Managed Care Insurance Consultants - Reinsurance Provider Stop Loss Insurance Health Insurance Group Insurance Construction Insurance

Managed Care Insurance Consultants - Reinsurance Provider Stop Loss Insurance Health Insurance Group Insurance Construction Insurance

We are here to serve you at Managed Care Insurance Consultants - Reinsurance Provider Stop Loss Insurance Health Insurance Group Insurance Construction Insurance
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Our customers enjoy distinctive and personal attention to assist them in all personal and commercial lines of insurance needs.  Our level of administration efficiency in underwriting and actuarial support permits us to pass on the savings to our clients in the form of lower than average premiums.

 



Homeowners Application


  

Please fill out all the sections completely.
After completing form above press

PERSONAL

 Name of Applicant:  Date of Birth:
 Applicant Social Security Number (no dashes):
 
Home Phone (area code and no dashes):   Business Phone:  
 Applicant Email Address:
 
Occupation:        Employer:   

 
Co-Applicant Name: Date of Birth:
 Social Security Number (no dashes):
 
Home Phone (area code and no dashes):     Business Phone:
 
Occupation:     Employer:


STRUCTURE:

CONSTRUCTION TYPE:   Frame Masonry Masonry Veneer Aluminum Siding 
                                           Plastic Siding  Asbestos Siding Fire Resistant
ROOF TYPE:  YEAR BUILT:
SQ. FEET:  MARKET VALUE:
STRUCTURE TYPE:   Dwelling   Apart   Condo   Townhouse   Rowhouse   Co-0p
USAGE:   Primary  Secondary   Seasonal   Unoccupied   Vacant
DISTANCE TO: Fire Hydrant: Ft. ,    Fire Station:miles  
HEAT TYPE (Primary): Electric   Natural Gas   Fuel Oil    Wood Stove   Other
RENOVATION (Year):   Wiring  Plumbing    Heating
                                        
Roof   Exterior Paint
LOCATION:    Within city limits    Within fire district    Within protected suburb
OCCUPIED BY:    Owner    Tenant        VISIBLE TO NEIGHBORS: Yes /No
SWIMMING POOL: Yes /No
( IF YES TO POOL )   Approved Fence?    Diving Board?   Above Ground?
OCCUPIED DAILY: Yes /No    STORM SHUTTERS:   Type A    Type B    None
PROTECTION: (For Fire and Burglary):    Central System    Direct System    Local System    Deadbolts   Smoke Detectors   Fire Extinguisher    In House Sprinkler System


GENERAL INFORMATION:

Any business conducted on premises? Yes /No
Any full time residence employees? Yes /No
Any flooding, brush, forest fire hazard, landslide, etc.? Yes /No
Any other residence owned. Occupied or rented?  Yes /No
Any other insurance with this company?   Yes /No
Has insurance been transferred within agency?  Yes /No   
Any coverage declined, canceled, or non-renewed during the last 3 years  ? Yes /No
Has applicant  had a foreclosure, repossession or bankruptcy  during the past 5 years? Yes /No
Does applicant or any tenant have any animals or exotic pets? Yes /No
Is property located within 2 miles of tidal water?   Yes /No
Is property situated on more than five acres?  Yes /No 
Does Applicant own any recreational vehicles (Snow mobiles), dune buggies, Mini bikes, ATVs, etc) Yes /No
During the last 10 years, has any applicant been convicted of any degree of the crime of Arson? Yes /No
Any uncorrected fire code violations? Yes /No 
Is building undergoing renovation of reconstruction? Yes /No   
Is house for sale? Yes /No 
Is property within 300 feet of a commercial or non-residential property? Yes /No
Is there a trampoline on the premises? Yes /No    
Was the structure originally built for other than a private residence and then converted? Yes /No

FOR RENTERS AND CONDO ONLY

Is there a manager on the premises?  Yes /No
Is there a security attendant? Yes /No
Is the building entrance locked? Yes /No

 
LOSS HISTORY
:

Amy losses whether or not paid by insurance during the past 3 years at this or any other location? Yes /No
 If Yes please give Date, Type, Description of Loss and Amount


PRIOR COVERAGE
:

 If this policy is to replace an existing give name of carrier, policy number and expiration date.
   


ADDITIONAL INTEREST
:
 

 Please list mortgage company(s) and/or anyone else who has a loss payee interest in the property.

Please fill out all the sections completely.
After completing form above press

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