AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA 11222 Quail Roost Drive, Miami FL 33157 - 6596 (305) 253-2244 REQUEST TO INC REASE COMPREHENSIVE PERSONAL LIABILITY COVERAGE FOR RENTERS INSURANCE Please provide the following information. Sign this form and return it to the address indicated below. INSURED NAME POLICY NUMBER HOME TELEPHONE NUMBER ADDRESS WORK TELEPHONE NUMBER LIMIT OF COVERAGE REQUESTED Comprehe nsive Personal Liability: $100,000 1. Any business conducted on the insured premises? Yes ____ No____ If so, describe: _____________________________________________________________________ 2. Have you reported any personal liability claims in the past 3 years? Yes ____ No____ Date of Loss: ______________________ Date of Loss: _______________________ Date of Loss: _______________________ Type of Loss: _______________________ Amount Paid: _______________________ Amount Paid: _______________________ 3. Do you own any pets or animals? Yes ____ No____ How many?________________________________________________________________________ Describe animals (if dogs, list breed): ___________________________________________________ The following dog breeds are unacceptable: Pit bull, German Shepard, “Husky Type”, Malamute, Doberman Pinscher, Chow, Great Dane, St. Bernard, Akita, and any “mixed breed” that includes the aforementioned breeds. Have any of your animals caused bodily harm or injury in the past? Yes ____ No ____ Have any of the animals been trained to attack or guard premises? Yes ___ _ No ____ Are the animals restrained when outside the home? Yes ____ No ____ Submission of this request does not guarantee coverage. Request must be reviewed and accepted before coverage will be bound. If your request is not accepted, your personal liability coverage will be reduced to $50,000 and any applicable premium will be refunded. Coverage will be effective the date of acceptance by American Bankers Insurance Company of Florida and its authorized representatives. I hereby request that my Comprehensive Personal Liability coverage be increased to $100,000. I understand that this change will increase my premium. I certify that the answers to the above questions are true and correct. / / AGENT INSURED SIGN ATURE DATE Fraud Notice - 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, informat ion concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and substantial civil penalties. (See reverse side for additional Fraud Notices) M3656-0199 FRAUD NOTICES FLORIDA: Any person who knowingly and with intent to injure, def raud, or deceive any insurer files a statement or claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. VIRGINIA: It is a crime to know ingly provide false, incomplete or misleading information to an insurance company of the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.