HOMEOWNERS POLICY APPLICATION

PROPOSED ON: 05/13/2003

PROPOSAL NUMBER: 318

MAILING ADDRESS:

SERVICE CENTER: 58      AGENT: 3143

GLENN SMITH
N7907 STATE HWY 81
WATERLOO NY 53595

STEPHEN MILLER
104 W LAKE SHORE BLDV
LADYSMITH NY 54848
OFFICE: (715) 542-6732

TERM LENGTH: 12 MONTHS

EFFECTIVE: 05/30/2003

NAMED INSURED:

GLENN SMITH
N7907 STATE HWY 81
WATERLOO WI 53595

SUMMARY OF COVERAGES & PREMIUMS

PROPERTY & LIABILITY COVERAGES PREMIUM
Property Coverages
Dwelling $943
Other Structures Included
Personal Property Included
Loss of Use Included
Liability & Medical Coverages
Personal Liability $8
Medical Payments to Others $2
Optional Coverages
Miscellaneous Endorsements $428
Watercraft $193
Recreational Vehicle $405
Personal Umbrella Liability Coverage No coverage
 
TOTAL POLICY PREMIUM $1,979

LOCATION 1

N7907 STATE HWY 81
WATERLOO NY 53595
Protection Class 9

Coverage at the described location is provided only where a limit of liability is shown or a premium is stated.

DWELLING
RM3 - DWELLING AND PERSONAL PROPERTY COVERAGES - COMPREHENSIVE FORM
Property Loss Deductible $250
RM-290 Personal Property Replacement Cost
RM-184 Automatic Value-up
RM-216 Premium Credit for Protective Devices

CoveragesLimit of LiabilityPremium
A. Dwelling$197,763$943
B. Other Structures$19,776Included
C. Personal Property$98,882Included
D. Loss of Use$39,553Included
E. Personal LiabilityEach occurrence:$300,000$8
F. Medical Payments to OthersEach person:$1,000$2
Miscellaneous Endorsements
RM-48 Increased Coverage on Other Structures$6,000$14
RM-56 Use of Woodburner on Premises $50
CONDOMINIUM
RM9 - CONDOMINIUM UNIT-OWNERS COVERAGE SPECIAL FORM
Property Loss Deductible $500
RM-290 Personal Property Replacement Cost

CoveragesLimit of LiabilityPremium
C. Personal Property$20,000Included
A. Dwelling$2,000Included
D. Loss of Use$8,000Included
E. Personal LiabilityEach occurrence:$300,000Included
F. Medical Payments to OthersEach person:$1,000Included
Theft Loss Deductible - $250.00 Included
TOTAL PREMIUM - LOCATION 1 $1,017

 

WATERCRAFT
BOAT - WATERCRAFT
Property Loss Deductible $0

CoveragesLimit of LiabilityPremium
BT-20 Watercraft - Liability$300,000$24
Watercraft Trailer Physical Damage$1,500$14
Watercraft Medical Payments$1,000$5
Uninsured Motorist Watercraft$300,000Included
Underinsured Motorist Watercraft$300,000Included
BT-60 Watercraft - Physical Damage$10,000$79
Watercraft Motor Physical Damage$8,500$71
Description of Watercraft
Year: 1997  Length:18  Type:O - OUTBOARD BOATS & PONTOONS  Serial:DJASDLKK 
RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

CoveragesLimit of LiabilityPremium
RV-20 Recreational Vehicle Liability$300,000$36
Recreational Vehicle Medical Payments$1,000$2
Uninsured Motorist Recreational Vehicle$300,000Included
Underinsured Motorist Recreational Vehicle$300,000Included
RV-60 Recreational Vehicle - Physical Damage$2,500Included
Description of Recreational Vehicle
Year: 1994  Length:  Type:SN - SNOWMOBILE  Serial: 
RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

CoveragesLimit of LiabilityPremium
RV-20 Recreational Vehicle Liability$300,000$36
Recreational Vehicle Medical Payments$1,000$2
Uninsured Motorist Recreational Vehicle$300,000Included
Underinsured Motorist Recreational Vehicle$300,000Included
RV-60 Recreational Vehicle - Physical Damage$3,000$99
Trailer Physical Damage$1,000$30
Description of Recreational Vehicle
Year: 1995  Length:  Type:SN - SNOWMOBILE  Serial: 
RECREATIONAL VEHICLE
RECVE - RECREATIONAL VEHICLE
Property Loss Deductible $0

CoveragesLimit of LiabilityPremium
RV-20 Recreational Vehicle Liability$300,000$33
Recreational Vehicle Medical Payments$1,000$2
Uninsured Motorist Recreational Vehicle$300,000Included
Underinsured Motorist Recreational Vehicle$300,000Included
RV-60 Recreational Vehicle - Physical Damage$5,500$165
Description of Recreational Vehicle
Year: 2001  Length:  Type:SN - SNOWMOBILE  Serial: 

 

CONDOMINIUM
RM9 - CONDOMINIUM UNIT-OWNERS COVERAGE SPECIAL FORM
Property Loss Deductible $500
RM-290 Personal Property Replacement Cost

CoveragesLimit of LiabilityPremium
C. Personal Property$20,000Included
A. Dwelling$2,000Included
D. Loss of Use$8,000Included
E. Personal LiabilityEach occurrence:$300,000Included
F. Medical Payments to OthersEach person:$1,000Included
Theft Loss Deductible - $250.00 Included

Miscellaneous Policy Coverages

Miscellaneous Endorsements

Coverages Limit of Liability Premium
RM-61 - Scheduled Personal Property - Fine Arts, Glass, Porcelain & Ceramics (Non-Breakable) $11,535 $127
RM-61 - Scheduled Personal Property - Guns $13,000 $182
RM-61 - Scheduled Personal Property - Jewelry $5,475 $55


1 LOSS PAYABLE CLAUSE-AUDIO, VISUAL & DATA ELECTRONICS EQUIPMENT    PREMISE 1

  LEASE CORP AMERICA
340 E BIG BEAVER RD
TROY NY 48083

General Risk Selection

(1) Have you been rejected, cancelled or non-renewed?
Explain: 
(2) Have you had liens, judgements, foreclosures or bankruptcies in the past 3 years?
Explain: 
(3) List all prior losses or claims on this or other property:
(4) Are any other business operations owned or operated from your premises ?
(5) Any evidence of mold or prior water damage in buildings ?
Explain: 
(6) Have you obtained certificates of insurance from tenants ?
(7) Has the insured been insured with TRITECH in the last 6 months ?
(8) Do you have a formal safety program for your business ?
(9) Is all business conducted in the State ?
(10) Do you have a dog ?
Breed: 
(11) Any bites, scratches or incidents with the dog ?
(12) Is there a trampoline ?
(13) Do you heat your dwelling or any building with wood ?
(14) Do any unrelated adults reside in your household ?

SIGNATURES

The undersigned hereby agrees and represents that:

a) This application contains a full and true description and statement of the condition, situation, value, encumbrance, occupancy and title to the property to be insured with TRITECH Insurance Company to the best of my knowledge.
b) The answers to the questions and statements made are true.
c) Notification will be given to the agent of any changes(s).

NOTICE OF INSURANCE INFORMATION PRACTICES:

Personal information about you may be collected from persons other than you. Such information as well as consumer reports which may include credit information, collected by us or our agents, may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent for instruction on how to submit a request to us.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject the person to criminal and civil penalties, including recission of coverage.

APPLICANT’S STATEMENT:   I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true.

 X Applicant’s Signature ____________________     Date __________      Agent’s Signature __________________

 


PROXY

The agent should have applicant read and sign the following designation:

The undersigned hereby appoints the Company, Cooperative, by any representative designated by its Board of Directors, attorney in fact for me to vote and act as my proxy at any meeting of policyholders of the TRITECH Insurance Company hereafter held, not attended by me in person, granting said attorney full authority to act for me in the transaction of any business coming before such meeting.

 X Applicant’s Signature ____________________       

 

TRITECH INSURANCE COMPANY