Docstoc

Credit Check Application Template

Document Sample
Credit Check Application Template Powered By Docstoc
					AmRisc Application
      Schedule of Values
              General Property
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 or
misleading information, or conceals for the purpose of misleading, information                                                                                                                                           *First Named Insured:
concerning any fact material thereto, commits a fraudulent insurance act, which is a                                                                                                                                     Expiration date of existing coverage?
crime and subjects the person to criminal and (NY; substantial) civil penalties. In some
states insurance benfits may also be denied. By submission of this application the                                                                                                                                       *Does any location include External Insulation & Finishing Systems (EIFS)
insured and the agent represent that all information is true and correct to the best
of their knowledge and that they have not deleted or altered the questions herein.                                                                                                                                       *List any locs with aluminum wiring. If so, any type of protection? (Warranted)
                                                                                                                                                                                                                         Describe any gut rehabs, location number, year and extent of rehab.
                                                                                                                                                                                                                         Is square footage gross or net leasable?

Starred * information is needed to process the account.                                                                                                                                                                  *Describe any tax credits, Sr. housing or otherwise subsidized properties. (Warranted)

                                                                                                                                                                                                                         Are any locations less than 200 ft. apart?
                                                                                                                    Coinsurance (must be 100% if requested to waive coinsurance):    100%         100%          100%        100%


                                                                                                                          Is Prop                                                                             Other Value                                                                                   Yr Bldg     Flood
                                                                                                                        within 1000                                        *Orig                 Personal     $ (outdoor                                                                   Percent ISO      updated    Zone (if
* Bldg                                                                                     *State                           ft of   *# of *ISO Construction *# of          Year *Real Property   Property    prop must be   Rental                                     *# of    *Square    Sprinkle Prot    (Mand if    Flood
  No.      Location Name              *Street Address                    *City              Code    *Zip   County        saltwater Bldgs Const Description Stories          Built Value ($)      Value ($)      sch'd)    Income ($)      *Total TIV    *Occupancy     Units    Footage      red    Class   >25 yrs)   reqst'd)
   1
   2
   3
   4
   5
   6
   7
   8
   9
  10
  11
  12
  13
  14
  15
  16
  17
  18
  19
  20
  21
  22
  23
  24
  25
  26
  27
  28
  29
  30
  31
  32
  33
  34
  35
  36
  37
  38
Has any policy or coverage been declined, cancelled or non-renewed during the prior 3 years (not applicable in MO.)
Is the applicant a S-Chapter Corporation, partnership or any other type of sole proprietor organization?
*Has any applicant been convicted of arson in the past 10 years?
Any bankruptcies or tax credit leans against applicant in prior 5 years?
*Do any of the buildings have unrepaired damage from a recent loss? If yes, describe extent of damage.
Does the applicant have any reason that they would not be aware of all losses for the prior 5 years? If so, explain

*Property losses min 3 years, prefer 5 years (DOL, Cause, Incurred $, ded, status). Warranted.

Comments
----------------------------------------------------------------------------------- CAT EXPOSED (<100 miles to Gulf or Atlantic) ** is mandatory for 5 County   -----------------------------------------------------------------------------------------------------------------------------------                                                           IF HABITATIONAL
                                                                                                                                                                                                                                                                                                              --------------------------------------------------------------    -------------------------------------------------------



                                                                                                                                                                                                                                                                         *EIFS? -                     Distance                                                                  Credit   Avg Unit
                                                                                                                                                                                                                       *Yr. Roof                                         Coverage Wind                    to      Date   Is prop *%     *%                             % Hard check all   Rental  City /                             Onsite
                                 *Building                                      **Roof                                                                            *Roof strapped (if              Building             covering                                          warrants  Pool               Saltwater added to Owned occupi Subsidi             *Type of      wired tenants on   per    Sub /                               Grd
       *Basement                Foundation       *Construction Quality     Framing/Structure             **Shape of roof             **Type of Roof Covering        ISO 1 OR 2)                  Maintenance            last repl         **Exterior Cladding            no EIFS Eligible?             (miles)   Sched. or Mg'd  ed    zed                 wiring      Smk Det    file   month($) Rural?                             Serv.

				
DOCUMENT INFO
Description: Credit Check Application Template document sample