Carrier - Underwriting Questions - Mutual of Enumclaw

Mutual of Enumclaw
Underwriting Questionnaire

Name(Required)

First Last

Phone(Required)

Email(Required)

Home Additional Questions

1. Is there a swimming pool greater than 6' in diameter and 3' deep on premises?(Required)

Is there a 5' fence with self-locking gate surrounding the pool or yard?(Required)

2. Was the structure originally built for other than a private residence and then converted?(Required)

3. Is there a trampoline on premises?(Required)

Is there a 5' fence with self-locking gate surrounding the trampoline or yard?(Required)

4. Are there any domestic, farm, or exotic animals on premises?(Required)

Are any dogs on premises of the following breeds (including mixed breeds? Akita, Chow Chow, Doberman, Pitbull (Staffordshire Terrier), Presa Canario, or Rottweiler)?(Required)

Do any dogs on premises have a bite history?(Required)

Are there any horses on premises?(Required)

Number of Horses:(Required)

Are there any other domestic, farm, or exotic animals on premises?(Required)

Type and number of other domestic, farm, and exotic animals:(Required)

5. Is business conducted on premises?(Required)

Underwriting Questions

1. Any other residence owned, occupied, or rented?(Required)

Please provide description.(Required)

2. Any other insurance with this company?(Required)

Please provide a list of policy numbers.(Required)

3. Any coverage declined, cancelled, or nonrenewed in the last 3 years?(Required)

Please provide an explanation.(Required)

4. Is property located within two miles of tidal water?(Required)

Please provide an explanation.(Required)

5. During the last 5 years, has any household member been convicted of any degree of the crime of arson?(Required)

Please provide an explanation.(Required)

6. Is building undergoing renovation or reconstruction?(Required)

Please provide the estimated completion date and dollar value.(Required)

7. Is house for sale?(Required)

Please provide explanation.(Required)

8. Is property within 300ft of a commercial non-residential property?(Required)

Please provide explanation.(Required)

Auto Questionnaire

Current Carrier:(Required)

Months Continuously Insured With Carrier:(Required)

Current Liability Type:(Required)

Current Liability Limit:(Required)

Prior Policy Number:(Required)

Policy Expiration Date:(Required)

Days Lapse in Coverage:(Required)

Landlord / Dwelling Fire Questions

1. Was the structure originally built for other than a private residence and then converted?(Required)

2. Wood Stove:(Required)

Is woodstove located in a garage or outbuilding?(Required)

3. Primary Heat :(Required)

4. Is there a swimming pool greater than 6' in diameter and 3' deep on premises?(Required)

Is there a 5' fence with self-locking gate surrounding the pool or yard?(Required)

5. Is there a trampoline on premises?(Required)

Is there a 5' fence with self-locking gate surrounding the trampoline or yard?(Required)

6. Are there any domestic, farm, or exotic animals on premises?(Required)

Are any dogs on premises of the following breeds (including mixed breeds? Akita, Chow Chow, Doberman, Pitbull (Staffordshire Terrier), Presa Canario, or Rottweiler)?(Required)

Do any dogs on the listed premises have a history of aggression or biting?(Required)

Are there any horses on premises?(Required)

Number of Horses:(Required)

Are there any other domestic, farm, or exotic animals on premises>(Required)

Type and number of other domestic, farm, and exotic animals:(Required)

Underwriting Questions

1. Any residence employees at any listed property?(Required)

Please provide the number and type of full and part time employees.(Required)

2. Any flooding, brush, forest fire hazard, landslide, etc. for any listed property?(Required)

Please provide a description of the hazard(s).(Required)

3. Any other residence owned, occupied, or rented that are not insured with Mutual of Enumclaw?(Required)

Please provide description.(Required)

4. Any other insurance with this company?(Required)

Please provide a list of policy numbers.(Required)

5. Any coverage declined, cancelled, or nonrenewed in the last 3 years?(Required)

Please provide an explanation.(Required)

6. Are any of the listed properties located within two miles of tidal water?(Required)

Please provide an explanation.(Required)

7. During the last 5 years, has any household member been convicted of any degree of the crime of arson?(Required)

Please provide an explanation.(Required)

8. Is any building on any of the listed properties undergoing renovation or reconstruction?(Required)

Please provide the estimated completion date and dollar value.(Required)

9. Are any of the listed properties currently for sale?(Required)

Please provide an explanation.(Required)

10. Are any of the listed properties within 300 ft of a commercial non-residential property?(Required)

Please provide an explanation.(Required)

Umbrella Questions

Mutual of Enumclaw Auto Policy#:(Required)

Mutual of Enumclaw Home Policy#:(Required)

Has any operator had an at-fault accident or been convicted of any traffic violation during the last 3 years?(Required)

Are there any household members between the ages of 15 and 21 (rated or not rated)?(Required)

Liability Limit:(Required)

Underwriting Questions

1. Any prior liability losses?(Required)

Please describe.(Required)

2. Any pending litigation, court proceedings or judgments?(Required)

Please describe.(Required)

3. Any aircraft, owned, leased, chartered or furnished for regular use?(Required)

Please describe.(Required)

4. Any real estate, vehicles, watercraft, aircraft, owned, hired, leased or regularly used, for business or personal purposes, not covered by primary policies?(Required)

Please describe.(Required)

5. Do you engage in any type of farming operation?(Required)

Please describe the operation, acreage, crop type, gross income and animal exposures.

6. Do you hold any non-compensated board or volunteer positions?(Required)

Please describe.(Required)

7. Any full-time household employees?(Required)

Provide number of employees.(Required)

8. Any non-owned property exceeding $1,000 in value, in your care, custody, or control?(Required)

Please describe.

9. Any business and/or professional activities included in the primary policies?(Required)

Please indicate the occupation and whether any business is conducted on any owned residential premises.(Required)

10. Does any underlying policy have reduced limits of liability or eliminate coverage for specific exposures?(Required)

Please describe.(Required)

11. Any coverage declined, cancelled, or nonrenewed during the last 5 years?(Required)

Please explain.(Required)

12. Does any member of the household have an occupation as a professional entertainer, athlete, media personality, or an appointed or elected political figure?(Required)

Please describe.(Required)

13. Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes?(Required)

Please describe.(Required)

14. Any owned motor or recreational vehicles not insured with Mutual of Enumclaw?(Required)

Please list company insured with and garaging state.(Required)

15. Are any properties or vehicles titled to a LLC, Corporation or trust?(Required)

Please explain.(Required)

16. Any portion of any property or vehicle rented on a daily, weekly or monthly basis?(Required)

Please explain.(Required)

17. Any operators convicted of any traffic violations during the last 3 years?(Required)

Please provide the operator name, date and description of violation.(Required)

18. Has any operator had an accident, regardless of fault, during the last 3 years?(Required)

Please provide operator name, date and description of accident.(Required)

19. Any operator have physical or mental impairments?(Required)

Please provide operator name and description of impairment.(Required)

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Admin Use Only

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Form Category

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Form Name

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Agency Name

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AMS ID

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CRM ID

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Internal Use

Yes

Mutual of Enumclaw Underwriting Questionnaire

Home Additional Questions

Underwriting Questions

Auto Questionnaire

Landlord / Dwelling Fire Questions

Underwriting Questions

Umbrella Questions

Underwriting Questions

Admin Use Only

Mutual of Enumclaw
Underwriting Questionnaire