Application for Enrollment

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1. Name(s) and email addresses of all owners of the home that is the subject of this Application

Owner name 1:

Email address 1:

Owner name 2 (Optional):

Email address 2 (Optional):

Owner name 3 (Optional):

Email address 3 (Optional):

Owner name 4 (Optional):

Email address 4 (Optional):

Owner name 5 (Optional):

Email address 5 (Optional):

2. Contact Information

Owner who will be primary point of contact:

Phone number:

3. Address of the subject home

Street:

City/town:

State:

ZIP code:

4. If available, information regarding one or more Travelers Policies that insured the subject home and were in effect on or before December 6, 2018

Policy #1 (Optional):

Policy #2 (Optional):

Named insured 1 (Optional):

Named insured 2 (Optional):

Named insured 3 (Optional):

5. Have you enrolled in the Connecticut Foundations Solutions Indemnity Company program? Yes No

6. Have you received a CFSIC enrollment approval letter? Yes No

7. Have you authorized CFSIC to provide the CFSIC approval letter and the other CFSIC documentation required by the Travelers Benefit Program to Travelers? Yes No

8. If the home is not currently insured under a policy issued by Travelers, what company is the current insurer?

Company Name (Optional):

Pressing the SUBMIT button below constitutes certification that all owners of the home are listed above, all have agreed to submission of this application on their behalf and all have agreed that the provided information is true and accurate.

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