EFTA01221608.pdf

DATE (MIVEMprenr) ACORD- HOMEOWNER APPLICATION OP ID SW 06/02/2010 AGENCY inac nair c cNo mop 340-779-1799 APPLICANT'S NAME AND MAILING ADDRESS (Maud° county / ZIP•1) -HNC CODE • • • inc.,00 340-779-1926 'AMITY COOT Tnhn L i TInannt-th First Insurance: Port of Sale POLICY • P.O. Box 306359 NA St. Thomas, VI 00803-6359 On ." COIPLATIOnta.la IMMonirl tore • Lloyd.* 1 NOME PHONE CUM It DAY Tom Fit zatertons EVE CODE: SUISCOOE: OPECTF/E DATE EXPIRATION DATE BUSINESS MOM N DAY AGENCY CUSTOMER ID HIM 05/31/10 05/31/11 EVE APPLICANT INFORMATION PREVIOUS ADDRESS (Ilion than 3 yaws) YRS AT LOCATION OP PROPERTY If OFF FROM ABM floc county 4 DPI PREY ADDR APPLICANTS EMPLOYER NAME AND Aii SS nimbi MM., fan/. DATE OF BIRTH SOCIAL SECURITY • ISII:le 1 Marriets lieffisif•••mployed) °5 ,22- alaNOCC STAT GOVONOR VI GOVERMENT N COAPPI ICANT OCCUPATION ISIAlo new. 01 OOOOO SSW sinployfd) i Cifleetlekirieerktifelt AND \JMOSS -ores vain lft UE away CrisMSPI. ImoTtan STAY DATE OF BIRTH IAL SECURITY FINANCIAL ANALYST I KIW TONG HAY! YOU KNOWN THE APPLICANT I FTC INC GATE AGENT LAST INSPECIFO PROPERTY: N COVERAGES/LIMITS OF UABIUTY DED (Type & Amount) RIO FORMI DWELLING OTHER PERSONAL I LOSSOF USE PERSONAL MEDICAL ** Au, PER.. I STRUCTURES PROPERTY UAUILITY PAYMENTS - — —.-_—.-- ! I. ACII OCCURRENCE EACH PERSON • * wirycjiHAR I ! i•• 'THEFT . IC03 1%700 000 I 5 40000 540,000. I s NIL 3100,000. 4,000. . lia5PC-AT ET ...._._ I ,. ENDORSEMENTS PREMIUM • erflACOAFPP COST OWELL MG I I REPLACEMENT COST CONTENTS EST TOTAL PREMES mum fle)01ISIEMENT(SI 12870 . 00 itsiDEDUCTIBLEt WINDSTORM HURRICANE, EARTHQUAKE =POW WHICH IS 5% OF SUM INSU*ED EACH AND EVERY LOSS (SUBJECT TO MINIMUM OF $1,000). ALL OTHER PERILS 51. 54 $500 BACH SAM EVERY LOSS. OPAANIat S 12921.54 PAYMENT PLAN I I ACORD 810 Attached (NOT APPLICABLE IN NC) ACCOUNT V: MAIL POLICY TO. BILLWIC IF ',ERECT BILL: — 1-IF APPLICANT SW AGENT DIRECT All [ HILL APPLICANT OTTER: FULL PAY APPLICANT Xi AGENCY BI I BRE monrcaGet OTHER: OTHER RATING/UNDERWRITING FRAME MI G HOME USAGE TYPE PAM. • PURCHAS FARM LIES HEINLE DATE/PRICE xrIASOMM .VPALSKING 1970 12 s 950000 X DWELLING r TOWNHOUSE X 'PRIMARY 03G MASONRY MUMMA SOFT OMITS REPLACEMENT COST APART ROOMS( • SECONDARY COMP- We 1 VENEER ORE RES NUMBER OF I I SONG TIRE 4595 PREM 17ROTECT I S 700000 COTANCE TO CANDO T... 1. .LLGO-OP I,. 