Universal Homeowner
Application Request Form
Fax to 1-888-767-0826
Email to [email protected]
Requested Effective Date*
_____ / _____ / _____
Please send back to my
office via:
 Fax
 E-mail
*Coverage is not bound until information is entered and
approved in carrier system.
Customer Name:
Social Security No.:
Occupation:
Co-Applicant Name:
Relationship:
Date of Birth:
Social Security No.:
Occupation:
Submission #:
Name of Signing Agent:
Underwriting Questions
Any sinkhole exposure (within 5 miles) or
claims?
 Yes  No
If yes, explain
If yes, is damage from sinkhole repaired?
 Yes  No
Is the property currently condemned?
 Yes  No
If yes, explain
Any existing damage to property?
 Yes  No
If yes, when is the estimated completion date
for repairs?
Swimming pool or similar structure?
 Yes  No
If yes, is pool screened or fenced?
 Yes  No
If yes, what is the height of fence in feet?
If yes, does pool have diving board or slide?
 Yes  No
Is there a trampoline on property?
 Yes  No
Is there a skateboard ramp on property?
 Yes  No
Is the dwelling located on a farm, ranch,
orchard or grove, or any other property on
which farming, ranching, or any other
agricultural activity is conducted?
 Yes  No
Applicant Questions
Under the policy requested in this application, the “Insured” includes
the applicant, spouse if a resident of the same household, and other
residents of the same household who are relatives or are under the
age of 21 an in the care of any person included in this definition.
Has any prospective insured been convicted of
a felony in the last 5 years?
 Yes  No
Has any prospective insured been convicted of
arson or attempt to commit arson?
 Yes  No
Has any prospective insured been successfully denied within the
preceding 5 year period, payment by an insurer of a claim under a
home insurance policy based on evidence of arson, conspiracy to
commit arson, fraud, or conspiracy to commit fraud, committed by or
on behalf of the person?  Yes  No
Does any prospective insured seek to insure the home/condo/
apartment for use of any illegal or demonstrably hazardous purposes?
 Yes  No
Does any prospective insured plan to use the property as a fraternity,
sorority, or as a student housing or any similar housing arrangement?
 Yes  No
Seasonal Occupied Property
Is there any person checking property while it
is unoccupied?
 Yes  No
How often is property checked?
Name of person checking property:
Phone number of person checking property:
Are there neighbors within viewing distance of
property?
Homeowners (March 2017)
 Yes  No
Page 2
Customer Name:___________________________________________________________
Mortgagee Information
Construction Details
Are pipes copper?
 Yes  No
Age of hot water heater?
 Yes  No
Washing machine hoses replaced in the last 5
years?
 Yes  No
Any knob-tube, aluminum (excluding Alumicon
and Copalum), cloth or double tap wires in
house?
 Yes  No
Does home have 100 Amp or greater electrical
service?
 Yes  No
Do you currently have or have any plans for
portable heating?
 Yes  No
Any poly-butylene or pex pipes in home?
 Yes  No
Name:
Address:
Address:
City, State, Zip
Loan Number:
Billing Information
Billing:  1-Pay  2-Pay  4-Pay  Mortgagee
Initial Invoice:  Bill Insured  Bill Mortgagee
Renewal Invoice:  Bill Insured  Bill Mortgagee
Routing No.
Account Holder Name:
Acct. No.