Microsoft Word - H150000 NV 02 16 Homeowners On-LineApp.doc

Homeowners Insurance Application

H150000 NV 02 16 Page 1 of 7

Named Insured(s) and Mailing Address Insurance Company

650 Davis Street

San Francisco, CA 94111

Primary Email: Insured Property

Primary Phone #:

Alternate Phone #:

Bought through:

NOTICE OF INSURANCE INFORMATION PRACTICES

In some insurance transactions, we may not be able to get all the information we need directly from you. In that case, we may obtain

information from outside sources at our own expense. We would also like to inform you that without prior authorization, we may as

permitted by law, provide information about you contained in our records and files to certain persons or organizations.

NOTICE: As part of Esurance's underwriting/qualification procedure and subject to applicable laws and regulations, we may obtain

information regarding you and other individuals who may be covered by the insurance you are applying for, including: (i) driving

record, based on state motor vehicle reports and loss information reports; (ii) your prior insurance record, if any, which will be obtained

from your current or prior carrier(s); (iii) credit reports; and (iv) claim history, based on loss information reports.

Policy Number Purchase Date and Time Effective Date Expiration Date

Primary Applicant

Information

Name

Date of Birth Gender Marital Status Education Level

Existing Esurance Policy Drivers License Number DL State Currently Insured - Auto

Length of Time with Current Auto Carrier

Length of Time with Prior Auto Carrier

Years

with Prior

Property Company

Type of

Current

Property Policy

Applican

t Information

Name

Date of Birth Gender Marital Status Education Level

Relationship to Primary Applicant

Drivers License Number

DL State

Currently Insured

Auto

Length of Time with Current Auto Carrier

Length of Time with Prior Auto

Carrier

Years with Prior Property Company

Type of Current Property Policy

otal

Auto Claims, Accidents, and Violations

for all Applicants

Number of Auto Accidents

Number of Violations

Number of Comp Claims

Fault

Not

Fault

Major

Minor

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H150000 NV 02 16 Page 2 of 7

Property/Dwelling Information

Year Built Property Type Number of Stories Square Footage

Fire Hydrant is Within 1000ft

Original Owner Purchase Date Historic Home Number of Fireplaces and Wood Stoves

Number of Full Bathrooms Number of Half Bathrooms Predominant Bathroom Quality

Foundation Type

Exterior Wall

ype

Predominant

Kitchen Quality

Year Roof Most Recently

Built or Replaced

Roof Shape

Primary Roof Composition

Lock S

hingles or Asbestos Material

Garage Type

Garage Capacity

Basement

Percent of

asement

Finished

Under Construction or Remodeling

Visible Home or Roof Damage

Unfenced Trampoline

Unfenced Pool

Home Safety Devices / Fire and/or Theft Systems

General

Household Information

Residence Type Number of Residents Any Residents Smoke Number of Cars

Mortgages on Home

Do You Own a Dog Dog with Bite History Is Dog Vicious or a Restricted Breed Any Wild or Exotic Animals

Home Financing

and

Ownership

In Foreclosure/

Foreclosure Purchase

Residence Used for

Business Purpose

Current Home

Insurance Carrier

Any Property

Claims

in Last 5 Years

Customer Disclosed Property Claims

Date

Claim Type

I understand that upon issuance of the insurance applied for the Property Insurance Adjustment (P.I.A.) condition will apply to the

policy. In accordance with the terms of this condition, the limits of liability may be adjusted at each anniversary of the policy.

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H150000 NV 02 16 Page 3 of 7

COVERAGE DETAIL

FOR THE INSURED

PROPERTY

Coverage

Limits of Liability

Dwelling Protection

Increased Building Structure Coverage

Other Structures Protection

Personal Property Protection

Additional Living Expense Coverage

Family Liability Protection

Guest Medical Protection

Water Backup Coverage

Roof Surfaces Coverage

Fire Department Charges Coverage

Building Codes Coverage

Eco Upgrade

Golf Cart Coverage

Golf Cart Year / Make / Serial Number

Electronic Data Recovery Expense Coverage

Fair Rental Income Protection

Additional Coverage on Business Property

Home Day Care Coverage

Loss Assessments Coverage

Additional Coverage for Yard and Garden

Extended Premises

Additional Coverage on Cameras

Additional Coverage on Jewelry, Watches, and Furs

Additional Coverage on Musical Instruments

Additional Coverage on Sports Equipment

Additional Coverage on Silverware Theft

5% Back with Claim Forgiveness

Deductible

Deductible Amounts

Windstorm and Hail

All other perils

Other Purchase

Products

Limits of Liability

Identity Theft Expense Coverage

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H150000 NV 02 16 Page 4 of 7

Sch

eduled Personal Property Coverage

Scheduled Personal Property Deductible:

Description of item

Value

Mortgagee Information

Mortgagee Name

Loan Number

Mortgagee Street City, State Zip Code

Additional Insured Information (Trust)

Name of Trust

Name of Trustee

Address

Loss Payee?

