C.Ku Hartford App

C.Ku Hartford App - 09/09/2011 CHING-YA KU 535 GAYLEY AVE...

Info iconThis preview shows pages 1–3. Sign up to view the full content.

View Full Document Right Arrow Icon
CPF-321-0 (Ed. 7/02) 09/09/2011 CHING-YA KU 535 GAYLEY AVE Apt# 212 LOS ANGELES, CA 90024 Policy Number: 61RBB541539 Dear CHING-YA KU, Thank you for requesting a Hartford Homeowners Policy through our agency. As you may have already learned, we're required by California law to attach a completed copy of the form enclosed to your application. The information you provide will have no affect on your application for insurance. It is simply used by the California Insurance Department to ensure that insurance is available to state residents. At your earliest convenience, please mail your completed form to the address shown below. Or, you may prefer to fax it to the number that is also provided below. Thank you for your attention to this request. We're looking forward to welcoming you as one of our valued customers. Best regards from all of us, TWFG INSURANCE SERVICES INC 6080 CENTER DR SUITE 600 LOS ANGELES, CA 90045 (310) 242-6820 (310) 733-1769 Fax Please mail your completed form to: The Hartford 200 Executive Blvd Southington, CT 06489 Or Fax your completed form to: 1-877-755-5637 (toll-free)
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
PART COMP YEAR YEARS IN YEARS W/ YEARS W/ CURR OCC CURR EMPL PRIOR EMPL YEARS IN YEARS W/ YEARS W/ CURR OCC CURR EMPL PRIOR EMPL ABOVE GROUND ON MASONRY FLOOR ABOVE GROUND ABOVE GROUND NOT ON MASONRY FLOOR BELOW GROUND MANNED SECURITY OFF PREMISES THEFT EXCL BURGLAR HSEHLD SWIMMING POOL YES DATE(MM/DD/YYYY) PHONE AGENCY (A/C, No, Ext): FAX NAIC CODE FACILITY CODE (A/C, No): POLICY # DATE AT HOME PHONE # CO/PLAN CURR RES CODE: SUBCODE: EFFECTIVE DATE EXPIRATION DATE BUSINESS PHONE # AGENCY CUSTOMER ID PREVIOUS ADDRESS (If less than 3 years) YRS AT PREV ADDR APPLICANT'SOCCUPATION MAR APPLICANT'S EMPLOYER NAME AND ADDRESS DATE OF BIRTH SOCIAL SECURITY # (State nature of business if self-employed) STAT CO-APPLICANT'SOCCUPATION MAR CO-APPLICANT'S EMPLOYER NAME AND ADDRESS DATE OF BIRTH SOCIAL SECURITY # (State nature of business if self-employed) STAT HO FORM DWELLING OTHER PERSONAL LOSS OF USE PERSONAL MEDICAL STRUCTURES PROPERTY LIABILITY PAYMENTS $ $ $ $ $ $ MAIL POLICY TO: ACCOUNT #: BILLING IF DIRECT BILL: IF APPLICANT BILL: # YR BUILT #ROOMS MARKET VALUE STRUCTURE TYPE USAGE TYPE #FAM- PURCHASE ILIES DATE/PRICE RES $ SQ FT # APTS REPLACEMENT COST $ RENOVATION TYPE NUMBER OF TERR PREM PROTECT DISTANCE TO PROTECTION DEVICE TYPE HEAT TYPE CODE GROUP CLASS FIRE UNITSIN FIRE HYDRANT DIVS FIRE DIV STATION FIRE/EC RATE FIRE DISTRICT/CODE NUMBER HOUSEKEEPING CONDITION DATE HEATING SYSTEM NUMOF AMPS CIRCUIT BREAKERS FUSES PLUMBING SYSTEM PLUMBING SYSTEM FOUNDATION LAST SERVICED (ELEC SYST) ALUMINUMWIRING CONDITION ANY KNOWN LEAKS OIL STORAGE TANK LOCATION WINDSTORMLOSSMITIGATION DWELLING LOCATION OCCUPANCY FEATURES INSPECTED? TAX CODE CONDITION OF ROOF BLDG CODE #WKS OCCUPIED DAILY? WINDCLASS RATING ROOF MATERIAL GRADE RENTED NO
Background image of page 2
Image of page 3
This is the end of the preview. Sign up to access the rest of the document.

Page1 / 16

C.Ku Hartford App - 09/09/2011 CHING-YA KU 535 GAYLEY AVE...

This preview shows document pages 1 - 3. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online