General Information



General Information

Applicant Name and Address : Agency Information :

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Policy Information:

Fire Class Information

Property Coverages

|Coverage | Description | Coverage | Premium |

|A. Residence | | | |

Discounts/Credits

|Deductible Factors |( $500 = 0.95 ( $1,000 = 0.90 ( $2,500 = 0.85 |x |

| |( $5,000 = 0.80 | |

| |= |

|Base Premium | |

For Coverage B – List all other Structures to be insured Included Additional

Other Coverages 10% of coverage ‘A’ is included. $5.00 per 1,000 for additional Amount Amount

|B. Other Structures | | | | |

|10% of Cov. A - Included | | | | |

|(Coverage B must be charged for | | | | |

|on Mobile Homeowners) | | | | |

|B. Garage/Shed/Pool | | | | |

|(Detached) | | | | |

|C. Contents |Standard =50% of Coverage A Preferred =75% of Coverage A | | | |

| |$2.00 per 1,000 for additional HO-3/3+ = 70% of Coverage A | | | |

|D. Additional Living Expense |Standard =20 % of Coverage A | | |Included |

| |Preferred =20 % of Coverage A | | | |

| |Mobile Home =10% of Coverage A | | | |

| |Tenant = 20% of Coverage C | | | |

| | |

|Amount Received with Application |$ |

|Property Options |

|( |Replacement Cost on Contents $ 35.00 (N/C on Preferred Homeowners) |

|( |Solid Fuel Burning Surcharge – Complete Wood Heat Supplement $25.00 Flat Fee |

|( |Builder’s Risk – Collapse $50 and/or Theft $50 {If both are requested, charge $100} |

|( |Inland Marine (Complete Inland marine Section on Page 3) |

|( |Inflation Guard (automatic on Preferred Homeowners). 3% at renewal |

|( |Identity Theft ($1,000 included) $5/$1000 up to $5,000 limit |

|( |Water & Sewer Back-up ($1,000 included) $5/$1000 up to $25,000 limit |

|( |Antenna/Satellites – ($1,500 included) Use Inland Marine for add’l coverage) |

|( |Other Property Options – (See Agents Manual for Complete List of Options) |

| |Total “Property Options” Premium |

|Base Liability |

|Premium |Amount |Liability ($100,00, $300,000, $500,000, $1,000,000) |

| | |Initial Residence Premises |

| | |Initial Residence (Premises Only) |

| | |Additional Med Pay ($2,500, $5,000, $10,000) |

|Premium |Other Liability Coverages |

|( |Option 1 – Watercraft – Outboard Over 50 HP (each) |

|( |Option 1 – Watercraft – Inboard or I/O over 50 HP |

|( |Option 1 – Watercraft – Jet Ski’s |

|( |Option 2 – Office, School or Studio |

|( |Option 3 – Seasonal Residence Occupied by Insured |

|( |Option 3 – Rented to Others: ( 1 Family ( 2 Family ( 3 Family ( 4 Family |

|( |Option 4 – Recreational Vehicle – ATV (pers.) - Each |

|( |Option 4 – Recreational Vehicle – Golf Carts - Each (used off golf course) |

|( |Option 4 – Recreational Vehicle – Snowmobile - Each |

|( |Option 5 – Incidental Business Pursuits |

| |(Care Provided for Others – Maximum allowed is three children. Number cared for: ) |

|( |Option 6 – Additional Insured – Premises Only Name: |

|( |Option 8 – Additional Insured – PL Charge Name: |

|( |L: Personal Injury |

|( |L: Household Residence Employee - Each |

|( |Trampoline - MUST BE EXCLUDED – Exclusion Form DMIC-32 |

|( |Other: (Please describe) |

| |Total Liability Premium |

Ending Summary

| |Adjusted Base Premium |

| |Additional Coverage Premium |

| |Total Property Options Premium |

| |Total Liability Premium |

| |Installment Fee if Applicable (Semi-Annual $4.00 / Qtrly. $8.00 / Monthly $12.00) |

