Insurance Application Cea Form – Fill Out and Use This PDF

CALI FORNI A EARTHQUAKE AUTHORI TY

EARTHQUAKE I NSURANCE APPLI CATI ON I NSTRUCTI ONS

POLI CY EFFECTI VE DATE AND EXPI RATI ON DATE

Provide CEA policy effective date and expiration date. Expiration dat e must be the same as the expiration date of the companion policy.

APPLI CANT

Complete all requested information for applicant(s) including:

Name(s)

Telephone number(s)

Street address of physical location of insured propert y

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

COMPANI ON POLI CY I NFORMATI ON

Complete all requested information for companion policy including:

Name of Participating I nsurer

Policy number of companion policy

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

Expiration dat e of companion policy

Type of companion policy

POLI CY TYPE – RATI NG AND COVERAGE I NFORMATI ON

I dentify CEA policy t ype based on the t ype of companion policy as follows:

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

O M an u f act u r ed Ho m e ( M o b ileh o m e) (Written on CEA Homeowner Policy form; however, requires unique rating information.)

Condominium ( i.e. Common I nterest Development) ( Companion policy must be a Condominium Unit Owners HO-6 or equivalent policy.)

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

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

PAYMENT OPTI ONS

Select payment option:

Annual; or I nstallment s

SEND BI LL TO

Select who should receive the bill:

I nsured; or

Mortgagee

ADDI TI ONAL I NTERESTS

Complete information requested for each additional interest, including:

Type:

OMortgagee;

OAdditional insured; or

OLoss payee

Name and address

Loan number (if applicable)

REMARKS

I nclude any additional remarks as needed.

SI GNATURE

Secure the applicant’s signature on the applicat ion, the date, and time the application is complet ed. Provide the producer’s name, address and license number.

CEA Earthquake Insurance Application Instructions 01/2012 Revision