Additional Insured Information

Name

Date of Birth

Address

Resident

Relationship

Loss payee?

Loss Payee

Name

Date of Birth

Address

Homeowner Insurance Application continued...

H150000 NV 02 16 Page 5 of 7

Terms and Conditions Agreement

Please read this agreement carefully.

As used in this Terms and Conditions Agreement (“Agreement”), “we,” “us,” and “our” refer to Esurance Insurance Company.

“You” and “your” refer to the named insured(s) identified in the application for insurance (“Application”), and any spouse of

the named insured who resides in the same household. “Insurance Policy Documents” collectively refers to your Application,

this Agreement, and all forms, endorsements, and notices issued to you by us, which we are required by law to provide you in

writing.

By completing the Application and clicking on “I accept”, you: (i) declare that you have read and completed the Application;

(ii) declare that the Application has not been completed by any other individual, including an insurance agent, broker,

consultant, or representative, even if you have consulted with any such persons; (iii) agree to all of the terms and conditions

contained herein; (iv) declare that the statements contained in the Application are true to the best of your knowledge; (v) agree

to pay any applicable surcharges and/or recomputed premium resulting from inaccurate statements in the Application; (vi)

acknowledge that your insurance policy (“Policy”) may be rescinded or canceled and a claim may be denied if the Application

contains any false information or misrepresentation, or if any information that would affect our underwriting decision has been

omitted or misrepresented; (vii) declare that you have listed all residents in your household; (viii) declare that you have

described any business or commercial use of your insured premises in the Application; and (ix) agree that no coverage will be

bound if your financial institution does not honor, or we do not receive, your payment.

Disclosure of Fees

You may be charged an Installment Fee, as allowed by your state, if you elect to pay your premium in installments.

You may be charged a Late Payment Fee of $15.00 for each payment that is not received by the payment due date.

You may be charged a Paper Documents Fee of $25.00 for electing to receive paper copies of Insurance Policy Documents that

we would otherwise provide to you electronically.

You will be charged for fees as required by your state.

Cancellation for Non-Payment of Premium

To keep your Policy current and avoid cancellation, your payment must be received by its due date. We do not accept partial

payments of the invoiced amount. If your full payment for the invoiced amount is not received by the due date, a Late Payment

Fee will be charged to your account. Unpaid premium may result in the cancellation of your Policy. If a cancellation notice is

generated, the cancellation notice will be mailed to the address shown on your Policy.

Notice of Insurance Practices and Use of Consumer Reports

Personal information about you and other persons that may be covered by the insurance being applied for may be collected from

persons other than you. Such information, as well as other personal and privileged information collected by us or our agents,

may, in certain circumstances and as permitted by law, be disclosed to third parties. You have the right to review your personal

information in our files and request the correction of any inaccuracies. More information about your rights and our practices

regarding your personal information is available upon request. Please contact us for more information.

In order to evaluate your eligibility for insurance coverage with us and to determine the correct premium to charge you, we

order one or more reports provided by independent consumer reporting agencies. These reports are necessary to verify

information that you have provided us. Examples of reports include, but are not limited to, a Motor Vehicle Reports (MVR),

Comprehensive Loss Underwriting Exchange Reports (CLUE), an insurance claim history report, and, where allowed by law,

an insurance score based on information contained in your credit report. We may use a third party in connection with the

development of your insurance score. All reports are impartial statements of fact and are kept strictly confidential. The

information we obtain will be used only for business purposes and to ensure that each applicant is evaluated fairly. Future

reports may also be used for an update, renewal, extension, cancellation, or non-renewal of your insurance coverage. Upon

request, we will provide you with the name, address, and telephone number of any consumer reporting agency that furnishes us

with your report.

We will review your credit history when we are legally required to do so, or you may request a review once each policy term.

Any adjustment in premium made pursuant to a change in your credit history will be reflected on your next renewal offer, in

accordance with the law.

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Electronic Transactions Agreement

Esurance is an online company and we generally conduct business through our Web site and via email. We will from time to

time send information electronically and post documents to customers' online accounts.

Although we primarily conduct business electronically, Esurance is required by law to provide you with certain information in

writing. However, with your consent we can provide information and documents to you electronically instead, including your

Insurance Policy Documents. If you consent, you will receive all of your Insurance Policy Documents from us electronically, to

the extent permitted by law. Insurance Policy Documents in electronic format will have the same contractual force and effect as

Insurance Policy Documents in paper format. We reserve the right, in our sole discretion, to provide any Insurance Policy

Document to you in paper form instead.

