AmityFin || We keep our promises

Applicant Name *

Occupation *

Employer *

Date of Birth *

Insured Location (if different than mailing address) *

City *

State *

Zipcode *

Mailing Address (if different than insured location) *

City *

State *

Zipcode *

nspection Contact *

Phone Number *

Producer Name *

Phone Number *

Prior Carrier *

Expiration Date*

Expiring Premium *

Effective Date (of this policy) *

Year Built *

Square Footage *

# of Families*

# of Stories*

How many floors in the building? *

On which floor is the unit? *

s there 200 feet of brush clearance around all structures? Yes No

Is the roof type non-combustible? Yes No

s the ISO Protection Class 1-8? Yes No

Personal Property Replacement Cost	Yes No
Special Personal Property All Risk Coverage C	Yes No
Special Computer Coverage	Yes No
Extended Replacement Cost Dwelling 125% 150%	Yes No
Upgrade to Green Residential Endorsement	Yes No
LexElite Eco-Homeowner	Yes No
Personal Injury	Yes No
Water Back Up and Sump Pump Overflow $Limit	Yes No
Increased Special Limits (all)	Yes No
Increased Special Limits (Jewelry/Watches/Furs)	Yes No
Identity Fraud	Yes No
Directors & Officers Coverage	Yes No
Limited Fungi (Mold), Wet or Dry Rot Coverage Section I: $5K $10K $25K $50K Section II: $5K $10K $25K $50K	Yes No
Sinkhole Coverage (Florida Only)	Yes No
If yes to Sinkhole Coverage (Florida Only): 1) Have you observed: (i) the signs of settling, cracking, bulging, sagging, bending, leaning, shrinkage or expansion of any part of the dwelling or other structure or (ii) any depression in the ground surface on the premises?	Yes No
2) Have you been told, has it been disclosed to you or are you otherwise aware of: (i) a sinkhole that might affect the dwelling or other structures or (ii) any other partial or complete sinking or collapse of the dwelling or other structures?	Yes No
3) At any time, has this property had any prior sinkhole claims?	Yes No

Extending Liability # of properties Occupancy Address	Yes No
Watercraft Liability # of properties Engine Type: Inboard Outboard Length feet	Yes No
Increased Limits on Business Property If yes, $10,000 $25,000	Yes No
Golf Cart Coverage # of carts value year make model serial #	Yes No
Include Liability for Golf Carts	Yes No
HO6 All Risk Coverage A	Yes No
Pet Critical Injury Coverage # Dogs # Cats	Yes No
Vandalism & Malicious Mischief (DP3 only)	Yes No
Earthquake Coverage (States other than CA, OR, WA)	Yes No
Earthquake Coverage (CA, OR, WA Only) Limited Deluxe	Yes No
If yes to Earthquake Coverage in CA, OR, WA: 1) If located on a hillside, is the slope 25 degrees or less?	Yes No
2) If built between 1920 and 1950, is there full seismic retrofitting?	Yes No
3) Is the dwelling built on tall walls or posts?	Yes No
4) Is the foundation concrete/steel and reinforced?	Yes No
5) Are the water heater and fireplace chimney securely bolted to the dwelling studs or foundation?	Yes No

LexShare Home Rental Coverage Included on all HO3 & HO6 if occupancy is Secondary, Secondary Rental or Rental	Opt out Primary occupancy
Cyber Safety Coverage Included on all HO3, HO4 & HO6	Opt out
Mechanical Breakdown Included on all HO3	Opt out Add to HO6

Mandatory Evacuation Coverage Included on HO3, HO4 & HO6 if Coverage D applies in the following states only: AL, CA, CT, CO, DE, FL, GA, LA, MA, MS, NC, NJ, NY, SC,TX , ME, NH, RI, MD, VA	Opt out
Significant Other Coverage Included on HO3 or HO6 if occupancy is Primary and only 1 Named Insured	Opt out non-Primary occupancy

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