California Earthquake Authority Form PDF Details

When residents in California consider the protection of their homes against the unpredictable wrath of nature, particularly earthquakes, the California Earthquake Authority (CEA) form stands out as a pivotal document. This meticulously crafted application outlines a comprehensive range of details, beginning from the basic yet vital information such as the applicant's name, contact numbers, and the physical and mailing addresses of the insured property. It further delves into the specifics of the companion policy information, including the type and number of the policy and crucial details about the dwelling itself—ranging from the year it was built to the type of construction, the number of stories, and even specific earthquake preparedness measures like whether the dwelling is secured to its foundation. The form also presents various coverage options, deductibles, and limits for personal property, loss of use, and, if applicable, loss assessment and building code upgrade coverages, tailoring the insurance to meet individual needs. Payment options and instructions on how to designate additional interests such as mortgagees or loss payees are outlined, ensuring clarity and ease in the application process. This application not just signifies a step towards financial protection but also embodies a detailed record, meticulously aligning with both individual requirements and regulatory standards, showcasing the intricate interplay between policyholder information, property specifics, and coverage preferences—all aimed at fortifying Californians against the seismic uncertainties that lie ahead.

QuestionAnswer
Form NameCalifornia Earthquake Authority Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesunrepaired, Mobilehome, CEA, HO-6

Form Preview Example

Revised—Attachment A

 

Earthquake Insurance Application

Effective Date

 

Expiration Date

 

Applicant Information

 

 

 

 

 

 

 

 

Applicant

 

 

 

 

Telephone Numbers

 

 

 

Last Name

First Name

 

Middle I nitial

Home

 

Work

 

Co-Applicant (if applicable)

 

 

 

 

Telephone Numbers

 

 

 

Last Name

First Name

 

Middle I nitial

Home

 

Work

 

Street Address of Physical Location of I nsured Property

 

 

Mailing Address (if different)

 

 

 

 

Number and Street Address

 

 

Unit

Number and Street Address

 

 

 

Unit

City

State

ZI P Code

County

City

 

State

ZI P Code

Country

 

 

 

 

 

 

 

 

 

Companion Policy Information

 

 

 

 

 

 

 

 

Participating I nsurer

Companion Policy Number

 

Dwelling — Coverage A Limit

 

Expiration Date (must be same as CEA policy)

Type of Policy

 

 

 

 

 

 

 

 

Homeowner

Mobilehome / Manufactured Home

Condominium

 

 

Renters

 

Dwelling Fire

Other (explain in remarks)

 

 

 

 

 

 

Homeowner / Dwelling Fire

Mobilehome / Manufactured Home

CondominiumRenters

Rating Territory

Year Built

Number of Stories,

I ncluding Basement

Construction Type

 

Frame

Other

 

 

 

Number of Chimneys

 

 

 

 

 

 

Square Footage

 

 

 

 

 

 

 

Foundation Type

Raised

Slab

Other

 

 

 

Roof Type

Composition

Tile

 

Wood Shake

Other

 

 

 

Property I nspected?

Yes

No

Date

 

 

 

 

 

 

I s there unrepaired prior

Yes

No

earthquake damage to

 

 

the dwelling?

 

 

 

I f yes, DO NOT BI ND and explain in Remarks

 

 

 

 

Dwelling secured to

 

Yes

No

foundation?

 

 

 

 

 

 

 

Cripple walls braced with

Yes

No

plywood or equivalent?

 

 

 

 

 

Water heater secured to

Yes

No

building frame?

 

 

 

 

Dwelling — Coverage A

 

Dwelling Limit

$

 

 

 

 

 

Rating Territory

Construction Type

Mobile or Manufactured

 

 

 

Property I nspected?

Yes

No

Date

 

 

 

 

 

 

I s there unrepaired prior

Yes

No

earthquake damage to

 

 

the dwelling?

 

 

 

I f yes, DO NOT BI ND and explain in Remarks

 

 

 

Is the home reinforced by

Yes

No

an earthquake resistant

 

 

bracing system certified by

 

 

the California Department

 

 

of Housing and Community

 

 

Development?

 

 

 

I f yes, attach a copy of the certification

Dwelling — Coverage A

 

Dwelling Limit

$

 

 

 

 

 

Same as Companion Policy

 

 

Deductible

15%

 

10%

Personal Property — Coverage C

$5,000

$25,000

 

$50,000

$75,000

$100,000

 

 

No deductible for this coverage if Coverage A deductible is met. No coverage if Coverage A deductible is not met

Loss of Use — Coverage D

$1,500

$10,000

$15,000

 

No deductible for this coverage

 

Rating Territory

Number of Stories in building

Choose any combination of one or more

of the following options

Option One

Building Property — Coverage A

Real Property — $25,000

There is a $3,750 deductible for this coverage

Option Two

Personal Property — Coverage C

$5,000

$25,000

$50,000

$75,000

$100,000

 