If you consent to receiving your Insurance Policy Documents electronically, you may withdraw your consent at any time and

begin receiving Insurance Policy Documents in paper format. In addition, you may request paper copies of your Insurance

Policy Documents at any time. If you elect to receive paper copies of Insurance Policy Documents, you may, at any time,

request and consent to receiving Insurance Policy Documents electronically. Please call us at 1-800-ESURANCE (1-800-378-

7262) for any such withdrawals or requests, as well as to change the email address or other contact information that Esurance

has on file for you.

Before you give your consent to receive Insurance Policy Documents electronically, you must have: (i) a computer capable of

connecting to the internet; (ii) an internet service provider; (iii) a browser capable of viewing our web site; (iv) an email service

account that allows you to read, write, and send email; (v) an active email address, and (vi) the ability to use hyperlinks to

access other web sites (collectively referred to as the “Technical Requirements”). You must have the Technical Requirements to

download, display, print, and retain Insurance Policy Documents in Adobe Portable Display Format. Once you purchase your

Policy, you will be given the opportunity to download a free copy of Adobe Reader so that you can view Insurance Policy

Documents in Adobe Portable Display Format. If you do not have the Technical Requirements, you cannot receive Insurance

Policy Documents electronically.

When the box that indicates you want to receive your Insurance Policy Documents electronically is checked, and you click “I

accept”, you are confirming that you: (i) have the Technical Requirements described above; (ii) agree to make payments, renew

your Policy, make changes, and send to us and receive from us communications related to your Policy by email or through your

online account; (iii) agree to accept all Insurance Policy Documents electronically in lieu of delivery by U.S. Mail or other

physical delivery method; provided, however, that we may deliver certain Insurance Policy Documents in paper format via U.S.

Mail; (iv) agree to electronically sign all documents in connection with your Application; and (v) agree that your electronic

signature, including when you click "I accept", serves as and replaces the need for your physical signature for this and all future

transactions in connection with your Policy and Insurance Policy Documents, except as otherwise required by law.

If you want to receive your Insurance Policy Documents in paper format, before you click "I accept" to purchase your policy,

you must un-check the box that indicates you want to receive your Insurance Policy Documents electronically. If you did not

un-check the box or you completed your purchase by phone, you can also call 1-800-ESURANCE (1-800-378-7262) and

request to receive your Insurance Policy Documents in paper format.

Whether or not you elect to receive your Insurance Policy Documents electronically, by clicking “I accept” you are

electronically signing this Agreement.

Election of Document Delivery Method

You have elected to receive your insurance documents in electronic form. When you select the electronic documents option,

you: (i) will have to log in to your online account to make changes and view your documents; and (ii) acknowledge that you

read the disclosure regarding the use of electronic records and signatures in connection with your online account as provided on

our Web site.

YOUR DOCUMENT DELIVERY ELECTION: ____________________________

Accessing Your Online Account

To access your online account, go to www.esurance.com and log in to your account with the email address and password you

provided when you created or updated your account. Your Insurance Policy Documents will be accessible through your online

account. To print any of your Insurance Policy Documents from your online account, click the “print” button located on the

page or in your browser frame. To download and save any of your Insurance Policy Documents to your computer, open the

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H150000 NV 02 16 Page 7 of 7

insurance policy document by clicking on its hyperlink or icon and follow Adobe Reader’s directions for downloading and

saving documents.

Cell Phone Policy

You agree that you are providing your express consent to receive calls and text messages on your cellular telephone, and on any

other device on which you may receive calls or text messages, from Esurance, its agents, affiliates and service providers that are

placed using an automatic telephone dialing system or using artificial or prerecorded voice messages.

Updating Your Contact Information

You must notify us of any changes to your email address, mailing address, or telephone number by updating your online

account with your new contact information, calling our customer service center at 1-800-ESURANCE (1-800-378-7262), or by

sending an email to suppo[email protected]surance.com.

FLOOD AND EARTHQUAKE DISCLAIMER

Esurance homeowners policies do not provide coverage for flood and earthquake. If you would like to buy flood insurance,

please contact the National Flood Insurance Program, for information about insurers that work with the Federal Emergency

Management Agency (FEMA), to provide flood coverage.

FRAUDULENT INFORMATION STATEMENT

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of

defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits.

By signing this Application Agreement, I/we agree that I/we have read, and accepted, the Terms & Conditions and any

state specific notices. This also serves as my/our acknowledgement that notice of Esurance’s privacy policy, practices and

use of consumer reports in regards to the policy have been provided. I/we agree and understand that the Application

statements and Agreement will apply to all future renewals, continuations, reinstatements, substitutions or changes to the

Policy.

I have read this entire Application, including the Agreement, before signing. I understand Esurance will rely

on my statements in this Application and any documents that I provide, and ask Esurance, in reliance on those

statements and documents, to issue a policy.

_________________________

Primary Applicant Signature

_______________________

Date