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«Important Notice Changes 12/2015 Please read below Please do not use the “Submit Form” button at the top of the application. If you submit the ...»

Submit Form

Important Notice Changes 12/2015 Please read below

Please do not use the “Submit Form” button at the top of the application.

If you submit the application using this button, your application will not

be received. The application should be filled out and saved in a location

that is easy to locate.

Once a Quick Quote has been filled out and you are ready to submit for

processing, you can attach the application and (2) photos to the quote. A

payment can be made once the Quick Quote has been successfully submitted referencing the Quick Quote number.

If you need further assistance with the Quick Quote, be sure to reference the Quick Quote Guide located in the GUA website according to product.

More Important Information 2016 We will no longer accept applications by mail, fax or e-mail.. These will be returned. Upload the application to the Instaquote.

Please include a current Cost Estimator/Valuation with all applications except Mobile Homes.

Other changes coming soon:

For property located in the 6 coastal counties of Bryan, Camden, Chatham, Glynn, Liberty and McIntosh a 2% Wind and Hail Deductible will now apply for all new business.

Note: If a new application is required this is considered new business.

For property that is eligible for replacement cost coverage, Homeowner/Dwelling Wind Hail, Commercial and Commercial Wind Hail, an Actual Cash Value Endorsement is now being used for older roofs (see appropriate application for age).



(Also includes important information and changes) Agent name, license number and signature are required. Insured signature is required (see page 4).

Coverage should be placed in voluntary market if eligible.

All lines of information and signatures on application must be completed to process application.

4. Occupancy: Provide if the dwelling is owner or tenant occupied.

5. Amount of Insurance Requested: Building and Contents coverage combined cannot exceed $2 million.

Maximum coverage for any complex or related set of buildings cannot exceed an aggregate of $20 million and $2 million per building. Coverage for Other Structures is 10% of Coverage A. You may request an amount greater than 10% for an additional premium. If so, a photo is required. Coverage for Other Structures is subject to Wind Hail provisions. Refer to DP GUA 300. Please include a current Cost Estimator/Valuation with all applications.

7. Construction: Select the box that corresponds to the type of construction.

9. # of families: (1-4) only.

10. Deductible: The following deductibles are available: 5%, 7.5% and 10%.

13. Replacement Cost: Optional. Replacement Cost coverage for Building, Contents and Other Structures is an additional 20% of the EC premium on each.

For roofs 15 years old and older we will add the Actual Cash Value Loss Settlement Windstorm or Hail Losses to Roof Surfacing Endorsement DP GUA 04 75.

14. Primary Coverage: GUA offers to be the Primary carrier when coverage is needed. This coverage is only eligible for property valued at $2,000,000 or less. If the property is valued at more than $2,000,000 then we will offer coverage on a contributing basis. Claims will be adjusted based on the pro rata share. EX: 2M ÷ 10M =.20 GUA would pay 20% of the total claim less our deductible.

15. Loss of Use: Optional. Loss of Use Coverage is available for an additional premium. To request coverage, check the box which corresponds to the appropriate Dwelling Limits.

18. Mortgagee: For each Mortgagee, provide the Name, Address and Loan Number. If needed, attach a separate page for additional mortgagees.

19. The building must be built in accordance with the International Building Code.

20. Loss History: If there are no claims, enter “NONE”. Provide details for all claims including cause and origin, amounts paid, dates and repairs made. Attach a separate page if needed.

Hurricane Underwriting Restrictions: No request for increased coverage or new application shall be accepted at any time or period of time during which there exists any portion of a hurricane designated by the U.S. National Weather Service, National Hurricane Center or any successor thereto within the boundaries of 70 degrees west longitude and 20 degrees north latitude until the expiration of 24 hours after such hurricane warning has been lifted.

Coverage begins at 12:01 a.m. the day after payment is received by this Association. For New business written on or after 9/1/2013, a Policy/Inspection Fee of $50.00 applies. This fee is due with your first payment. Payments should be made payable to Georgia Underwriting Association. A $25 fee will be imposed for any check that is returned due to non-sufficient funds.