4 RENOVATION rrpens, xsts. GROUP CLASS PROTECTIONOEVIDE TYPE HEAT TYPE j HONE WRING x I Mt C°°€ „„. • nee On FIRE DIV 1 STATOR SYSTEM] SIAOICI TEMP funpoly. PLUMBING X 01 CEFITRAL SECONDARY NEATNG INERC IIATE TIRE DISTRICT/COOE NUMBER HOUSEKEEPING CONDITION I RomiNG °snot I 1 LOCH EXTEROR PAINT 02 DATE RIMING SYSTEM' I Num or ARPS DIRCUIT BREAKERS FUSES , Csolosknufm [ foLloualloweresr vomerecevemnififighnow NoNE CLOSED AST tEliTical) (ELFC STET) ALuimmisi WONG CONDITION ANT KNOWN LEAKS °NEWF* LOCATION oc6upoinci - I X YES 1.2 X YES LI M3 ' 1 yEs. [ I No . OIL STORAGE TAM( LOCATION Good STARRING S X No STORM SHUTTERS OPEN DEAODDLT WITHIN INDOORS OUTDOORS VOW° YES n HUM > d Its WY LOAN'S X - ▪I °GNI It UNOCC X FIRE EXT mum ti 'VETERE T ANN OPANIPIS ABOVE — ERVING ABOVE e GLASSFNO Al ORE KIST TENANT VACANT _& NEIGHBORS POS. GROUN OROUND WITHIN PROT *suss WOW SLIDE - citiiissei rims GROUN GROUND 61-60 C°°C INSPECTED? TAX CODE RATIN O DAILY? GUISE ROOF MATERIAL ROOF GRACE RENTECIN° RESISTIVE o_IC BASEMENT J • . •• If REPLACEMENT COST PERLIS: ACOROT " " lieTriMN .,1 rn we - Kivu i —treol ATTACHED I RATING CREDITS eateittiiiiir —til NON-SMOKER f_. LRESISTNE x OTHER SE CU OFF PREMISES 'HIFI FXCI 1.224BRANE SPRINKLER minim I-. 000C, , FIREPLACES (EMit Flumbet) CHIMNEYS r PRE-FAIT SO I SOFT I I SOFT 1-... II PROTECTION I -• Fs HEARTHS I WOOD STOVE INSERT ACORD 80 (2003109) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1981 EFTA01221608 GENERAL INFORMATION DZSCAT 2 apuvN ALL -yor RESPONSES IN REMARKS 1 EXPLAIN ALL •YES• RESPONSES IN REMARKS (EKcepl queellian 15. 16 and 1T) YES MD TES IK ANY FAHLMO oft — -l47 191AIMOVItE MS i FIVEVEAAS I Ii N rtats ortaiocit IsC ir lEavdog ayc"'J X HAS NIT APPUCANI BEEN CONVICTED Or ANY DECREE OF THE CRIME Of ARSON? Dr, RI. Mae sy cAscase SW 'mane Wan wan • ANY commas ts a rosaameadot passable a s mance 0 up loom itiotrbei end two d 6.4I and pal tan ansayasa X1 year cd agnomen, 1 3 ANY F 1001)1Na. BRUSH, FOREST FIRE HAZARD. LANESIDE ETC, X IS. IS MERE A WOMGER ON THE PREMISES? ... REAYERS AND -. — .. . ANY (RIRIE RE SONIC( OWNED OCCUIRO ONMENINX? A 16. WHERE A SECURITY ATTENDANT, ... CCNDOS MAY . . ._. _ .. . .. . . ... . .. ... _ , „ • ANY 011Wit INSURANCE WITH TIM COMPANY/TUE pc4cy nullibanN IT. IS THE 01111011.G ENTRANCE LOCKED? . . - ...• • • 4 INS INNIFLANCE KEN TRANSFERRED WITHIN AGENCY' X III ANY UNCORRECTED FRE OR BUILDING COO VIOLATIONS? : X is euitoins uwootooi.c nbac‘/Ai ion on tiEdliGlillete010 • ANY COVERAGE. DECUTRO. CANCA II CD Olt NONRENEWEO ouppo Tot LAS! 3 YEARS, (101400ceMon MO) i ... ...._..._.. _. .........._. ....___......_...