RE:   Company:  <<Pol_Company>>

Policy Number:  <<Pol_PolNum>>

 

Accept / Decline    Back-up of Sewers & Drains up to Policy Limits

 

Accept / Decline    Identity Theft

 

Accept / Decline    Fungi/Mold Endorsement

 

Accept / Decline    Replacement Cost Contents

 

Accept / Decline    Actual Cash Value for Roof Surfaces

 

I agree with the coverages as indicated above.

 

Insured signature:  ________________________________________________

 

I have reviewed the replacement cost estimator and accept the proposed amount of $<<Input:Proposed Replacement Cost >>coverage on my house, and a deductible of $<<Input:Deductible>>

 

Insured signature:  ________________________________________________

 

In connection with this or any future application/quote for insurance, we may review your credit report or obtain or use credit based insurance scores based on the information contained in that credit report.  We may use a third party in connection with the development of your insurance score.

 

Insured signature:  ________________________________________________

 

I understand the homeowners policy DOES NOT include Flood Insurance and a separate policy must be issued to add this coverage.

 

Insured signature:  ________________________________________________

 

I understand that by accepting the application, the home MAY NOT be vacant or unoccupied.  Upon vacating a home, I agree to notify the agent in writing within 10 days.

 

Insured signature:  ________________________________________________



Sincerely,


<<User Name>>
<<User_Notes>>, <<Agncy_Name>>
<<Agncy_Address>>, <<Agncy_City>>, <<Agncy_State>>  <<Agncy_Zip>>
Phone:<<Agncy_Phone>>  |  Fax: <<Agncy_Fax>>