–  –  –

(Attach a separate page to list additional Mortgagees)


19. If building was built within the past 10 years, include a copy of the Certificate of Occupancy or letter from a local building inspector, contractor, architect or engineer that states the structure is built in accordance with the International Building Code, including the wind-design requirement therein.

–  –  –

22. Other Comments:

DWH (12 15) Page 2 of 4


This request is made with the understanding that an inspection may be made of this property. I (we) understand that this request in no way binds any company to afford insurance on the described property. Inspection(s) made under this program and any report of the inspection(s) is for fire and extended coverage insurance underwriting purposes. Regardless of whether a policy is issued, neither the insurer, the Georgia Underwriting Association, the Insurance Services Office, nor any company represented thereby, will be liable for any injury or damage claimed to arise from the inspection(s), the inspection report(s) of the physical condition of the premises, omissions from such inspection(s) or report(s), or from compliance or non-compliance by the property owner or others with the recommendations, if any, contained in said inspection report(s). Nothing contained in or omitted from said inspection report(s) shall be construed to infer or imply that the hazardous physical conditions, if any, so noted or omitted, constitute all such conditions existing on the property at the time of said inspection(s). Permission is granted to submit copies of any inspection of action report(s) to the Georgia Insurance Department, the Georgia Underwriting Association, Insurance Services Office, insurers and my (our) agent(s) or representative(s).

I (we) understand that if coverage is accepted by the Georgia Underwriting Association, the policy will become effective at 12:01 A.M.

the day after the Georgia Underwriting Association has received payment of the full premium. I (we) further understand that any Agent or Broker that has assisted me (us) in procuring this insurance is not an Agent of the Georgia Underwriting Association, and all actions taken by such Agent or Broker, including the submitting of this application, collecting of premiums, and delivering of policies, are taken solely on my (our) behalf.

By signing this application I (we) certify that I (we) have an insurable interest in the property and that all statements contained herein are, to the best of my (our) knowledge, true. I (we) certify that I (we) have made a reasonable effort to obtain insurance and have been unable to obtain it elsewhere. Any willful concealment of misrepresentation of a material fact or circumstances heron may void any policy issued.


In accordance with the Federal Fair Credit Reporting Act (Public Law 91-508), this notice is to inform you that as part of our procedure for processing your Application for Insurance, an investigative report may be made whereby information is obtained through personal interviews with third parties, such as family members, business associates, financial sources, friends, neighbors or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics and mode of living whichever may be applicable. Further information on the nature and scope of such inquiry, if one is made, is available to you upon written request.

–  –  –

You have the right to know what kind of information we maintain on our files about you and may have access to that information.

You have the right to receive a copy of all personal information we keep on you and if necessary the right to request the correction, amendment or deletion of incorrect information. No information will be disclosed about you without your consent unless the disclosure is necessary for us to conduct our business.

Upon receipt of your request, we will furnish you with a more detailed notice of our information practices


For New business written on or after 9/1/2013, a Policy/Inspection Fee of $50.00 applies. This fee is due with your first payment. Quote, completed Application (including signature of Agent and Applicant), payment, color photos of front and back of risk, Appraisal, copy of MSB Valuation Report (if available), copy of previous insurance policy and copy of cancellation or non-renewal notice. A $25 fee will be imposed on checks returned for Non-Sufficient Funds.

Check should be made payable to GEORGIA UNDERWRITING ASSOCIATION

–  –  –

Applicant: Before signing below see “Certification of Applicant for Insurance”, “Fair Credit Reporting Act” on page 3 and “Notification of Information Practices” on page 4.

Now accepting electronic signature with last four digits of the social security number.

–  –  –

Title if applicant is corporation or firm Title if applicant is in the name of Estate: Executor, Administrator, or Power of Attorney and attach proper court documentation, Letter of Testamentary, POA etc.


–  –  –

DWH (12 15) Page 4 of 4

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