Homeowners Application - EliteCover Insurance

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Homeowners Property Supplemental Application

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+1 (858) 529-7763

info@ecoverins.com

22647 Ventura Blvd. Suite #132 Woodland Hills, CA 91364

Required items for Submission:

ACORD 80 application for High-Value Primary Homeowners Insurance
ACORD 131 application for Excess Homeowners Property Insurance
Supplemental application (attached)
Statement of Value
Riskmeter Wildfire report
Narrative of the account
Expiring premium (if available) & Target premium
The most recent property inspection report on file if available
5 year currently valued loss runs/CLUE report
Underlying quote/policy
Who else is quoting the account
Target Rate

Download PDF Application

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1. Name of Applicant:

2. Current Carrier:

3. Current Premium:

4. Location of Property:

5. Is the Home located in a gated community:

Yes
No

If yes, please describe access procedures for the fire department.

6. Home number of stories:

7. Renovations contemplated in the policy term:

Yes
No

8. Occupancy:

Primary
Secondary
Long Term Rental
Home Sharing
Vacant

9. Home equipped with wood burning stove:

Yes
No

If yes, please answer the following

Spark arrester on chimney.

Yes
No

Fire/Chimney cleaned on a regular basis:

Yes
No

Damper functional

Yes
No

10. Hardwired or battery-operated smoke detectors present:

Yes
No

11. How far is the home from the nearest unmanaged vegetation (brush), in all directions?

12. Indoor sprinkler system present:

Yes
No

If yes, full or partial:

Full
Partial

13. Outdoor sprinkler system present:

Yes
No

If yes, full structure perimeter or partial:

Full
Partial

14. Wood shake present on any part of the structure:

Yes
No

If yes, describe location of materials:

15. Central Station fire/smoke alarm present:

Yes
No

16. Are any of the following present in the electrical system of the home:

Yes
No

If yes, please answer the following

a. Aluminum wiring

Yes
No

b. Fuses

Yes
No

c. Knob & Tube wiring:

Yes
No

d. Stab-Lok circuit breakers:

Yes
No

e. Federal Pacific Electric (FPE) electrical panel/circuit breakers:

Yes
No

f. Challenger electrical panel/circuit breakers:

Yes
No

g. Zinsco/Sylvania electrical panel/circuit breakers:

Yes
No

h. Murray electrical panel manufactured between June 2010 – August 2010:

Yes
No

i. Square D electrical panel manufactured between December 2019 – March 2022:

Yes
No

17. If applicable, describe any other fire/wildfire mitigation efforts made not listed above:

18. 5 Year Loss History

No Losses

If applicable provide loss details (date of loss, description of loss, total incurred, and mitigating efforts made to help prevent future similar losses):

APPLICANT'S WARRANTY STATEMENT: THE UNDERSIGNED APPLICANT DECLARES THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I ACKNOWLEDGE THAT ANY POLICY WHICH MAY BE ISSUED BY THE COMPANY WILL BE ISSUED RELYING ON THE MATERIAL INFORMATION CONTAINED IN THIS APPLICATION. I AGREE THAT ANY MATERIAL CHANGE TO THE INFORMATION CONTAINED IN THIS APPLICATION WILL IMMEDIATELY BE REPORTED IN WRITING TO THE COMPANY AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR VOID ANY AUTHORIZATION OR AGREEMENT TO BIND INSURANCE.

Read and Understood

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, INFORMATION CONCERNING ANY MATERIAL FACT MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

Read and Understood

Applicant Name

Date

THE BELOW INDIVIDUAL HEREBY WARRANTS AND CERTIFIES THAT THIS APPLICATION AND ITS MATERIAL INFORMATION IS CORRECT; THAT THIS APPLICATION WAS COMPLETED AND THEN SIGNED BY THE APPLICANT; THAT A COPY OF THE COMPLETED APPLICATION HAS BEEN PROVIDED TO THE APPLICANT; AND THAT THE BELOW INDIVIDUAL IS RETAINING A DUPLICATE SIGNED COPY HEREOF.

Read and Understood

Producer Name

Date

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22647 Ventura Blvd. #132 Woodland Hills, CA 91364
Ph. (858) 529-7763 info@ecoverins.com

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