Ranchers and Farmers Mutual Insurance Company
[Pages:54]Ranchers and Farmers Mutual Insurance Company
A Farm Mutual Company
Managed by American Bankers General Agency, Inc. Administrative Offices: 11222 Quail Roost Drive, Miami, FL 33157
SPECIALTY HOMEOWNERS REQUEST FOR INSURANCE WITH BINDER FORM
POLICY NUMBER
POLICY INFORMATION
BILLING INFORMATION
EFFECTIVE DATE EXPIRATION DATE
TIME
TERM IN MONTHS ACCOUNT NUMBER (7 DIGITS)
1. BILL INSURED
4 pay
6 pay
8 pay
DOWN PAYMENT ENCLOSED $ __________
12:01 a.m. Standard Time at the location of YOUR address below.
AT TIME OF ISSUE
2. TOTAL PREMIUM 3. BILL ACCOUNT
1.
With Application
AMOUNT ENCLOSED $ _________________
4. BILL LIENHOLDER
AT TIME OF RENEWAL
BILL INSURED 2. BILL
3.
ACCOUNT
4 pay
6 pay
8 pay
BILL LIENHOLDER
INSURED NAME AND
MAILING ADDRESS
AREA CODE & PHONE
DATE OF BIRTH
/ /
PRINCIPAL LOCATION OF YOUR DWELLING (If different than mailing address
on left)
LIENHOLDER NAME AND ADDRESS
LOAN #
SELLING AGENT NAME AND ADDRESS
DESCRIPTION OF
DWELLING
RATING INFORMATION
SQUARE FEET MODULAR
N/A
LENGTH
FT
WIDTH
FT
TRADE NAME & MODEL
FULLY SKIRTED
YES
NO
SERIAL NUMBER(S)
SERIAL NUMBER
ADDITIONAL SERIAL NUMBER (IF APPLICABLE)
PURCHASED
MO.
YR.
/
PURCHASE PRICE
$______________
MODEL YEAR
PURPOSE OF USE
OWNER FULL-TIME
SEASONAL
UNIT TIED DOWN
RENTAL SIDING
TENANT
TERRITORY
COUNTY
UNIT IN A PARK
(must be over 25 units)
YES
NO
DISCOUNT/SURCHARGE (MARK ALL THAT APPLY)
YES
NO
HARDSIDING
OLDER UNIT SURCHARGE
OTHER _________________________
POLICY TYPE
TIER 1
TIER 2
PHYSICAL DAMAGE
RENTAL (NOT AVAILABLE ON TIER 2)
1.
UNDERWRITING QUESTIONS 2. 3.
Does the applicant currently own the home? (Answer `no' if you are in the process of purchasing the home or will be purchasing the home in the future.) If yes, answer the following questions: a. Have you had two or more losses within the past three years involving theft, fire or water damage? (Do not
include water damage losses that result from failure of an appliance.)
b. Is the home in the process of foreclosure or repossession at the time of this application?
c. Is the home vacant? (For the purpose of this question, a home is not considered vacant during the delivery and setup period.)
Does the home currently have any preexisting damage that has not been repaired?
Do you have a lienholder or mortgagee? If no, answer the following question: a. Is your home currently insured?
YES NO YES NO
YES NO YES NO
YES NO YES NO YES NO
A4547-0614
Page 1 of 4
Coverages: This policy provides only the insurance for which a specific premium charge is indicated below or which is indicated as included without specific charge either below or in your policy. Detailed descriptions and any limitations will be found in your policy.
BASIC COVERAGES
Limit of Liability Coverage
Deductible
Premium
ADDITIONAL PROTECTION & ENDORSEMENTS
Coverage
Premium
$ ______________ Dwelling
$____________ $____________
YES NO Flood Coverage
$____________
$ ______________ Adjacent Structures $____________ $____________
YES NO Dwelling Replacement Cost
$____________
$ ______________ Personal Effects $____________ $____________ (Including Theft)
TYPE OF COVERAGE
YES NO Full Cost to Repair YES NO Agreed Value
Policy Fee
$____________ $____________ $____________
COMPREHENSIVE
BROAD FORM
Catastrophe Fees
$____________
This area is to be used to show additional endorsements, coverages, and/or information:
Deductibles: N/A Wind, N/A Hail, N/A Earthquake, N/A Flood, N/A Hurricane.
INSURED'S SIGNATURE
X
NAMED INSURED
AGENT'S SIGNATURE
X
PRINT AGENT'S NAME
POLICY NUMBER LICENSE NUMBER AUTHORIZED REPRESENTATIVE
ADDITIONAL PREMIUM
TOTAL POLICY PREMIUM
DATE
/
$0.00
/
TELEPHONE NUMBER
( )
If this box is checked coverage as shown on this application is bound contingent upon the receipt of payment. Coverage under this binder begins as of the effective date shown on the application. In no case will the binder be effective prior to the date and time of the Agent's signature. This insurance is subject to the terms, conditions and limitations of the policy (ies) in current use by the Company. This binder is cancelled when replaced by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the rules and rates in use by the Company. The quoted premium is subject to verification and adjustment.
