C.Ku Hartford to Sign

C.Ku Hartford to Sign - DATE(MM/DD/YYYY HOMEOWNER...

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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 APPLICANT'SNAMEAND MAILINGADDRESS (Include county &ZIP+4) (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 LOCATION OF PROPERTY IF DIFF FROM ABOVE (Inc county & ZIP) PREV ADDR APPLICANT'SOCCUPATION MAR APPLICANT'S EMPLOYER NAME AND ADDRESS DATE OF BIRTH SOCIALSECURITY # (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 KNOB & TUBE OR PLUMBING SYSTEM PLUMBING SYSTEM FOUNDATION LAST SERVICED (ELEC SYST) ALUMINUMWIRING CONDITION ANY KNOWN LEAKS OIL STORAGE TANK LOCATION WINDSTORMLOSSMITIGATION DWELLING LOCATION OCCUPANCY FEATURES INSPECTED? TAXCODE CONDITION OF ROOF BLDG CODE #WKS OCCUPIED DAILY? WINDCLASS RATING ROOF MATERIAL GRADE RENTED NO IF REPLACEMENT COST APPLIES, ACORD 42 ATTACHED: SPRINKLER BASEMENT GARAGE BREEZEWAY DAY EVE DAY EVE EACH OCCURRENCE EACH PERSON REPLACEMENT COST DWELLING REPLACEMENT COST CONTENTS ENTER OTHER ENDORSEMENT(S) AGENT DIRECT BILL BILL APPLICANT OTHER: FULL PAY APPLICANT AGENCY BILL BILL MORTGAGEE OTHER: OTHER: FRAME MFG HOME FARM MASONRY VINYL SIDING DWELLING TOWNHOUSE PRIMARY COC MASONRY ALUMINUM COMP. DATE: APART ROWHOUSE SECONDARY VENEER SIDING FIRE RES CONDO CO-OP SEASONAL NONE WIRING SYSTEM SMOKE TEMP PRIMARY: PLUMBING FT MI CENTRAL SECONDARY: HEATING DIRECT ROOFING LOCAL EXTERIOR PAINT CLOSED YES NO YES NO YES NO YES NO OPEN NONE YES NO DEADBOLT UNOCC FIRE EXT INDOORS OUTDOORS WITHIN APPROVED OWNER CITYLIMITS FENCE VACANT VISIBLE TO ABOVE WITHIN DIVING TENANT GROUND FIRE DIST NEIGHBORS BOARD WITHIN PROT SLIDE IN - SUBURB GROUND SEMI- RESISTIVE YES NO RESISTIVE OTHER CLASS SPEC NON-SMOKER CHIMNEYS PRE-FAB PARTIAL LIGHTNING HEARTHS WOOD STOVE SQ FT SQ FT SQ FT FULL PROTECTION INSERT RATING CREDITS FIREPLACES (Enter Number) *Not Applicable in NC HOW LONG HAVE YOU KNOWN THE APPLICANT? DATE AGENT LAST INSPECTED PROPERTY:
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This note was uploaded on 01/11/2012 for the course ECON 200 taught by Professor Riley during the Fall '10 term at UCLA.

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C.Ku Hartford to Sign - DATE(MM/DD/YYYY HOMEOWNER...

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