Information Names of all owners:* Occupation for all owners:* Property address:* Mailing address:* Email address for all signers:* Phone number:* Marital status:* Date of birth (for all owners):* Mortgage company name, address and loan number:*Does your mortgage company escrow (pay for insurance)?*YesNoNo mortgageAny business (including day care) conducted on premises?*NoYesIs there any indication of past, present or potential sinkhole activity at the residence premises, or has any prospective insured previously filed a claim for sinkhole loss at any location? (if yes, explain)* Is the dwelling or any other structure at residence premises currently condemned?*NoYesAny existing damage to property?*NoYesIs there a swimming pool or similar structure at the residence premises?* No Yes Is the pool or similar structure regularly maintained for use, and is the structure completely enclosed by a wall, fence or screen which is at least four (4) feet high and has a self-locking gate or door which prevents access under, through or around that preventative barrier?* No Yes What is the height of fence in feet?* Does pool have diving board or slide?* No Yes Is there a trampoline on the property?*NoYesIs there a skateboard ramp on the property?*NoYesIs the property partially or entirely over water?*NoYesIs the property partially or entirely over sand?*NoYesIs agricultural activity present at the residence premisies, including but not limited to farming or ranching?*NoYesApplicant background questions:Under the policy requested in this application, the "Insured" includes the applicant, spouse if a resident of the same household, and other residents of the same household who are relatives or are under the age of 21 and in the care of any person included in this definition. Has any prospective insured had any bankruptcy in the past 60 months?*NoYesHas any prospective insured been subject to any lien in the past 60 months?*NoYesHas any prospective insured been subject to any judgments in the past 60 months?*NoYesHas any prospective insured had any voluntary repossession in the past 60 months?*NoYesHas any prospective insured had any involuntary repossession in the past 60 months?*NoYesHas any prospective insured been convicted of a felony in the last 10 years?*NoYesHas any prospective insured had his or her driver's license suspended in the last 5 years?*NoYesHas any prospective insured ever been involved in a 1st Party Personal Lines lawsuit against an Auto Insurance Company or a Homeowners Insurance Company?*NoYesHas any prospective insured ever been arrested for driving under the influence of alcohol or some other illegal substance, assault or battery or disorderly conduct in the past 10 years?*NoYesDoes any prospective insured have or intend to have any dogs(s) on the premises?*NoYesWhat kind of dogs (please include all breeds if dog is a mixed breed)?* Is the dog a full or partial breed of any of the following breeds: Akita, American Eskimo, Chow, Doberman, German Sheperd, Pit Bull, Presa Canario, Rottweiler or Staffordshire Terrier? (If yes please list all breeds that apply)* Has the dog(s) ever attacked anyone?*NoYesDo you have or intend to have any non-domesticated animals, exotic pets, or farm animals, regardless of the animals boarding location?*NoYesWhat kind of animals?* Does the electrical system contain any of the following: fuses or knob-tube, single strand aluminum or non-insulated cloth wiring?*NoYesThird ChoiceIs portable heating used or intended to be used in the dwelling?*NoYesDoes the electrical system use fuses?*NoYesDoes home have 100Amp electrical service?*NoYesDoes poly-butylene or pex piping exist in the dwelling?*NoYesWhat is the name brand of your electrical box:* Any prior claims at this or any other property in the last 5 years? 2) If yes, list the type of claim, the amount of claim and whether the claim is closed: 3) Is the claim damage repaired?* Do you have any pets? 2) If yes, what type of pet including breed if it is a dog: 3) Has the animal(s) ever attacked?*