AGENT SIGNATURE
X
DATE
/
/
TIME
AM PM
POLICY NUMBER
A4547-0614
Page 2 of 4
AMERICAN BANKERS INSURANCE COMPANY OF FLORIDA
11222 Quail Roost Drive, Miami, FL 33157-6596 (305) 253-2244
AREA ID
MH
APPLICATION FOR COMPREHENSIVE
POLICY NUMBER
PERSONAL LIABILITY COVERAGE WITH BINDER FORM
POLICY INFORMATION
EFFECTIVE DATE
EXPIRATION DATE
TIME
TERM IN MONTHS ACCOUNT NUMBER (7 DIGITS)
12:01 a.m. Standard Time at the location of YOUR address below.
INSURED NAME AND
MAILING ADDRESS
AREA CODE & PHONE
DATE OF BIRTH
PRINCIPAL LOCATION OF YOUR DWELLING (if different than mailing address
at left)
The residence premises covered by this policy is located at the address shown above.
1. If the applicant answers yes to any of the following questions, the policy cannot be issued with
comprehensive personal liability coverage:
a. Do you own an animal that has caused bodily injury to anyone in the past 3 years?
YES
NO
b. Do you have an unfenced pool? (Fence must be a minimum of 4 feet high and locked.)
YES
NO
UNDERWRITING
c. Do you have a pool with a diving board on the premises?
YES
NO
QUESTIONS
2. If the applicant answers yes to the following questions, a maximum limit of $25,000 comprehensive
personal liability coverage applies:
a. Do you have a business (including day-care), which brings visitors to the premises?
YES
NO
b. Is there a trampoline at the insured premises?
YES
NO
Coverages: This policy provides only the insurance for which a specific premium charge is indicated below or which is indicated as included without specific charge either below or in your policy. Detailed descriptions and any limitations will be found in your policy.
COVERAGE
LIMIT OF LIABILITY
PREMIUM
This area is to be used to show additional endorsements, coverages, and/or information:
TOTAL PREMIUM
TOTAL PREMIUMS DUE
INSURED'S SIGNATURE
x
AGENT'S SIGNATURE
x
PRINT AGENT'S NAME
INSURED'S NAME POLICY NUMBER AUTHORIZED REPRESENTATIVE
DATE
/
/
TELEPHONE NUMBER
If this box is checked coverage as shown on this application is bound contingent upon the receipt of payment. Coverage under this binder begins as
of the effective date shown on the application. In no case will the binder be effective prior to the date and time of the Agent's signature. This
insurance is subject to the terms, conditions and limitations of the policy(ies) in current use by the company. This binder is cancelled when replaced
by a policy. If this binder is not replaced by a policy, the Company is entitled to charge a premium for the binder according to the rules and rates in
use by the company. The quoted premium is subject to verification and adjustment.
AGENT'S SIGNATURE
DATE
TIME
POLICY NUMBER
x
/
/
AM PM
A4642-0804
Page 3 of 4
APPLICANT NAME
DISCLOSURE OF INFORMATION CONCERNING THE TEXAS SPECIALTY HOMEOWNERS PROGRAM INSURANCE PURCHASE
Agency Code No.
I understand that:
1. The Coverages, amounts and the Total Premium listed on my insurance application have been reviewed by me. I agree that they meet my present insurance needs. I understand that I may choose Coverages and amounts in excess of the requirements of my loan.
2. I may purchase insurance from any agent or insurance company to satisfy the insurance requirements of my loan contract. I have elected to purchase my insurance from Ranchers and Farmers Mutual Insurance Company through the agent signing on the bottom of this form.
3. I am paying the premium for this policy. I have not been offered any free coverage. If I choose to finance the policy premium, my lender will pay it and add the premium cost to my loan. I will repay the premium to the lender, plus interest, over the life of my loan. This will increase my monthly payment throughout the entire life of my loan.
4. My insurance needs may change over time. It is my responsibility to review my policy from time-to-time to make sure that I have the Coverages and amount of insurance that I want and need. I may contact my agent or Ranchers and Farmers Mutual Insurance Company to change the Coverages or amounts. Ranchers and Farmers Mutual Insurance Company will process Coverage or amount changes subject to its normal underwriting review.
5. Licensed agents, agencies and/or service providers, including my lender, will receive compensation from the sale of this policy to me. This compensation will be paid out of premium.
6. If I no longer want this policy, it may be canceled by notifying my agent or Ranchers and Farmers Mutual Insurance Company in writing. The cost of the insurance for the period the policy was in effect will be deducted prior to the unearned premium being refunded or credited to my loan balance if I finance the premium. If I finance my home and cancel this policy, the loan agreement still requires me to maintain insurance coverage. If I cancel this policy, I must replace it with other insurance acceptable to my lender. If I fail to maintain insurance required by my loan agreement, my lender may buy insurance for me and charge me for the insurance premium.
I acknowledge that I have read and understand the above items and have voluntarily chosen to sign this document.
BUYER'S SIGNATURE
DATE
X
/
/
CO-BUYER'S SIGNATURE
X
DATE
/
/
I certify that I have discussed with the Buyer and the Co-Buyer the terms of the insurance transaction, including the issues
addressed in the disclosures above
INSURANCE AGENT'S SIGNATURE
DATE
X
/
/
N3232-1010
Page 4 of 4
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- top rated mutual insurance companies
- farmers homeowners insurance quotes
- best insurance company for home and auto
- security mutual insurance company
- mutual insurance companies list
- farmers auto insurance quote
- security mutual insurance company ny
- security mutual insurance company claims
- security mutual insurance payment
- nationwide mutual insurance company
- country mutual insurance company claims
- liberty mutual insurance auto quote