There is a $750 deductible for this coverage

«AND »

Loss of Use — Coverage D

$1,500

$10,000

$15,000

No deductible for this coverage

Option Three

Loss Assessment — Coverage E

$25,000

$3,750 deductible

Only available if value of property is $135,000 or less

$50,000

$7,500 deductible

$75,000

$11,250 deductible

Rating Territory

Personal Property — Coverage C

$5,000

$25,000

$50,000

$75,000

$100,000

 

There is a $750 deductible for this coverage

Loss of Use — Coverage D

$1,500

$10,000

$15,000

 

No deductible for this coverage

 

Remarks

Same as Companion Policy

 

Deductible

15%

10%

Personal Property — Coverage C

$5,000

$25,000

$50,000

$75,000

$100,000

 

No deductible for this coverage if Coverage A deductible is met. No coverage if Coverage A deductible is not met

Loss of Use — Coverage D

$1,500

$10,000

$15,000

No deductible for this coverage

Additional Limited Building Code Upgrade

— optional —

I ncrease Limited Building Code Upgrade coverage from $10,000 to a total limit of $20,000

No deductible for this coverage if Coverage A deductible is met. No coverage if Coverage A deductible is not met

Premium Calculation

 

 

 

Payment Options

Base Premium

Increased Limits Premium

Hazard Reduction Discount

Total Premium

Annual

 

 

 

 

+

 

−

=

I nstallments

 

 

 

 

 

 

Homeowner and Mobilehome only

 

 

 

 

- if qualifications are met

 

 

Additional Interests

 

 

Send Bill To

 

Name

Loan Number

 

 

Mortgagee

 

 

 

I nsured

 

 

 

 

 

Additional I nsured

Address

 

 

Mortgagee

 

 

 

Loss Payee

 

 

 

 

City

State

ZI P Code

 

 

Name

Loan Number

 

 

2nd Mortgagee

 

 

 

I nsured

 

 

 

 

 

Additional I nsured Address

 

 

Mortgagee

Loss Payee

 

 

 

 

City

State

ZI P Code

 

I am applying for the insurance indicated, and the information on this application is correct

X

Applicant Signature

Producer Name and Address

Application Date and Time

Earthquake Application 05-09

Attachment A – Page 2

CALIFORNIA EARTHQUAKE AUTHORITY

EARTHQUAKE INSURANCE APPLICATION – 05/09 Edition

INSTRUCTIONS

POLICY EFFECTIVE DATE AND EXPIRATION DATE

Provide CEA policy effective date and expiration date. Expiration date MUST be the same as the expiration date of the companion policy.

APPLICANT

Complete all requested information for applicant(s) including: Name(s)

Telephone number(s)

Street address of physical location of insured property

Mailing address (if different from street address of property’s physical location)

COMPANION POLICY INFORMATION

Complete all requested information for companion policy including: Name of Participating Insurer

Policy number of companion policy

Dwelling limit (i.e., Coverage A) of companion policy (if companion policy has dwelling limit) Expiration date of companion policy

Type of companion policy

POLICY TYPE –RATING AND COVERAGE INFORMATION Identify CEA policy type based on the type of companion policy as follows:

•Homeowner (Companion policy must be either a Homeowners (HO-1, 2, 3, 5, or 8), Dwelling Fire (building), Landlord (building), or Mobilehome policy.)

O MOBILEHOME/MANUFACTURED HOME (Written on CEA Homeowner Policy form; however, requires unique rating information.)

Condominium (i.e. Common Interest Development) (Companion policy must be a Condominium Unit Owners (HO-6) policy.)

Renters (Companion policy must be a Renters (HO-4) , Mobilehome (tenant policy), Dwelling Fire (contents only), or Landlord (contents only) policy.)

Complete all information requested under the applicable CEA policy type. Answer all questions and select desired CEA policy limits and coverage options.

PREMIUM CALCULATION

Provide premium calculations.

PAYMENT OPTIONS

Select payment option:

Annual; or

Installments

SEND BILL TO

Select who should receive the bill:

Insured; or

Mortgagee

ADDITIONAL INTERESTS

Complete information requested for each additional interest, including:

Type:

OMortgagee;

OAdditional insured; or

OLoss payee

Name and address

Loan number (if applicable)

REMARKS

Include any additional remarks as needed.

SIGNATURE

Secure the applicant’s signature on the application.

Provide the producer’s name and address.

Provide the date and time the application is completed.

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2. Soon after this section is filled out, go on to enter the suitable details in these: I f yes attach a copy of the, AND , Property I nspected, Yes, Date, I s there unrepaired prior, Yes, I f yes DO NOT BI ND and explain, Dwelling secured to foundation, Yes, Cripple walls braced with plywood, Yes, Dwelling Coverage A, Loss of Use Coverage D, and Dwelling Limit.

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