Chubb Kraft Lake High Value Home Quote Request Form

You must be a Kraft Lake agent to Request a Quote. Please include your agency name and producer number prior to submission for a quote to be processed. If this information is not included or is not valid, the quote will not be processed.

Kraft Lake Program Guidelines:
• Primary dwelling value $1,000,000 or greater for risks outside of California. Risks with loss history may not be acceptable and are subject to underwriting approval to quote.

  * Means field required to obtain a quote
Agency Contact Name:  
*Farmers Producer Number:     *Chubb Producer Number (if known):  
*Producer Phone Number:     *Producer e-mail:  
*Customer Name:  
*DOB (mm/dd/yyyy):  
*Client Phone# (Home):     (Work)#: 
*Occupation:  
*Job Title:  
*Employer Name:  
*Employer Address:  
If Retired List Prior Occupation:  
   
Spouse’s Name:  
Spouse’s DOB (mm/dd/yyyy):  
Spouse’s Occupation:  
Spouse’s Job Title:  
Spouse’s Employer Name:  
Spouse’s Employer Address:  
If Retired List Prior Occupation:  
   
*Is this a new purchase?          Yes        No 
*Present Carrier:  
Expiration Date (mm/dd/yyyy):  
*Has policy been non-renewed?          Yes        No 
If Yes, Why?  



HOMEOWNERS QUOTE SHEET

You must be a Kraft Lake agent to Request a Quote. Please include your agency name and producer number prior to submission for a quote to be processed. If this information is not included or is not valid, the quote will not be processed.

Kraft Lake Program Guidelines:
• Primary dwelling value: $3,000,000 or greater. Risks with loss history may not be acceptable and are subject to underwriting approval to quote
• Primary dwelling values below $2,000,000 will not be considered.
• Primary dwelling values between $2,000,000 and $3,000,000 will be considered with a Farmers declination. Please send declination to kraftlake@chubb.com after submitting the online homeowner application.

     Yes      No     
Type of Dwelling:       House       Townhouse      
*Risk-Address:

* Dwelling value must be above $2,000,000 to qualify.
Mailing Address (If different than Risk Location):
*Dwelling Limit/Additions and Alterations:          
*Is the home currently under Renovation or Construction?      Yes      No 
If yes, estimated complete date of construction:   
Special Note: Quote cannot be released until 30 days of estimated completion date.
*If NO, are there any plans for renovation or construction within the next twelve months?     Yes     No 
*Contents/Personal Property:   
*Liability:   * Deductibles:  
*Inservant:       Yes      No     (Hours worked 20 or more)
*Outservant:     Yes      No    (Hours worked 10 or more)
Texas Deductibles
Wind and Hail - Choose either a flat or % deductible option
Flat Deductible:   
Percent Deductible:   
All Other Perils - Choose either a flat or % deductible option
Flat Deductible:   

Percent Deductible:   
*Is this the Primary Residence:     Yes      No 
*Is this a Secondary Residence:     Yes      No 
* Secondary Residence cannot be written without a qualifying primary home.
If Yes to Secondary, is it Rented to Others:     Yes      No 
*Total Square Footage of Home:  
*Number of Stories:  
*Year Built (yyyy):  
California Homes
If home was built before 1945, has it been retrofitted?   Yes     No 
Please indicate year home was retrofitted (yyyy):
(If home not retrofitted, it is not eligible for the program).
Is earthquake coverage desired?   Yes     No 
Distance To Brush (California):  
*Construction Type:  
*Roof Type:   
*Roof Covering:   
*Foundation Type:   
Finished Basement:   Yes     No 
PROTECTION: Homes must be within 1,000 feet of a fire hydrant and within 5 miles of a fire station to qualify
*Within 5 Miles From Fire Department:   Yes          No 
*Within 1,000 Feet From Hydrant:   Yes          No 
Texas Protection Classes 1 - 10    
*Burglar Alarm: Central Station  Yes          No 
*Fire Alarm: Central Station:   Yes          No 
Sprinkler System:   Yes          No 
Monitored Water Flow Alarm:   Yes          No 
Gated Community:   Yes          No 
Guarded Community:   Yes          No 
Distance From Water:   Cross Street:  
Updates to Electrical/Plumbing:
  (If Yes, list Year)     
Yes          No 
MORTGAGE INFORMATION:
*Is there a mortgage?   Yes         No 
*Number of Mortgages listed on the policy:       
Mortgage Company Name and Address:
Homeowner Loss History:
*Have there been any homeowner losses within the last 5 years?          Yes          No 
Was it a CAT loss?          Yes          No 
If there are losses, please list the type of loss, date and amount paid:



VALUABLE ARTICLE QUOTE SHEET

Jewelry: # of Items:  Itemized Amt:  Blanket Amt: 
In-Vault: # of Items:  Itemized Amt:  Blanket Amt: 
Furs: # of Items:  Itemized Amt:  Blanket Amt: 
Fine Arts: # of Items:  Itemized Amt:  Blanket Amt: 
Collectibles: # of Items:  Itemized Amt:  Blanket Amt: 
Silverware: # of Items:  Itemized Amt:  Blanket Amt: 
Cameras: # of Items:  Itemized Amt:  Blanket Amt: 
Other-Misc: # of Items:  Itemized Amt:  Blanket Amt: 
In-Vault, please provide bank address below:
Valuable Article Loss History:
Have there been any valuable article losses within the last 5 years?        Yes          No 
If yes, please list valuable article loss information below:



EXCESS LIABILITY QUOTE SHEET

Excess Liability Limit:   
If applicable: Underlying Automobile Liability Limits:   
# OF RESIDENCES:
Residence #1
Residence #2
Residence #3
Residence #4
If more than 4 residences, list in comment section at end of form

AUTOMOBILE QUOTE SHEET

     Yes       No
Does client have a Corporate Car:     Yes           No 


DRIVERS
* Driver Name * Date of Birth * License# * Vehicle #
1  
2  
3  
4  
5 


VEHICLES
        * Year     * Make     * Model
1   
2  
3  
4  
5  
6  
7  
8  
9  
10


Accident, Violation, Loss History:
Have there been any accidents, violations or losses within the last 5 years?      Yes          No 
If yes, please list all accidents, violations or loss information below:
NUMBER OF WATERCRAFT:
YEAR MAKE MODEL LENGTH HP/SPEED
 
Watercraft Accident, Violation, Loss History:
Have there been any watercraft accidents, violations or losses within the last 5 years?     Yes        No 
If yes, please list below:
If more than 4 watercraft, list in comment section at end of form
Comments:
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