| $20.00 |Annual Policy Fee |

|- |Claims-Free Discount (please provide proof of prior claim-free status). |

| |(Claims-Free Discount on Fire, E/C and Inland Marine Only) |

| | Total Policy Premium |

Additional Policy Information

|Inland Marine – See inland Marine of Manual for Acceptability and Rates |

|Deductible |Article |Description, including Serial Number, Make, Model, HP, etc. |Amount of |Premium |

| | | |Insurance | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Recreational Vehicle Liability |

|1. Year |Make |Model |

|Size Engine |CC Serial # |Other |

|2. Year |Make |Model |

|Size Engine |CC Serial # |Other |

|3. Year |Make |Model |

|Size Engine |CC Serial # |Other |

Location of Insured Residence

|Address: |

|Sec |TN |Range |Township |County |

|Driving Instructions if Rural: |

| |

|Additional Locations: ( Seasonal ( Rental ( Other |

| |

| |

Mortgage/Lienholder Information

|M = Mortgagee L = Loss Payee LCH = Land Contract Holder (Send Billing to Mortgagee – Escrow Payments |

|M L LCH Name And Address: |

|( ( ( Indicate Secured Property |

| |

|M L LCH Name And Address: |

|( ( ( |

| |

Underwriting

|Property |Age |Roof Age |General Condition |Heat Type |Housekeeping |Updating – Remodeling Describe in |

| | | | | | |Detail |

|Residence | | | | | | |

|Other Structure | | | | | | |

|Other Structure | | | | | | |

ACH PAYMENT FORM:

As a convenience to me, I hereby request and authorize you to draw payments on my bank checking account maintained at the bank named on the attached `voided' check for payment to the Darlington Mutual Insurance Company.

It is agreed that:

1. An automatic payment shall be deducted in accordance with the method of payment stated on my policy. The Company shall incur no liability by reason of the dishonor of any such payments.

2. This plan may be terminated by me or Darlington Mutual Insurance Company upon 30 days written notice to the other party. Darlington Mutual Insurance Company may terminate the plan immediately if any payment is not paid upon presentation.

________ ___________________ ____________________ ________________________________________

Date Bank Routing # Checking Account # Signature of Depositor as it Appears on Bank Records

|Estimate market value of the home. $ ________________Purchase price if purchased in last 3 years. $_____________ |

|Wiring- ( Old ( Some Updates ( New Breaker Box & Circuits within last 15 years |

|Size of AMP service ( 200 ( 100 ( 60 Heat- ( Oil ( Gas ( Wood Heat ( Electric |

|Y N -Must Complete Heat Supplement- |

|Y N Homes with 60 AMP Fuses are ONLY acceptable if upgraded within 60 days |

|( Included are two photos of homes and each outbuilding to be insured-front and rear. |

|( One picture of dwelling roof MUST be sent in with application. * REQUIRED * |

|( Included is a diagram of house & replacement cost figures. * REQUIRED * |

|( ( Does the home have proper number of smoke alarms and are they working order? |

|( ( Is there any business conducted on the premises? If yes, explain |

|( ( Is there a swimming pool on the premises? If yes, Is it fenced in? |

|Other comments and remarks: |

Statements of the Applicant:

(The answers to the following will be the basis for which Darlington Mutual Insurance Company

relies upon to issue the insurance applied for.)

|( Yes ( No The applicant has authorized the above named insurance carrier (s) to release loss and claim history to Darlington |

|Mutual Insurance Company. |

|( Yes ( No Any losses or pending claims incurred, paid and/or denied within the last three years? |

|If yes, give amount and description of each loss. |

|I authorize my previous insurance carrier(s) to release my loss and claim history to Darlington Mutual Insurance Company. Name of Previous |

|Carrier: ______________________________________________________________ |

|( Yes ( No Does applicant rent appurtenant structures to others? If yes, describe structures |

|( Yes ( No Is the applicant owner of the dwelling? If no, explain |

|If yes to any of the following, do not bind. Please review complete list of binding restrictions in manual. |

|( Yes ( No Has any of the property to be insured been without insurance coverage within the last 30 days? |