__.._._._._ .. ill (Ma esionated comiaann dale ma 005.1 WON) " . - .i: X a las APPLICANT HADA FORECLOSURE. nrivssessioN. IIANKRUPTCY. JUDGEMENT MI LEN DURING TIC PAST FIVE Yi.ARS2 L20 11 IS I OUSE FOIL SALE? IS PITOPERTYIfiN3COODIAOONMETLCIN.Ort — -- - - — - --- -- . -1—" .. _ X . X X 9 ARE THERE ANY AMELMS OR EXOTIC PETS KEPT ON 22. IS THERE A TRIMAPOTLINE ON THE PREMISES? X PREMISES? (14010 brad and OM Walt X 23. WAS ME STRUCTURE ORIGINALLY WILT FOR OTHER THAN A !It IS PHOPERTY L °CARO WIDEN MO MILES OE TRIAL WATER? X PRIVATE RESIDENCE AND THEN CONVERTED? X Is B PROPERTY SITUATED ON MORE TIM ENE ACRES? 24. ANY LEAD PARR HAZARD? X (II yas. desalt* and vie) X 26. IF A FUEL OIL TAW SON PREMISES. HAS OTHER MRIRANEE I). DOES APPLICANT OWN MN RECREATIONAL VEHICLES BEEN OBTAINED rout THE TANK? Olve Fail Party and INK and 'SNOW MOBILES. DIME BIGOTS. MINI BIKES. ATVS. EICN X mad Party and Im11) TUN sm. ON. Tab. meg 26. IF BLIRDING IS UNDER CONSTRUCTON. IS TIE APPLICANT X x 13 IS OLIN DING RE IROFITTEO FOR EARN/CLIME? .100/Kattel X THE GENERAL CONTRACTOR? ANY LOSSES. WHETNER OR HOT pAiDBY INSURANCE, DURING APPLICANTS LOSS HISTORY DATE I THE LASTS_ YEARS. AT THIS OR AT ANY OTHER LOCATION? TYPE DESCREITION OF LOSS I YES J ] NO IF YES. INDICATE BELOW MIMES: CAT I/ AMOUNT PRIOR COVERAGE PRIOR CARRIER PRIOR POLICY 'ENRON EXPIRATION DATE ADDITIONAL INTEREST Wra Lwow : /LAME AND ADDRESS LOANNUMBER immteri l Firot Bank ;P.O. Box 309600 St. Thomas VI 00803 • REMARKS (Attach Additional Sheets If Moro Spans Is Required) ATTACHMENTS STATE SUPPLEMENTS:DI apicat* I PROTECTION DEVICE CERTITCATT INLAND MARINE APPLICATION PERS EXCESSAJIAMELLAAPP REPLACEMENT COST ESTIMATE RECREATIDNAL VEMCLE API' .._ _ . PHOTOGRAPH WATERCRAFT APPLICATION SOLID FUEL SUPPLEMII NT LEAD FREE PAINT Cr IMF/EATON EARTHQUAKE APPLICATION HOME EAST D BuS INE SS Sufi' TOR COMPANY USE ONLY 0 INDER/SIGNATURE INSURANCE FENDER N THE -BINDER' BOX TO THE LEFT IS COMPLETED, THE FOUL:MN° CONDITIONSAPPLY: EFFECTIVE OATS EXPIRATION DATE TINS COMPANY WOOS TIN MID(S)Ct iNSURINCE STIPULATED ON THIS APPLICATION. THIS INAIRANCE IS SUBJECT TO THE TERMS. CONDOIONS AND LIMITATIONS OF THE POLICY(CS) IN CURRENT USE BY THE COMPANY. _ . .. _ THIS BINDER MAY BE CANCELLED BY TIDE INSURED BY SURRENDER 01 THIS DIMIER OR NY WRITTEN NOTICE 70 ME 'Sc COMPANY STATING MIEN CANCELLATIONWILL DE EFFECTIVE THIS BINDER MAY OE CANCELLED BY ME COMPANY 12'.01 AM.. —. . BY NOTICE TO 1.IC INSURE 0 IN ACCORDANCE WITH THE POLICY CONDITIONS II IR ENDER IS CANCELLED WHEN NOON REPIACELI UT A POLICY IS I HIS HINDER IS NOT REPLACED BY A POLICY. THE COMPANY IS ENTITLED TO CHARGE A i PREMIUM FOR MEROGATION ACC.ORDING TO THE RULES NO RATES IN THE OY lliE COMPANY THE OUOTED PRELIM.. IS . COVERAGE IS NO I BOUND SUBJECT TO KNIT ION AND ADJUST...M.WHEN NECESSARY. BY THE COMPANY. in MON. 'KORNAIIONNOVI YOU INCI MANG IN ORLIATION FROM A CREDIT REPORT. MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN OMNI C HONWIIn 116 MEI ICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS/KID RENEWALS CREDIT SCORING INORMATION MAY EC USED TO 'Ir II WWI HITHER EMOTION. ITY FOR INSURANCE OR THE PREMIUM YOU WEL OE CHARGE 0 WE MAY USE A TIERD PARTY IN CONNECTION WITH THE JI VII (WIC NI 01 VI UR SCORE SUCH INFORMATION AS WELL AS OTTER PERSONAL &NU MIA (CEO INOTU4M-01 COT I I ClL D OY US OR OUR AGENTS MAY Wait !AN cHNIAISI ANC, S BE CCCLOSED TO 111.110 PAR IMPS WITHOUT YOUR AuMORVATION YOU HAVE Till INGOT ID REVIEW YOUR PERSONAL INCEREATION IN OUR FILLS AND CAN REQUEST CORRECTION O. ANY NACCUNACES. A MOM OE TAILED OESCRIPTPM OF YOUR RIGHTS AND OUR PRACTICES RICARDING SUCH MOH/M.710N IS AVARAOLE VON REOUEST CONTACT YOUR AGENT OR BROKER I OR INSTRUCIIONS ON HOW TO SUBMIT A M OM SI TO US LI COPY Or DIE NOTICE Or INFOWAA NON PRACTICES WRIVRNI HAS Ill ER GIVEN TOME APPLICANT INN salsa, in EaleiesI ANY MORON 1,40 KNOWNGI YAM) VOIR INTENT 10 MERANO NW INSURANCE COL.PANY OR ANOTHER PERSON FILES AN APPLICATION ron INSURANCE 0/1S i A NEC( T Of CLAM CONTAINER ANY MATE RIAI LY FµSE INT ORMATIC.I. OR CONCEALS FOR TIE PURPOSE OF MSLEADING INFOIDAMION COMMMING ANY FACT MATERIAL THERETO. COMAIIS A FRAUDULENT INSURANCE. ACT. WHiCII IS A COME ANO SUDJECTS THE PERSON TO MINION. MO ANY MSS TANI WU CNN PENN TES INN appinala m CO. N. NE. 011. OK. OR. a VT: in DC. LA ME. TN end VA. idaworce bonefts may Ma De Mad) AIMS ICARUS STATEMENT I HAVE. OEM ME .1ECNE APPLICATION AND MN MEACHAM HIS I DI CLARE TINT HE INFORMATIONPROVIDED IN THEM IS TRUE. COMM EN AND CORRECT TO TIC BEM OE MY WY/LEDGE NAID BELIEF. 1145 INT ORMA HON IS APING OFFERED TO 111E COMPANY AS AN INDUCEMENT TO ISSUE 7 N^I Olt FOR TM A DATE PRODUtECS SIGNATURE I NATIONAL PRODUCER NUMBER I .5 - .2/ 4 1 Tom Fitzsimmons ACOR EFTA01221609  Insurance ACIENCV,1 MC. Firs Insurance. Port of Sale P.O Box 306359 St. Thomas VI 00803-6359 340-779-1799 ENCLOSURE RENEWAL AGREEMENT Named Insured: John & Cecile DeJongh Insurance Company: TYSER & CO LTD. Expiring Policy Number: Expiring Policy Date: 05/31/10 Renewal Effective Date: 05/31/10 Renewal Premium: $12,921.54 IN CONSIDERATION OF THE PREMIUM CHARGED, IT IS HEREBY UNDERSTOOD AND AGREED THAT THE INSURANCE COVERAGE PROVIDED BY THE RENEWAL OF THE ABOVE POLICY IS SUBJECT TO THE SAME TERMS AND CONDITIONS AS THE EXPIRING POLICY. THESE TERMS AND CONDITIONS INCLUDE THE DECLARATIONS MADE AT THE TIME THE PREVIOUS APPLICATION WAS TAKEN AND THAT INFORMATION IS HEREIN INCORPORATED AS THE BASIS FOR THE RENEWAL OF THIS POLICY OF INSURANCE. AC ED (NA ED I RED) DAT EFTA01221610