Dwelling Liability Application

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Please provide us with your SSN:

Please provide your DOB:

INCLUDE PHOTO OF PREMISES WITH APPLICATION.

PRIVACY POLICY

I have received and read a copy of the “Scottsdale Insurance 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 Scottsdale Insurance 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.

FAIR CREDIT REPORTING ACT:

This notice is given to comply with Federal Fair Credit Reporting Act (Public law 91-508) and any similar state law which is applicable as part of our underwriting procedure. A routine inquiry may be made which will provide information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to nature and scope of the report will be provided.

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.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

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.

FRAUD WARNING 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.

APPLICANT NAME AND TITLE:                                                                                                                  

APPLICANT’S SIGNATURE:                                                                                             DATE:                 

PRODUCER’S SIGNATURE: _____________________________________________     DATE:                 

AGENT NAME:                                                                           AGENT LICENSE NUMBER:             

(Applicable to Florida Agents Only)

IOWA LICENSED AGENT:                                                                                                                              

(Applicable in Iowa Only)