Loss Payee/Mortgagee Information

Is there a loss payee or mortgagee?
Is loss payee a mortgagee?
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?
Loan Number
Is there another loss payee or mortgagee?

Is loss payee a mortgagee?
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?
Loan Number
Is there another loss payee or mortgagee?

Is loss payee a mortgagee?
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?
Loan Number
Is there another loss payee or mortgagee?

Is loss payee a mortgagee?
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?
Loan Number
Is there another loss payee or mortgagee?

Is loss payee a mortgagee?
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:
Loss Payee Zipcode:
Loss payee's relationship to the property?
Loan Number
Is there a financial interest?

Phone:	804-359-4568
Toll Free:	800-396-6226
Fax:	804-359-6994
E-Mail:	info@commund.com

Agent Information:
Commonwealth Underwriters Agent Code:	Note: this field is optional

Agency Name:
Agent Name:
Agent Phone:
Agent Email:	(A copy of the quote will be sent to this address)

Insured Information:
Insured Name:
Insured Email:	(will only be used to communicate on this account)
Insured Phone Number:
Occupation:
Employer:
Date of Birth:	//
Is there an additional resident or spouse?
Additional Resident's Name:
Additional Resident's Occupation:
Additional Resident's Employer:
Additional Resident's Date of Birth:	//
Street Address of Residence to be Insured:
,
Insured Zip

Is the Mailing Address the same as the Street Address?
Mailing Address
,
Mailing Zip

Is this a corporation?
Is this a trust?
Trustee Name:
Trustee Mailing Address:
Trustee Mailing City:
Trustee Mailing State:
Trustee Mailing Zip:
Would you like a finance quote?
Agency Address
Agency City
Agency State
Agency Zip

Dwelling:
Protection Class:*
	* If you do not choose a protection class, your quote is not valid and cannot be honored by Commonwealth Underwriters.
Is dwelling visible to neighbors?
Is dwelling within 1000 feet of an adequate water source to fight a fire?
Is response time of primary responding fire department less than 15 minutes?
Is dwelling easily accessible year-round?
Number of Stories:
Is Dwelling Owner Occupied?
Type of Dwelling:
Is dwelling rented to others?
Is this a Single Family Residence?
Is this a manufactured home?
Year Built:*
	* Please note: Dwellings built before 1999 must have had updates within the last 20 years to qualify for this program. Details of updates will be required on application. (Roof, Electrical, Plumbing, and Heating)
Dwelling Area (sq. footage):	sq. ft.
Is Dwelling in Good Condition?
Does Dwelling Have any Existing Damage?
Is Dwelling Undergoing any Renovation or Construction?
Type of Construction:
	* Condo's cannot be quoted online, please contact Laura Fraley at 800-396-6226 x107 for assistance.
Type of Foundation:
	* Please provide an explanation in the Additional Comments section at the bottom of the page
Any animals with a bite history on the premises?
Are there horses on premises? (If yes, quote will become submission)
Does the dwelling have central heating regularly serviced by a licensed professional?
Is there a Wood Burning Stove?
Is the wood burning stove the primary heat source?
Is there any Polybutylene or Qwest Plumbing?*
	* Polybutylene plumbing is flexible gray plastic piping that is put together with a crimp connector.
Any Business Pursuits on the Premises?
Is the dwelling located on more than 2 acres of land?
Is the dwelling located on more than 10 acres of land?
Any unfenced swimming pool or body of water on the premises?
Have there been any Repossessions in the last 3 years?

Is the Dwelling Located Within 1,000 Feet of the Ocean, Bay or Sound?
	1st Tier Coastal Counties include: Brunswick, New Hanover, Onslow, Pender, Carteret, Currituck, Dare and Hyde.

Type of roofing material:
Is the roof flat?
Type of siding material:
Year of last water heater replacement?
Number of Golf Carts?

Applicant:
Please choose one of the following to describe insured's credit history:
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?
Has there been a Bankruptcy Within the Last Year?
Has there been any Foreclosure within the last Five Years?
Any past due Child Support?

Insurance History:
Is this a new Purchase?
Year Purchased?
Was this a foreclosed property when purchased?
What was the purchase price?
Has there been any Prior Insurance on this Account?
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Prior Policy Premium:
Risk New to Agency?
Was Policy Terminated at Companies' Request?
Has there been a Lapse of Coverage over 30 Days?
Previous Wind/Hail Deductible?
What was the Reason for Termination?
	* Please provide an explanation in the Additional Comments section at the bottom of the page

Any Open Claims?	Yes No
Number of Losses in the Last Five Years:

	Date (mm\|yyyy)	Type of Loss	Details	Amount Paid
1)				$
2)				$
3)				$
4)				$
5)				$

Coverages:
Replacement Cost - Coverage A	$
Coverage B - Other Structures - Percentage of Coverage A
Coverage C - Contents - Percentage of Coverage A
Coverage D - Loss of Use - Percentage of Coverage A

Credits:
Deadbolts, Smoke Alarms, Fire Extinguishers?
Central Station Fire and Smoke Alarms?
Central Station Burglar Alarm?
Higher Deductible?

Effective Date
Proposed Effective Date

Mortgage Payments:
Are Mortgage Payments Current?

Liability
Limit of Liability:
Increased Medical Pay:

Loss Payee/Mortgagee Information

Loss History: