Personal Lines

Applicant Information

First Named Insured:

Secondary Named Insured:

Address:

City:

State:

NJ AK AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VT WA WI WV WY

Zip:

Telephone:

Marital Status:

First Named Insured's
Date of Birth:

Secondary Named Insured
Date of Birth:

First Named Insured
Occupation/Employer:

Secondary Named Insured
Occupation/Employer:

Number of years at current address:

Less than 1 2 3 4 5 or more

Prior address (If less than 3 years at current address):

Address:

City:

State:

NJ AK AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VT WA WI WV WY

Zip:

Dwelling Information

Year Built:

Date Moved In:

Construction Type:

Frame Masonry Frame with Siding Other

Roof Type:

Asphalt/Fiberglass Metal Slate Tile Other

Dwelling Type:

Primary Secondary

# of Families:

One Two

Miles to nearest fire department:

Within 5 Miles Not Within 5 Miles

Feet to nearest fire hydrant:

Within 1,000 feet Not Within 1,000 feet

Year Wiring was last updated:

Year Heating was last updated:

Year Plumbing was last updated:

Year Roof was last updated:

If condominium or apartment, how many units in same building:

Coverage Limits

Coverage A Dwelling:
(required for houses & condos)

Coverage B Other Structures: Automatically 10% of dwelling limit
If dwelling is a house Coverage C Contents: Automatically 70% of dwelling
limit.

Coverage C Contents (required for apartments and condos):

Coverage D Loss of Use: Automatically 20% of dwelling limit

Coverage E Personal Liability:

Coverage F Medical Payments:

All Perils deductible:

$250 $500 $1,000 $1,500 $2,500 $5,000

General Information

Is the roof on your house flat?

Yes No

Is there an underground oil tank on
the premises?

Yes No

Is the dwelling within 2,750 feet of
tidal water?

Yes No

Is the dwelling within 250 feet of a commercial property?

Yes No

If yes, please describe:

Is there a swimming pool with a high diving board or a pool without a locking fence on the premises?

Yes No

Are there any trampolines or treehouses on the premises?

Yes No

Are there any pets or animals on the premises?

Yes No

If yes, please describe:

Do you conduct any business on the premises?

Yes No

Do you operate a daycare out of your home?

Yes No

Have you had any home insurance claims within the past 5 years?

Yes No

If yes, please describe:

Do you currently have automobile insurance with NJ Skylands?

Yes No

If yes, please provide Skylands auto policy number:

Are you or your spouse a member of ABCO Federal Credit Union?

Yes No