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

<<Today>>

<<Cli_NamedInsureds:PC>>
<<Cli_Address:PC>>
<<Cli_City:PC>>,<<Cli_State:UC>> <<Cli_Zip>>
 
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>>
<<User_Email>>