| If you are an individual owner(s).... |
|
Name of the Owner of the Property:
|
Last 4 digits of your social security number: |
| Other Names on Deed: |
|
| Name & Date of Birth of Oldest Deeded Property Owner: |
Birth Date: |
| If you are an Estate or Trust..... |
| Estate or Trust Name: |
Last 4 digits of your EIN number: |
| If you are a Company or Corporation.... |
| Company or Corporation Name: |
Last 4 digits of your EIN number: |
| Associations Insuring a Condominium or Cooperative..... |
| Association Name: |
Last 4 digits of your EIN number: |
| Individuals Paying Premiums for a Condominium Unit or Cooperative Proprietary Leasehold....
(Please contact your association and encourage them to insure the structure prior to applying for a policy. |
| Your Name: |
Last 4 digits of your social security number: |
| Birth Date: |
|
| Association Name: |
|
| Structure Information (Throughout this application the term “structure” refers to the structure under application.) |
| Requested Insurance Amount |
$ (coverage cannot exceed $ 250,000 or replacement cost of structure) |
|
Street Address: |
|
|
City:
|
State: Zipcode: |
|
County:
|
Municipality: |
Structure Type:
(Note: Each structure requires
a separate application)
|
|
Number of Units:
(if insuring a multi-unit
structure)
|
Structure Configuration: (if insuring a multi-unit structure)
Horizontal /
Vertical |
|
Year Built:
|
Number of Stories:
Estimated Replacement Cost
of Structure: (can be found in your Homeowners Insurance
Policy) |
| Primary Residence of Person(s) on Deed? |
Yes / No |
| Contact Information (Tell us how to contact you and where to send the payment notices) |
Home Phone: |
Work Phone: Cell
Phone:
Which phone can be called between 8:00am & 4:00pm
Home Work
Cell |
|
E-Mail Address:
|
Would you be willing to receive billing notices through E-mail?
Yes /
No |
Structure Condition Information
(Coverage is dependent upon the accuracy of the following information. Failure to identify all pre-existing damage, be it structural or superficial, may result in voiding your policy. The MSI Fund reserves the right to require further documentation or actions to complete this application when it determines that the pre-existing damages are significant. If you are filling out a paper application, you may attach additional sheets of paper as needed for complete responses to questions.) |
1. Is this structure a complete building? (Must contain a roof, walls and a foundation which firmly attaches the structure
to the earth.) Yes /
No
If "NO", please describe: |
2. Is any part of this structure used for anything other than a residence? Yes / No
If yes, please estimate the percentage of the structure that is used for non-residential purposes %, and explain the
usage in detail. NOTE: A detached garage for a residence is 0%. |
3. Are you aware of any damages or other problems with walls, floors, foundations, or other structural components due
to past or present movement, shifting, deterioration, etc.? Yes / No
If "YES", please explain in detail: |
4. Are you aware of any earth movement or stability problems such as sliding, settling, upheaval, mine
discharge or mine subsidence that have occurred on or affected your property? Yes / No
If "YES", please explain in detail: |
5. Are you aware of any earth movement or stability problems such as sliding, settling, upheaval, mine discharge or mine
subsidence that have occurred in the surrounding areas of your structure or your neighborhood? Yes / No
If "YES", please explain in detail: |
6. Have you ever filed a claim with the Mine Subsidence Insurance Fund or reported losses to your homeowners insurance
or any third party, such as a coal operator, regarding ANY damages or problems with your property? Yes / No
If "YES", please explain in detail: |