Client Name

Address

Effective Date

Coverage A (Dwelling)

Coverage B (Other Structures)

Coverage C (Unscheduled Contents)

Coverage D (Loss of Use)

Coverage E (Personal Liability)

Premise Liability

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Scheduled Personal Property - Jewelry

Scheduled Personal Property - Silverware

Scheduled Personal Property - Fine Arts

Scheduled Personal Property - Cameras

Structures Rented to Others (HO-40)

Additional Structures (HO-48)

Special Personal Property (HO-15)

Personal Property Replacement Cost (HO-90)

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Permitted Incidental Occupancies (HO-42)

Personal Injury (HO-82)

Is there a Swimming Pool?

Permission to Rent

Additional Residence Rented (HO-70)

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Storm Shutters

Select Type

Fire Alarm

Burglar Alarm

Claims Free Discount

Claims Free Years

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Coverage Amounts

Additional Property Coverages