|( Yes ( No Has the applicant been informed that any insurance property is or will be cancelled, non-renewed, or rejected by |

|any insurances company? |

|( Yes ( No Has the applicant, or anyone in their household, sustained any fire or theft loss in the last year at their present or |

|prior location? |

|( Yes ( No Is the applicant aware of any water damage or water claim to this property at anytime in the past? |

|( Yes ( No Is the property currently, or likely to be vacant, unoccupied, or for sale in the near future? |

|( Yes ( No Is the applicant currently seeking bankruptcy protection or in default of property taxes? |

|( Yes ( No Does the property have any un-repaired wind, hail, fire, or other damaged? |

|( Yes ( No Does applicant, or anyone in their household, own or care for a Rottweiler, Doberman, Pit Bull, Chow Chows, German Shepherd, |

|Huskies, Alaskan Malamute, Great Dane, St. Bernard, Akita, or any vicious dog or animal? |

|( Yes ( No Does applicant, or anyone in the household own, or care for, any dog that has previously caused injury or property |

|damage? |

|( Yes ( No Homeowner has 60 Amp Fuses |

| |

|CAUTION: READ CAREFULLY BEFORE SIGNING |

|I have read the above questions and I hereby declare to the best of my knowledge and belief that all of the statements are true and that these |

|statements are offered as an inducement to the company to issue the policy for which I am applying. I understand that Darlington Mutual Insurance |

|may inspect my property. The inspection of any resulting advice or report does not warrant that the property or operations are safe or are in |

|compliance with any law, rule regulations. |

|In the order to underwrite the Insurance applied for above I understand that Darlington Mutual Insurance may request a consumer report and may |

|investigate information as the character of the applicant for insurance and the persons to be insured under the policy applied for, their general |

|reputation, personal characteristics, mode of living, and credit standing. I understand that I may make request within reasonable time after |

|receipt of this notice for Darlington Mutual Insurance Company of the nature and scope of the investigation. |

| |

|UNDERTAKING TO PAY PREMIUMS AND ASSESSMENTS |

|I, of in consideration of insurance on my buildings and on my personal property,|

|insured to myself, my heirs and assigns by the Darlington Mutual Insurance Company, bind myself, and to the extend of their interest in the |

|property of my heirs and assigns, to pay to the company the premiums for such insurances and, within the period of time stated in the notice of |

|assessment, my share of all legal assessments, if any levied by the company, together with all legal coat and charges incurred in legal proceeding |

|to collect any assessments levied upon me and statutory penalties for non-insurance, both personal and real, shall be liable for that share, |

|waiving all exemptions. |

|Applicant Signature Date |

|. |

| |

|I, as agent, have seen the above property and recommend it. Agent Signature . |

| |

-----------------------

Darlington Mutual Insurance Company Homeowner Application

P.O. Box 165 Darlington, WI 53530

Phone: 608-776-2319 Fax: 608-776-4567

-------Select One:----------- -----------------------------------------Select One---------------------------------------------------------

( New Bound Application ( Standard Homeowner Form 2 ( Tenant HO Form 4

( Non-Bound Application ( Standard Homeowners – Form 3 (ACV) ( Standard Homeowners – Form 3 (HO-3+)*

( Quote Only ( Mobile Homeowner ( Preferred Homeowners*

_________________________________________

Phone # SS# / / Contact Person (if different than above)((((((((((((((((((((((

Cell # _________________ email: ____________________________________________________

Agency Name:

Agency Number:

Policy Effective Date: / / at 12:01 AM ---------METHOD OF PAYMENT--------

( 1 Month – Pay Monthly $12.00

Deductible: ( $500 ( $1,000 ( $2,500 ( 3 Months – Pay Quarterly $ 8.00

( $5,000 ( 6 Months – Pay Semi-Annually $ 4.00

( Pay Annually No Fee

( Pay via ACH (see form p. 3)

Fire Class: Responding Fire Dept: Distance: miles by road.

( Fire Hydrant within 1,000 ft. ( Other Sources of Water – Describe:((((((((((((((((((

( Protected ( Un-Protected

Policy Number:

*Please submit underwriting checklists.

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