COMMERCIAL INSURANCE UNDERWRITERS, INC.
HOMEOWNER APPLICATION
PH: 417.883.3277 / 800.241.9759 - Fax: 417.883.3393
Applicant's Name(s):
Agency Name:
Mailing Address:
Your Name:
City, State, Zip:
Email Address:
Inspection Contact Phone Number: Agency Address:
City, State, Zip:
Agency Phone Number:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

APPLICANT INFORMATION
Previous Address (if less than three years)  Years at Previous Address: Location of property if different from above:
Street: Street:
City:    ST:    Zip: City:    ST:    Zip:    County:
Applicant's Occupation (State nature of business if selfemployed:)
Marital Status
DOB
Applicant's Employer Name and Address:
Co-Applicant's Occupation (State nature of business if selfemployed:)
Marital Status
DOB
Co-Applicant's Employer Name and Address:

COVERAGES / LIMITS OF LIABILITY
PREMIUM
HO Form
Dwelling
Other Structures
Personal Property
Loss of Use
Personal / Premises Liability Each Occurrence
Med Pay Each Person
Est. Total Premium
$
$
$
$
$
$
$
Deposit
$
Balance
$
PERILS   Fire    EC    VMM
Deductible Type and Amount:
All perils:    Wind and Hail:    Named Storm:    Other:

ENDORSEMENTS / ADDITIONAL COVERAGES
Replacement Cost Dwelling Identify Fraud Workers Comp (CA and NY)
Replacement Cost Contents Earthquake Zone: Tenant Relocation (MA only)
ERC (Extended Replacement Cost Water Back-up Limit: $ Other:
Personal Injury (Primary Owner Only) Ordinance or Law

PAYMENT PLAN
Billing: Insured   Mortgagee   Agency Bill

RATING / UNDERWRITING
Year Built
Purchase Date
Construction Type
Structure Type
Usage Type
Occupancy
No. Stories
Windstorm Loss Mitigation Features
Frame Modular Home Dwelling Primary Owner
Hurricane Straps
Square Feet
Replacement Cost
Masonry EIFS Townhouse Secondary Unoccupied
No. Families
Hurricane Shutters
$
Masonry Veneer Log Home Appartment Seasonal Tenant
HIP Roof
Market Value
Joisted Masonry       Hand-hewn Rowhouse Farm Vacant
No. H/H Residents
Impact Resistant
       Glass
$
Fire Resistive      Milled Condo COC/Reno
No. Weeks Rented
MFG/Mobile Home Co-op
Completion Date:
Other:
Territory Code
Protection Class
Distance To
Protection Device Type
Foundation: Open  Closed  Stilts
Hydrant
Fire Station
System
Smoke
Temp
Burglar
Deadbolt  Fire Extinguisher  Visible to Neighbors
FT
MI
Central
Sprinklers: Full  Partial
Fire District / Code No.: /
Local
Swimming Pool: Yes No
Approved Fencing  Diving Board  Slide

Updates
Partial
Complete
Year
Details
Wiring
  Circuit Breakers:Yes No Fuses:Yes No      No. of Amps
  Aluminum:Yes No Knob and Tube:Yes No
Plumbing
  Type: Copper  PVC  Other:         Any known leaks? Yes No
Heating
  Primary: Seondary:
  Wood Stove?Yes No Portable Space Heaters?Yes No
Roofing
  Roof Type/Material: Condition of Roof:
  Any known leaks?Yes No Exclude Roof?Yes No

LOSS HISTORY
Any losses, whether or not paid by insurance, in the last three years, at this or any other location?
Yes No        If Yes, indicate below:
DATE
TYPE
DESCRIPTION OF LOSS
AMOUNT PAID / RESERVED
OPEN / CLOSED
$
    Open
    Closed
$
    Open
    Closed
$
    Open
    Closed

PRIOR / CURRENT COVERAGE
Prior / Current carrier: Policy number: Expiration Date:
If lapse or no prior coverage, provide explanation:

GENERAL INFORMATION
   Explain all "Yes" responses in the "Remarks" section
YES
NO
   Explain all "Yes" responses in the "Remarks" section
YES
NO
1.
Any business conducted on premises? (Including farms, day care, etc.)
12.
Is property situated on more than five acres?
2.
Any residence employees?
No. of acres:
Number and type of full time and part time employees: Describe land use:
3.
Any brush, flooding, forest fire hazard, landslide, etc.?
13.
Other structures on premises? (barns, sheds, etc.)
4.
Any other residences owned, occupied or rented?
5.
Any other insurance with this company?
14.
Is building retrofitted for earthquake?
List policy numbers: (If applicable)
6.
Any coverage declined, cancelled or non-renewed during the last three years?
15.
During the last five years (ten [10] years in RI) has any applicant or household
(Not applicable in MO or CA) member been indicted or convicted of any crime? (In RI, failure to disclose the
existence of an arson conviction is a misdemeanor punishable by a sentence of
up to one year of imprisonment.)
7.
Has applicant had any foreclosure, repossession, bankruptcy, judgment or lien
16.
Is there any existing fire, water or structural damage?
procedures filed during the past five years?
Reason:
17.
Is building undergoing renovation or reconstruction?
Contractor Name:
Open Yes No      Date closed/discharged: Completion Date:
Completed Value: $
8.
Is applicant delinquent on mortgage or tax payments?
18.
Is house for sale?
9.
Are there any animals or exotic pets kept on premises?
19.
Is property within 300ft. of a commercial or non-residential property?
Breed:
20.
Is there a trampoline on the premises?
Bite History:
10.
Any lake, pond or dock on premises?
21.
Was the structure originally built for other than a private residence and then converted?
11.
Distance to tidal water:    Miles   Feet

REMARKS (Attach additional word document if additional space is required)

ADDITIONAL INTEREST
INT No.:
Type Of Interest
Mortgagee Information
Loan Number:
   Mortgagee    Name:
   Additional Interest    Address:
   Trust    City:          ST:          Zip:
   Mortgagee    Name:
   Additional Interest    Address:
   Trust    City:          ST:          Zip:

ADDITIONAL REQUIREMENTS / ATTACHMENTS
Inspection Protection Class 9/10 Questionnaire Inland Marine Supplemental Application Replacement Cost Extimator
Photographs Woodstove Questionnaire/Photos (2) In-Home Business Suplemental Questionnaire

If necessary you can add 3 attachments to this application below:

NOTICES, FRAUD WARNINGS AND ATTESTATION

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 expiratioin, for appropriate renewal policies issued by Scottsdale Insurance Company and/or other member 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 and company within the Scottsdale group to issue, review, and renew the insurance for which I am applying.

FAIR CREDIT REPORTING ACT NOTICE:
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. (Not applicable to Nebraska, Oregon or Vermont applicants).

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: 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.

APPLICABLE IN HAWAII (AUTOMOBILE): For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud of helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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.

NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefits or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA 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.

NEW YORK OTHER THAN AUTOMOBILE 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 and fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

APPLICANT'S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)


APPLICANT’S SIGNATURE:_______________________________________________ DATE:__________________


CO-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)


Before You Submit your Application, Make Sure You Fill in the RED Boxes.  We Also Recommend Printing a Copy!!
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
Select your account executive, if you have one. If you do not please select Marsha Peck: