Homeowner Application 80
The underwriting process for any personal lines policy begins with submitting a completed application. This guide assists in completing the ACORD Homeowner Application. The ACORD Personal Inland Marine Application (ACORD 81) should be used for scheduling personal property which is being submitted as part of the Homeowner Application.
The Generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide on the ACORD website (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS.
Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.
Location of Property if Different From Above
Enter the physical address of the property to be insured only if it is different from the mailing address listed above.
Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed.
Applicant's/Co-Applicant's Employer Name and Address
Name and address of the organization that employs the applicant(s) named in the identification section.
Yrs in Curr. Occ.
Number of years in current occupation or business.
Yrs w/Curr. Empl.
Number of years with the present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section.
Yrs w/Prior Empl.
Number of years with the prior employer.
Marital status of each named applicant. Codes:
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married
D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced
SP . . . . . . . . . . . . . . . . . . . . . . . . . . .Separated
W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed
Date of Birth
Birth date of each named applicant (MM/DD/YYYY). (E.g., March 7, 1944 should be 03/07/1944.)
Social Security #
Social security number for each named applicant.
Questions Relating to Knowledge of Applicant and Inspection of Property
Indicate how long the applicant is known to the agent, and the date of the last property inspection.
COVERAGES/LIMITS OF LIABILITY/ENDORSEMENTS/PAYMENT PLAN
Enter the anticipated dollar limit and premium charge for each applicable coverage. List any optional endorsement(s), corresponding limit(s) and any endorsement information that is to be included in this policy.
Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are:
1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic
2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad
3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special
4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents
4A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Tenants
5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive
6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Condominium
6A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Condominium.
Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.)
Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit.
Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment.
Provide the information below for each dwelling.
Check the primary type of building material used to construct the dwelling. Also indicate the siding type.
Examples of siding types not shown on the form include stucco, log, asbestos, and synthetic stucco/ EIFS (Exterior Insulation Finishing System).
Synthetic stucco is an artificial stucco used for exterior insulation and finishing systems (EIFS). It is created by affixing a styrofoam panel to the wall sheathing. The styrofoam is covered with reinforcing mesh, followed by a base coat and a finish coat. Both the base coat and the finish coats include an acrylic resin. The resin is water soluble in its liquid form, but once applied and dried, it becomes waterproof. Typically, this type of surface is less than a half-inch thick. It is relatively light, and sounds hollow when tapped. Real stucco is relatively heavy and feels and sounds solid when tapped. It is a much harder material than synthetic stucco, and is more resistant to injury by a blow or impact.
NOTE: you must advise the insurer if synthetic stucco (EIFS) siding is present.
Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alternations in the Remarks section. Also complete the Renovation Update section.
Dwelling's total square footage of living area.
Total number of rooms in a residence, including full and half rooms (bath).
Complete only for tenant or condominium policies. Enter the number of apartments (residences) in the building.
Estimated total dollar amount for which the dwelling could be sold under current market conditions.
Estimated total dollar amount required to rebuild the dwelling without depreciation.
Indicate the residence type. The full meaning of each abbreviation is:
DWELLING Dwelling, intended to be a free standing, up to 4 family building.
Applicant's use for the dwelling within the guidelines listed. ("COC" refers to dwellings in the "course of construction.")
Number of separate family units in the dwelling. Not required for HO-4 or HO-6.
# Hsehold Res
Number of residents in the household.
Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format.
# of Fire Div/ # of Units in Fire Div
Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved firewalls.
Dwelling location based on individual state bureau or company homeowners manual pages.
Premium group codes are found in individual state homeowner manuals. Some companies may require this data, others will generate it. Premium Group is a combination of Protection Class, Territory Code and Construction Type Code used to determine the applicable rate
based upon the dwelling's location, construction and fire protection code.
Dwelling's four-character fire protection grade found in individual state homeowners manuals.
Distance to Hydrant
Distance in feet from the nearest hydrant to support the protection class used.
Distance to Fire Station
Distance in miles from the nearest fire station to support the protection class used.
Complete if residence is specifically rated. Refer to thecompany rate manual.
Fire District/Code Number
Residence's fire district name and correspoding code number, which can be found in the idividual state manual pages.
Protection Device Type
For temperature, smoke and burglar alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies.
Type of heating device for the residence. If there is more than one type, indicate the primary and secondary types. Use the Remarks section if necessary. Some possible types are:
Electric - Permanent/Portable
Liquid Propane - Permanent/Portable
Kerosene - Permanent/Portable
Coal -Professionally/Non-Professionally Installed
Other - Explain the heating system in Remarks
Enter the evaluation of the interior upkeep of the dwelling.
If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year.
Date Heating System Last Serviced
Indicate the date (mm/dd/yyyy) heating system was last serviced.
Num of Amps (Elec. Syst)
Indicate the number of amps in the electrical system.
Check the applicable box.
Check the applicable box.
Knob & Tube or Aluminum Wiring
Check the appropriate box.
Plumbing System Condition
Indicate condition of the plumbing system.
Plumbing System - Any Known Leaks
Indicate if there are any known leaks in the plumbing system.
Check the applicable box.
Location of the dwelling within the guidelines listed. Complete only if applicable.
Indicate if the dwelling is occupied by the owner or a tenant, unoccupied or vacant.
If all entry (exterior) doors are fitted with deadbolt locks, check the box.
If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space.
Visible to Neighbors
If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box.
Oil Storage Tank Location
If the fuel type is oil, provide the location of the fuel oil storage tank. Options are:
Indoors above ground on masonry floor
Indoors above ground not on a masonry floor
Outdoors above ground
Outdoors below ground
Also show the distance from the dwelling, if the storage tank is outdoors.
If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board, slide or approved fence.
Check the applicable boxes.
Hurricane Resistant Glass
Check the applicable box.
Bldg Code Grade
Enter the ISO Building Code Grade, if applicable. Also check the appropriate box to indicate whether or not the building was inspected.
Enter the city, county or state tax code, if required.
Check the applicable box.
Check the applicable box.
# Weeks Rented
Number of weeks the dwelling is rented by the insured to others.
Check the applicable box.
Enter the material used to construct the roof. Examples:
Composition (fiberglass, asphalt, etc.)
Other If used, explain in Remarks
Condition of Roof
Indicate the condition of the roof.
If Replacement Cost coverage applies, check the appropriate box if an ACORD replacement cost worksheet has been used (i. e., ACORD 40, 41, or 42.)
Indicate the number of square feet in the basement. Leave this field blank if there is no basement.
Indicate the number of square feet in the garage. Leave this field blank if there is no garage.
Indicate the number of square feet in the breezeway. Leave this field blank if there is no breezeway.
Check the applicable box(es) if any rating credits apply.
If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system.
Enter the number in the applicable box(es) to describe the fireplace(s.)
Use the Remarks section to provide additional information for any questions answered with a "Yes" response (Except questions 15, 16 and 17.)
1. Any farming or other business conducted on premises?
Describe the business, where business is conducted on the premises, and if applicable, whether corporal punishment or day care coverage is to be provided.
2. Any residence employees?
Use the Remarks section to provide information regarding the number of employees, the nature of their employment, hours worked per week, and whether employed inside (inservants) or outside (outservants).
3. Any flooding/brush, forest fire hazard/landslide, etc.?
Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph.
4. Any other residence owned, occupied or rented?
Use the Remarks section to detail the occupancy or use of the other residence. If no liability coverage is requested for this residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property.
5. Any other insurance with this company?
Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available. If other insurance is in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal.
6. Has insurance been transferred within agency?
Indicate why this insurance has been moved from the last company.
7. Any coverage declined, cancelled, or non-renewed?
Explain the circumstances surrounding this situation, including the reason for the cancellation. This question cannot be asked in Missouri.
8. Has applicant had a foreclosure, repossession, bankruptcy, judgement or lien during the past five years?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or bankruptcy filing, judgement or lien during the specified time period.
9. Are there any animals or exotic pets kept on the premises?
Use the Remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others or to other animals.
10. Is property located within two miles of tidal water?
Use the Remarks section to describe the coastal hazard, if applicable. Indicate actual distance.
11. Is property situated on more than five acres?
Use the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose.
12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)?
Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description.
13. Is building retrofitted for earthquake?
Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest "earthquake resistant" technology and building codes.
14. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.
15-17. Renters and Condos Only.
15. There is a manager on the premises.
16. A security attendant.
17. The building entrance is locked.
18. Any uncorrected code violations?
Describe any violations of applicable building codes that have not been corrected.
19. Is building undergoing renovation or reconstruction?
Describe the type and scope of renovation or reconstruction of any part of the building.
20. Is the house for sale?
Provide the length of time the house has been for sale, and the expected sale date if known.
21. Is property within 300 ft. of a commercial or non-residential property?
Describe the occupancy of any commercial or non-residential property.
22. Is there a trampoline on the premises?
Describe the device.
23. Was structure originally built & converted for other than private residence?
Indicate what the structure was originally built for.
24. Any lead paint hazard?
Describe the location and the extent of the hazard.
25. If a fuel tank is on premises, has other insurance been obtained for the tank?
Give the First Party and the applicable limit, and the Third Party and the applicable limit.
26. If building is under construction, is the applicant the general contractor?
This section shows the losses this applicant has had in the past. List losses for the time period required by the company.
CAT# refers to a Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events.
Provision is made for the applicant to initial this section.
Provide the prior insurance company's name.
Prior Policy Number/Expiration Date
List the complete policy number including prefix and suffix, and the policy's expiration date.
Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is held) or other interest, the name and address of the
interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.