Commercial Insurance Underwriter

CIU

Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

 

Dwelling & Habitational Fire

 

Applicant's Name:

Agent Name:

Mailing Address:

Agent Address:

 

 

Inspection Contact:

Email Address:

Phone:

PROPOSED EFFECTIVE DATE:
   

From   To

Perils to be Insured:

      12:01 A.M., Standard Time at the address of the Applicant
       Fire   E.C.   VMM   Special Perils   Premises Liability   Personal Liability   Residence Burglary

        Deductible: $
         MORTGAGEE
         ADDRESS LOAN #

 

Dwelling Limits:

          

$

a. Masonry

Frame

Other

    
 

b. 1 family

2 family

3 family

4 family

  
 

c. Owner

Tenant

Renovation

    
 

d. Vacant

Seasonal

Builders Risk

    
 

e.  Located at:

   

           

$

On contents in the above dwelling.

$

Premises Liability/Personal Liability.

$

Medical Payments

$

Residence Burglary.

$

Additional Living Expense/Loss of Use.

$

Other Structures describe:

Is there any existing fire damage?    

 

 

UNDERWRITING QUESTIONNAIRE:        
1.If vacant--how long has dwelling been vacant?

Reason for vacancy:
2. Did you inspect dwelling? Comments:
   
3. Do you recommend risk? Comments:
   
4. Swimming Pool?     Fenced?    Diving Board?    Slide?    Trampoline?    Safety Net?

5. Year of Construction:    Total Sq. Feet of Living Area:   

             Updated:   If yes, confirm the date the following items were updated

Wiring:

Plumbing:

Roof:

Heating & Air Conditioning:

Full/Part:

 

 

 

Year:

 

 

 
                Physical condition of buildings:
6. Fire Protection Class:     Fire District:
7. Primary source of heat:   If wood burning stove, questionnaire and photo required.
8. Renovation/Builders Risk:   Number of years experience:
    Name of licensed contractor:
    Extent of Renovation:
9. Applicant's occupation(s):
10. Are any business pursuits conducted on the premises?    If yes, describe:
   
11. Any animals?   If yes, describe:   Bite History:
     Bite History Description:        
   
12. Acreage?   If yes, number of acres:   Usage:
13. Has any company canceled or refused coverage to the applicant? (Not applicable in Missouri)     Comments:
   
14. Previous Carrier:   Policy Number:
          
    Past Losses?        

 

 Date   Type / Description  Amount

 

UNDERWRITING GUIDELINES:

 

Prefer photo with application.

 

As part of the underwriting procedure, a routine inquiry may be made which will provide applicable information concerning character, general reputation,

personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be

provided.

 

PRIVACY POLICY:

 

I have received and read a copy of the “National Casualty Company Privacy Statement and Procedures” . By submitting this application, I am applying

for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by National Casualty Company and/or other members

of the Scottsdale group of insurance companies. I understand and agree that any information about me that is contained in, or that is obtained in connection

with, this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review, and renew the insurance

for which I am applying.

 

APPLICABLE IN THE STATE OF NEW YORK:

 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a

fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the

claim for each such violation.

 

FRAUD WARNING:

 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent

insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

 

Producer's Signature________________________________________________________________  Date______________

 

 

Applicant's Signature________________________________________________________________  Date______________

 

Applicant Date of Birth:                         Applicant Social Security #:

 

 

Agent Name __________________________________________________________  Agent License Number _________________________

 

 

IMPORTANT NOTICE

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general

reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the

report, if one is made, will be provided.

 

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.