Fulmont Mutual Insurance Company   PO Box 487   Johnstown   NY  12095-0487      Ed. 01/08/2010 

 LANDLORDS UNDERWRITING AND LOSS HISTORY SUPPLEMENTAL

**Please submit this completed form with all Landlord Applications as well as photo of dwelling and all outbuildings** 

                            LOSS HISTORY & PREVIOUS INSURANCE

1. Any previous losses, whether or not paid by insurance during the last 5 years, on this risk or any other previously owned building of the insured? If yes, please complete the following:

Date: _______________

Type: ____________________________________________________

Description of loss: __________________________________________________________________

__________________________________________________________________________________

Amount: $_______________

       2.    If loss has occurred, has damage been repaired?          Yes     No

3. Name previous insurance Company: _________________________ Policy expiration date: _________
4. Has any company cancelled, non-renewed or refused insurance (including non-payment of premium) for this applicant?

           Yes    No  If yes, why? _________________________________________________________________________ 

UNDERWRITING INFORMATION

General Information:

Does this property have a local caretaker?   Yes    No 

If yes, please provide name and number: ________________________________________          How long has applicant owned this risk? _________________ years

If less than 3 years, provide:  Purchase price $______________, & Cost of improvements $________________

If more than 3 years, provide: Market Value $______________, & Replacement Cost $____________________

Is this property currently rented?    Yes    No

If no, advise anticipated date of occupancy ______________. Is there a signed lease?     Yes    No

Are any tenants college students?    Yes    No  **IF YES, DOES NOT QUALIFY

Is this a seasonal rental property?    Yes    No  **IF YES, DOES NOT QUALIFY

Are there any other structures on premises considered to be related private structures (garages, sheds, etc.)?   If yes, describe: ____________________________________________________________________________

Are there any farm style buildings on premises (farm barns, silo, etc.)?    Yes    No           If yes, describe: ____________________________________________________________________________

Utilities:

Type of central heat system:   Hot Air Furnace/Fuel Type? _____________  Hot Water Boiler

 Electric Baseboard    Other, please specify: __________________________  Year updated: __________

Any of the following:  Woodstove  Yes    No         Pellet Stove   Yes    No   

                                    Freestanding Space Heaters   Yes    No  **IF YES, DOES NOT QUALIFY

Does dwelling have working smoke detectors and carbon monoxide detectors in each apartment?  Yes  No

Does dwelling contain circuit breakers at main service panel?    Yes    No             Year updated _________

Are there any fuses or knob and tube wiring?    Yes    No  **IF YES, DOES NOT QUALIFY 

Has roof been replaced in last 20 years?    Yes    No  Age of Roof?_________

What is roof type?  Asphalt Shingle   Metal    Slate   Other   Specify_____________________________________

Liability Questions:

Any business conducted on premises (in dwelling or outbuilding)?    Yes    No

If yes, describe: _________________________________________________________________________________________

Any of the following:  Swimming Pool   Pond    Other water frontage   Dock    None  **IF YES, DOES NOT QUALIFY

Any dogs on premises?   Yes    No

If yes, give breed_______________________  Any bite history?   Yes    No

Any other animals owned or kept on property?    Yes    No

If yes, explain: __________________________________________________________________________________________

Are all stairways equipped with handrails?    Yes    No   Any uncovered stairs or deck?    Yes    No

Is yard free of debris and unregistered motor vehicles?    Yes    No

If no, explain ___________________________________________________________________________________________

Is there a second means of egress from each apartment?    Yes    No