Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
Residential Application for Earthquake or DIC
Named Insured
Mailing Address
Street
City, State
Zip Code
Street
City, State
Zip Code
Location Address
Three Product Options: see descriptions below on page 4.
1. Earthquake Only
2. DIC with EQ & Flood
3. DIC with EQ, Flood & Landslide
Flood Zone __________
Flood Zone __________
Zones A & V Excluded
Zones A & V Excluded
Landslide Supplemental Required
Year Built ______________
Home Square Footage ______________
Number of Family Units ______________
Foundation ______________
Select:
 Basement
 Crawl space with closed concrete perimeter
 Crawl space with wooden perimeter
 Post and Pier
 Slab
 Stilts
If there is a Basement:
Basement Square Footage Finished ______________
Basement Square Footage Un-Finished ______________
Is This a Daylight Basement
Yes
No
Number of Levels ______________
(Includes Basement or Garages)
Unit Type ______________
Select:
 Single Family Home - Residential
 Condominium
 Townhouse - End Unit
 Townhouse - Center Unit
Construction ______________
Select:
 Adobe
 Log
 Masonry
 Metal/Steel
 Frame
12/09
Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]





Mobile Home
Modular Home
Pre-fabricated Home
Wood Frame
Other
Garage Type ______________
Select:
 Attached
 Basement
 Built In
 Carport
 Detached
 None
 Subterranean
 Tuck Under Parking
Garage Size ______________
Owner Occupied
Tenant Occupied
On firm, natural ground?
YES
NO (Explain: ________________________________)
Degree of Slope ______________
 Flat 0°
 Minimal 1-15°
 Gentle 16-20°
 Moderate 21-30°
 Steep 31-45°
 Very Steep >45°
Earthquake Retrofitting ____________________________
Loss History or other risk detail ____________________________________________________
Deductible Option:
Limits Requested
Dwelling
Other Structures
Contents
Loss of Use
2%
5%
10%
15%
25%
$ ________________________________(100% Replacement Value)
$ ________________________________(100% Replacement Value)
$ ________________________________(100% Replacement Value)
$ ________________________________(40% of Dwelling Max.)
Ordinance or Law:
Check for Coverage A – Coverage for Loss to the Undamaged Portion of the Building.
Specify Limit for Coverage B and/or C:
$
Limit of Insurance for Coverage B (Demolition Cost Coverage)
$
Limit of Insurance for Coverage C (Increased Cost of Construction)
$
Blanket Limit of Insurance for Coverage B and C
12/09
Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
Continued on next page…
12/09
Orange Insurance LLC
206.774.7867 [ Office ]
877.288.6103 [ Toll Free ]
206.774.2076 [ Fax ]
ron@insuredbyorange.com [ Email ]
www.insuredbyorange.com [ Web ]
Coverage cannot be back dated prior to the date we receive written notice to bind. Coverage is subject to
25% minimum earned premium. Your agency is responsible for that 25%, plus the broker fee, if the
premium is not collected from the insured. Terms are Net 20 days from invoice date.
Product Options:
1. Earthquake Only
2. DIC including Earthquake & Flood
3. DIC including Earthquake & Flood & Landslide
1.
Earthquake coverage includes Earthquake Shock, meaning physical damage caused by
Earth Movement including Landslide, Mudflow, Earth Sinking, Earth Rising or Shifting,
only as a direct and immediate result of Earthquake. Includes coverage for Earthquake
Sprinkler Leakage (EQSL). Includes coverage for Volcanic Eruption, meaning eruption,
explosion or effusion of a volcano.
2.
DIC including Earthquake & Flood includes above Earthquake perils. Coverage includes
Flood except in Special Flood Hazard Zones A or V. Coverage includes All Other Perils
(AOP) not excluded. Perils excluded include standard fire policy perils (DP1 or Basic
Perils) and theft to personal property in the open or not contained in a building. Perils
excluded include a Landslide Exclusion Clause limiting coverage for Landslide,
Mudslide or Mudflow only as a direct result of Earthquake, Volcanic Action or Flood.
3.
DIC including Earthquake & Flood & Landslide covers the same as above but does not
contain a Landslide Exclusion Clause. The root cause of Landslide, Mudslide or
Mudflow does not have to be Earthquake, Volcanic Action or Flood.
A Landslide Supplemental Application is required for this product.
DIC excludes Flood in Special Flood Hazard Zones A and V. Ask us about
Excess Flood over NFIP.
The product descriptions are intended only to be a general description of coverage.
Specific coverages, conditions and exclusions are given only in the policy contract
itself.
For Official Agency Use:
Agency & Individual Contact: Orange Insurance, LLC c/o Ron Sievers
Phone #: 206.774.7867
Fax #: 206.774.2076
Email: ron@insuredbyorange.com
Need by Date:
12/09