COMMERCIAL INSURANCE UNDERWRITERS, INC.
DWELLING LIABILITY 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
REQUEST COVERAGE: PERSONAL LIABILITY PREMISES LIABILITY
LIMIT OF LIABILITY: $ MEDICAL PAYMENTS: $

LOCATION #1
LOCATION #2
Located at:
Located at:
Value of Dwelling: $
Value of Dwelling: $
1 family
2 family 3 family
4 family
1 family
2 family 3 family
4 family
Owner
Tenant
Renovation
Owner
Tenant
Renovation
Vacant
Seasonal
Builder's risk
Vacant
Seasonal
Builder's Risk
Vacant land
Condo
Short-term rental
Vacant land
Condo
Short-term rental
Year of construction:
Year of construction:
Updated? Yes No
Updated? Yes No
If yes, provide the date the following items were updated:
If yes, provide the date the following items were updated:
Roof:
Roof:
Wiring:
Wiring:
Plumbing:
Plumbing:
Heating and Air Conditioning:
Heating and Air Conditioning:
Physical condition of property:
Physical condition of property:
   Additional insured:
   Additional insured:

PLEASE ANSWER ALL QUESTIONS:

1. Is there a swimming pool on premises? Yes No
If yes, is there a diving board or slide? Yes No
If yes, is the pool fenced with a self-locking gate? Yes No

2. Any other water exposure; i.e., ponds, lakes, jacuzzi/hot tubs? Yes No
If yes, describe:

3. Any animals on premises? Yes No
If yes, describe:
If yes, any bite/aggressive behavior history? Yes No

4. Any smoke detectors? Yes No

5. Any trampolines? Yes No

6. Trip and fall hazards? Yes No
If yes, explain:

7. Do steps have secured handrails? Yes No

8. Applicant's occupation:

9. Any business on premises? Yes No
If yes, describe:

10. Is there a day care operation on premises? Yes No
If yes, is commercial General Liability coverage written? Yes No
Number of children:

11. Any hobbies? Yes No
If yes, what are they?

12. Is the dwelling under renovation or builder's risk? Yes No
If yes, Provide contractor's name:
Duration of project:
Provide certificate of insurance from contractor.

13. Any adjacent structures on premises, other than a garage? Yes No
If yes, what are they used for?

14. Any acreage? Yes No
If yes: Number of acres:
How is it used?

15. Any losses at this location or any other location owned/rented within the last three years? Yes No
If yes, details:

16. Any residence employees? Yes No
If yes: Number of: In-servants: Hours/week per employee:
Number of: Out-servants: Hours/week per employee:

17. Has any company canceled or refused coverage to the applicant (Not applicable in Missouri or California)? Yes No

18. Additional space to explain yes answers:

19. Please provide:
Prior insurance carrier:
Policy number:      Expiration date:
(Not applicable in Missouri or California.)

INCLUDE PHOTO OF PREMISES WITH APPLICATION.

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

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)


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: