Personal Catastrophe Survey 1. Do you own any dwellings and/or farms other than the primary residence, which are rented to others, maintained as seasonal residences, or vacant, and you have not previously notified us about? * Yes No 2. Are there any motorized vehicles (Private Passenger, Commercial Automobiles, or Recreational Motor Vehicles), which are owned, leased or regularly furnished to the applicant or spouse that are not covered by underlying policies? * Yes No If 'Yes', please list: 3. Has any member of the household ever had insurance in an automobile assigned risk program? Ex: High Risk Car Insurance * Yes No 4. Is any member of the household an excluded driver on an underlying auto policy? * Yes No 5. Has any driver or member of the household received a ticket for speeding or any other vehicle code violation within the last 5 years? * Yes No 6. Has any driver or member of the household, while driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the last 5 years? * Yes No 7. Has any member of the household had any license suspensions within the past 5 years? * Yes No 8. Does any member of the household participate in automobile, recreational vehicle or watercraft races, contests or exhibitions? * Yes No 9. Has any member of the household had any primary or excess liability insurance cancelled or denied within the past 5 years? * Yes No 10. Does any member of the household serve as an officer or member of the Board of Directors of a non-profit corporation or organization? * Yes No 11. Do you employ any domestic workers? * Yes No 12. Is there any incidental business exposure, example; Avon, Amway, Longenberger? * Yes No 13. Do you have any lawsuits currently pending? * Yes No 14. Do you have any aircraft exposure or watercraft exposure? * Yes No 15. Any members of the household newly licensed within the last year? * Yes No 16. Any unusual hazards, ex: pools, trampolines, lakes, and ponds? * Yes No 17. Do you require uninsured/underinsured motorist coverage under the personal catastrophe policy? * Yes No 18. Do you have any problems, questions or concerns? * Yes No Name: * Policy #: Phone #: * Email Address: * Date: * reCAPTCHA If you are human, leave this field blank.
