FRE-024 Burglary Rider - 2 Applicants | Independent Mutual Fire Insurance Company

Policy Number

Effective Date

Amount Collected

Phone Number

Agency Number

District Number

Account Number

Named Insured Primary First Name

Named Insured Primary Middle Iniitial

Named Insured Primary Last Name

Named Insured Secondary First Name

Named Insured Secondary Middle Initial

Named Insured Secondary Last Name

Named Insured Primary SSN

Named Insured Secondary SSN

Street Address

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Residence Code

Limit of Liability

Monthly Premium

Loss by burglary means (I) the unlawful taking and removing your Household Goods from within your residence or private garage (but no other out buildings) used solely in connection with the occupancy of the residence, without your consent and with the intent to deprive you of its value and (ii) with entry into such residence or private garage being made by the visible breakage of a window or window lock, door or door lock, wall or roof. The mere cutting of a window or door screen, or the opening of an unsecured or unlocked window or door, does not constitute visible breakage into a structure: and the burglary of Household Goods from a structure gained through such an entry is not covered or insured under this policy. This definition of the term “Burglary” may not, and is not intended to, conform to the definitions of such term under any criminal statue or ordinance. We will not be liable for any loss due to Burglary unless the burglary is reported to local law enforcement within 24 hours of discovery of the burglary. We will not be liable for any loss due to Burglary unless supported by (1) Proof satisfactory to us (receipt or bill) showing the date of purchase and (2) Proof of ownership at the time of claim. Upon submission of the law enforcement agency report and a Proof Of Loss and Inventory Of Stolen Household Goods, the claim for loss will be adjusted and determined under all applicable terms and provisions of this Rider Endorsement and the Policy to which it is attached.

a) Actual Cash Value means the replacement of Household Goods at the time of loss, less depreciation for age, usage and obsolescence. b) “Property Insured Under The Policy” means the household goods described under the definitions of Personal Property Coverage in the Policy, except for losses excluded in paragraph 4 of this Rider Endorsement.

a) Actual Cash Value means the replacement of Household Goods at the time of loss, less depreciation for age, usage and obsolescence. a. Our maximum liability for loss due to Burglary shall not exceed the amount of Burglary insurance inforce under this Rider Endorsement, nor more than it would cost at the time of loss to replace the stolen property with other like kind and quality, nor the actual cash value thereof at the time of loss. b. Special Limits of Liability: This peril does not include loss caused by Burglary: 1. Committed by the Insured, or a member of your family residing with you: or 2. Property of roomers, boarders, tenants and others who are not a named insured or minor dependent children of the named insured: or 3. From a dwelling under construction or of materials and supplies for use in construction until the dwelling is completed and occupied: or 4. Of business equipment c. The limit of liability for each of the following categories is the limit for each occurrence for all items listed in that category. In no event, will we pay for the same item or category of items listed under more than one category. Our maximum liability for loss for all such items in each category will not exceed the amount indicated.

Limit Of Liability	Sporting Goods	Jewelry	Photographic and Computer Equipment	Clothing	Audio and Visual Equipment
$3,000.00	$500.00	$250.00	$500.00	$500.00	$1,000.00
$4,000.00	$500.00	$250.00	$500.00	$500.00	$1,200.00
$5,000.00	$500.00	$250.00	$500.00	$500.00	$1,500.00
$6,000.00	$600.00	$300.00	$600.00	$600.00	$1,800.00
$7,000.00	$700.00	$350.00	$700.00	$700.00	$2,100.00
$8,000.00	$800.00	$400.00	$800.00	$800.00	$2,400.00
$9,000.00	$900.00	$450.00	$900.00	$900.00	$2,700.00
$10,000.00	$1,000.00	$500.00	$1,000.00	$1,000.00	$3,000.00
	All Sporting Goods and equipment including but not limited to: Firearms, Ammunition, Golf Equipment, Fishing Equipment, Pool Cues, Sports Card Collections	All Jewelry including but not limited to: Watches, Precious and semi-precious stones, Antiques, China, Fine Arts, silver, silverware, gold, goldware, precious metals	Photographic equipment including but not limited to: Video Cameras, Digital Cameras and Cam-Corders, Computer Equipment, iPads, Tablets, Printers, Scanners, Satellite Accessory Equipment, Musical Instruments, Video Game Consoles, Controllers, Games and Game Cartridges	Clothing and apparel including but not limited to: Furs, Outerwear, Footwear, Headwear, Handbags, Accessories	Including but not limited to: Radios, Audio/Stereo Equipment, Televisions, VCR’s, DVD Players and Recorders, Records, Tapes, Cassettes, CD’s and DVD’s, Video Cassettes and Laser Disks

I have reviewed the above limitations Insured

This Rider Endorsement shall not apply: a) if on the date of loss the policy to which this endorsement is attached is not in full force and effect; or b) to loss due to mysterious disappearance, mislaying or losing of property; or c) to loss sustained by a person other than you, the named Insured, your spouse or your minor dependent children who reside with you; or d) to loss by Burglary or attempt thereof, away from the Insured Address: or e) to loss of (1) tools, tools of the trade, (2) articles held for sale, or for delivery, (3) money, coins, stamps, and securities, (4) food, beverages, and alcoholic beverages, (5) citizen band, short wave and radio equipment, (6) yard or lawn equipment, (7) motorized and non-motorized vehicles and bikes, (8) items excluded under the Policy to which this Rider Endorsement is attached f) any personal property that is damaged or destroyed during the burglary, or personal property that is damaged due to an act of vandalism or malicious mischief.

Initial

Each claim for loss (separately occurring) caused by the Peril Burglary to property insured shall be adjusted separately, any limits to liability applied, and from the remaining amount, the sum of $200.00 shall be deducted.

Initial

Day Signed

Month Signed

Year Signed

Legal Consent(Required)

I agree to the terms and conditions.

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

State To File In

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Named Insured Primary Signature

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Named Insured Secondary Email(Required)

Named Insured Secondary Signature

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