Lexington Insurance Company - Application

Applicant	SS #	Occupation	Employer	Date of Birth


Mailing Address:
Insured Location:			County:

Producer Name:		Address:
Fax #:	Inspection-Contact:	E-mail:	Phone #:

TYPE		COV. PART 1			COV. PART 2		COV. PART 3	COV. PART 4
	New	HO-3	HO-4	HO-6	Umbrella	Excess Liability	Excess Flood	PAF
	Renewal

Prior Carrier:	Expires:		Expiring/Renewal Premium $:
Within the last 5 years, has applicant had a:		Foreclosure Bankruptcy Repossession
If prior carrier non-renewed, why?
Comments:

Coverage Part 1: Homeowner Information

Mortgagee Information/Additional Interests:

Loan #1		Name/Address
Loan #1		Name/Address

General Information

County:	Protection Class #:	Distance to Fire Hydrant: ft.	Fire Dept: Paid
ISO Territory #:		Distance to Fire Station: mi.	Volunteer
Occupancy: Primary Secondary Rental Vacant Secondary Rental Builder's Risk- use supplemental application
Construction: Frame/Stucco Brick, Stone or Masonry Superior Pre-Fabricated EFIS/Synthetic Stucco
Year Built: Age of Roof: Sq. Ft.: Market Val. $: # of stories: # of families:
Protection Devices: Fire Burglar Motion Det. Smoke Det. Deadbolts Sprinklers: Interior Exterior Combo
Caretakers: Yes No If yes, resident or non resident Gated Community: Yes No Patrolled? Yes No

Loss History - Must be filled out COMPLETELY:

Date	Type of Loss	Cause	Amount	Preventative Measures?
			$
			$
			$
			$

Limits:

Dwelling	$	Other Structures	$	Personal Property	$
Loss of Use	$	Personal Liability	$	Medical Payments	$
Full Property TIV Yes No		Loss Assessment	$ Ordinance or Law: None 10%
Foundation: Concrete Slab Concrete/Block Pilings/Stilts Roof: Asphalt Tile Wood Shake Other

PC 9 or 10 ONLY: Fire Dept Response Time: Minutes
Wash Out: Yes No	Visible to Others: Yes No
Distance to Water Source: ft.	Type of Source:
Water Trucks: Pumper Tanker Gallons:

Requested AOP Deductible: $

Eligible for Wind-Pool: Yes No
Exclude Wind: Yes No If no, Wind: %
Distance to the Ocean/Bay/Gulf:	ft.		miles
Straps	Shutters	Protective Glass
Wind Deductible Buyback: Yes No

Earthquake: Yes No %
If yes, EQ Zone:	Territory:	Soil Type:

CA ONLY:	Slope: °	Brush Zone: Yes No
Brush clearance: ft.

Replacement Cost Contents:	Yes No
All Risk Contents:	Yes No	HO-6 All-Risk Cov A-
Special Computer Coverage:	Yes No
Personal Injury:	Yes No
Special Limits Coverage C:	All items Jewelry Only
Water Backup Coverage:	$5k $10k $25k
Identify Fraud:	Yes No
Extended Liability:	Yes No	# of Locations (U.S. only)
Watercraft Liability:	Yes No	Sailboat:
Engine: In Out In/Out	HP Length ft.
Home Business Coverage:	Yes No
Golf Cart Coverage:	Yes No	Liability- Yes No
Property Information:	(Required home > 25 years old)
Update - Full Partial	Update year for:
	Roof: Wiring: Heating: Plumbing:
Occupied Daily:	Yes No If no, then:
Unoccupied for > 30 days in a row:	Yes No
Dwelling for Sale:	Yes No
Dwelling Rented:	Yes No	If yes, how many weeks:
Under Lease:	Yes No
Swimming Pool on Premises:	Yes No If yes,
Fenced: Screened: Diving Board:	Yes No
Type of Heat:	Gas: Electric: Oil:
If home oil heated, is tank underground:	Yes No
EFIS or Synthetic Stucco construction:	Yes No
Prior/Current Mold Exposure:	Yes No
Day Care Conducted on Premises:	Yes No
Business Conducted on Premises:	Yes No
Explain:
Wood Stoves/Sup. Heating:	Yes No
Is this a primary heat source?	Yes No
Explain:
Animals on the Premises:	Yes No	Bite history: Yes
Explain:

NOTICE OF INSURANCE INFORMATION PRACTICES: Personal information about you may be collected from persons other than you. Such information, as well as other personal and privileged information, collected by us or your agent may, in certain circumstances, be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent/broker for instruction on how to submit a request to us. FL Residents Only: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE (817.234). NJ Residents Only: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES (Bulletin 95-16, citing P.L.1995, c.132). VA Residents Only: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS (52-40). Note to Agents: No binding or quoting authority! Please call or fax for same day binding and follow up with an application. Application must be signed by the Named Insured. Any incomplete applications received could jeopardize binding coverage!