RE:      <<Cli_NamedInsureds>>      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


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