TINY APPLICATION
TINY HOMES PROGRAM (OWNER OCCUPIED)
APPLICANT INFORMATION:
Name:
Mailing Address:
Location Address (Tiny Home address):
Located at:
Owned PremisesLeased/Rented Premises
RETAIL BROKER INFORMATION:
Name:
REQUESTED LIMITS:
Dwelling:
Other Structures:
Personal Property
Loss of Use
Personal Liability: None: $100k$200k$250k
*Medical Payments - $1000 FLAT (if personal liability chosen)
PROPERTY INFORMATION:
Construction Type: FrameMetalOther (details)
Protection Class:
Year Built/Assembled:
Assembled by: Owner:Contractor (licensed):
Electrical Inspection (if assembled by owner): YesNo
Number of Fire Extinguishers and Size:
Occupancy: OwnerTenant:Seasonal:Vacant:
Heating: None:Space Heater: Wood/Pellet Stove:Fireplace: Other:
Heating Inspection/Cleaning (if wood/pellet stove and/or fireplace):YesNo
Distance to Fire Station:Distance to Fire Hydrant:
Designated Wind Area:YesNo
Smoker:YesNo
-If yes, any smoking and/or extinguishing inside and/or within 10’ of the dwelling? YesNo
Square Footage:
Updates (if older than 15 years):
Roof
Plumbing
Electrical
Heating
Tiny Home in a designated brush zone:YesNo
ADDITIONAL QUESTIONS:
Coverage Declined, Non-renewed, Cancelled the last 3 years: YesNo
Reason: (i.e. proper program for Tiny Homes not available):
Foreclosures, Repossession, bankruptcy last 5 years: YesNo
Liens – last 5 years:YesNo
Has the Applicant ever been convicted of arson or insurance fraud?YesNo
Does the dwelling have existing damage?YesNo
-If yes, please provide details:
Is the dwelling vacant, unoccupied, tenant occupied, or in
foreclosure?YesNo
Is the dwelling’s primary source of heat a wood, coal or
a pellet burning stove?YesNo
Is the dwelling next to any damaged or abandoned building?YesNo
Is the brush clearance of the dwelling less than 250 feet?YesNo
If the dwelling is in a designated brush area, is the brush
clearance of the dwelling less than 500 feet?YesNo
Does the dwelling have a swimming pool, Jacuzzi, or hot tub
that is not surrounded by a six foot fence with a self locking
gate?YesNo
Loss/Claim/known occurrence History:
Any business conducted on the premises:YesNo
If yes, please provide details:
Mortgaee:
Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties.
I hereby apply for a policy of insurance as set forth in this application, and I certify that all
of the information provided by me in this application is true and complete. I understand
that any policy, which may be issued by the Company, will be issued on the basis of, and in
reliance upon, my statements in this application, and that any intentional or non-intentional
material misrepresentation made by me may affect the payment of claims. This application
is not a binder, and nothing herein contained shall be construed as an agreement to provide
insurance of any kind.
Signature of Applicant:
Date:
Signature of Retail Broker:
Date: