Claim Type 2 – Connecticut Foundation Solutions Indemnity Company, LLC

Claim Type 2: Reimbursement Application

ESIS Claim Number
Soteria Unique ID
This field is hidden when viewing the form
Claim Type
BEFORE YOU COMPLETE THIS APPLICATION:
Did you purchase this home on or after February 1, 2019?
If the answer is "no," please proceed to the application.
If the answer is "yes," PLEASE CONTINUE TO READ and be aware of CFSIC's guidelines on this subject.
1. If "yes"…you MUST HAVE in your possession EITHER a visual examination report assigning a CFSIC Severity Class code of 3, 2, or 1 to the foundation OR a foundation core testing report (not both…it's just EITHER).
2. If "yes"…the date of either report MUST BE a date prior to the date on which you purchased the home.
3. If "yes"…for an inspection report, it doesn't make any difference if the Severity Class assigned is 3, 2, or 1.
4. If "yes"…for a foundation core test report, it doesn't make any difference whether the results are positive OR negative for the existence of pyrrhotite…and if positive, it makes no difference as to the amount of pyrrhotite.
If you purchased your home on or after February 1, 2019 and you have not observed these rules, your claim will be rejected.

Claimant Notice:
** You are applying as a Pending claimant. Because of that specific designation,
your application will be registered and confirmed, but your claim details may not be
reviewed by an adjuster for some time to come, based on the backlog of earlier applications
and the way in which the CFSIC program is funded.
We will not lose your application. **
* If you start this application and need more time, there is a "Save and Continue Later" button
at the very end of the application to save your work and return to the application later.

1. Name of Claimant*
First (10 character max) Last (15 character max)
2. Address of Claimant*
Address Line 1 (30 character max) Address Line 2 (30 character max) City (25 character max) State ZIP Code
Is this the address of the building with a crumbling foundation claim? If "No", please provide address of affected building below*
- Yes
- No
Address of Foundation Claim
Address Line 1 (30 character max) Address Line 2 (30 character max) City (25 character max) State ZIP Code
3. Contact Phone Number*
4. Contact Email*

(40 character max)
5(a) Is the affected building a single-family dwelling?*
- Yes
- No
5(b) A multiple-family dwelling?
- Yes
- No
5(c) A condominium?
- Yes
- No
5(d) A planned unit development?
- Yes
- No
6. What is the date on which you purchased the affected residential building?
MM slash DD slash YYYY

(To learn about why the date of purchase is important to your eligibility, please go to Appendix 1 to this application, which is found at the very end of the application after the signature and date lines.)
7. Are you the owner of the residential building?*
- Yes
- No
8. If you are not the owner, state your relationship to the owner:
(PLEASE NOTE: If you completed question #8, you will be required to provide a Power of Attorney granting you permission to act as the owner's representative for purposes of making a claim. The Power of Attorney form will be provided to you by the office of CFSIC's Superintendent if your claim is otherwise determined to be eligible.)
9. If you are the owner and are also a contractor, did you, as a contractor, carry out any of the work on the foundation for which you seek reimbursement?
- Yes
- No
- Not Applicable
(PLEASE NOTE: If the owner of an eligible residential building is a contractor who participates or plans to participate in the CFSIC program as a contractor providing foundation replacement services to the public, that contractor will be ineligible to apply for either a Type 1 or Type 2 claim with respect to any eligible residential building unless such contractor seeks acceptable bids for Type 1 foundation replacement claims from contractors not owned or controlled directly or indirectly, in whole or in part, by the contractor-owner of the eligible residential building. With respect to a Type 2 claim involving a contractor-owner, the contractor-owner will have to represent and warrant that the work performed to replace a foundation for an eligible residential building was not performed by that contractor-owner or by a contractor owned or controlled directly or indirectly, in whole or in part, by the contractor-owner of the residential building. If you check “yes” to Question 9, you are representing and warranting that this is the case with respect to either type of claim.)
10. How long have you (or the owner) occupied this residential building?*
11. When was this building built (year)?*
12. Is this building located in the state of Connecticut?*
- Yes
- No
13. Is this claim for a partial foundation replacement?
- Yes
- No
PLEASE NOTE: Type 2 claimants may make a claim for the reimbursement of a partial foundation replacement on a one-time basis, with the understanding that the claim payment made for a partial foundation replacement will be considered as part of a single claim involving the residential building and will be deducted from any final claim payment made, the total of which will at all times be subject to CFSIC’s cap on a total eligible claim.
For a full foundation replacement?
- Yes
- No
PLEASE NOTE: Before answering question #14 and #15 below, please note that CFSIC will not consider as eligible for reimbursement any of the following costs or expenses which may have been incurred as a result of the partial or full replacement of any foundation:

• Replacement of drywall and/or finishing wall features, including re-framing;
• Removal/replacement of porches or decks;
• Removal/replacement of gutters;
• Removal/replacement of landscaping features such as driveways, walkways, paths, shrubs, lawns, trees, gardens, or other plantings or garden structures;
• Any work done to outbuildings, sheds, or barns;
• Swimming pools, whether in-ground or above-ground, or any ponds or water features;
• Moving or relocation expense;
• Temporary housing expense;
• Meals, transportation, mileage, and incidentals;
• Loss of wages or income or revenue associated with any work or any business, whether such business is home-based or not;
• Any liability incurred by the homeowner or any other person on a direct, indirect, or consequential basis.
14. What was the total cost of the partial or full foundation replacement?*
15. Of the total cost shown in #14 above, how much of that cost was allocable eligible concrete work under CFSIC's underwriting and claims management guidelines?*
[PLEASE NOTE: If your foundation was replaced on or after January 10, 2019, you cannot submit a Type 2 claim for foundation reimbursement unless that work was performed by a CRCOG-approved contractor.]

[ALSO NOTE: The amount in the answer to #15 above must correspond exactly to the amount shown in the contractor’s contract amendment or separate letter and on contractor’s letterhead (in either case, inclusive of the contractor worksheet) to be attached to your application.]
16. Did you pay for the foundation replacement on the residential building in question using exclusively your own funds?*
- Yes
- No
If "yes," have you submitted a claim to a current or prior homeowner's insurer?
- Yes
- No
If "no," please indicate below in the space provided the amount of any payment made by any insurer for any partial or full foundation replacement.
Name of Insurer:
Amount: $
If you have not submitted a claim to an insurer, do you intend to do so?*
- Yes
- No
(PLEASE NOTE: Claim payments made by CFSIC will be offset by and will not be made prior to any claim payments made by a homeowner’s insurer or other source of insurance, whether such insurer claim payments were made pursuant to a claim process or as the result of litigation between or among the homeowner, acting individually or as part of a group, and an insurer.)
(PLEASE NOTE: You will be required to provide, as an attachment to this application, evidence that you have applied to a commercial insurer to have your foundation claim paid. This is true regardless of whether a claim made to an insurer has already been denied, in whole or in part, or may still be pending. You will be required to provide evidence of either the denial by the insurer or the pending status of your claim. If your claim with a commercial insurer is still pending, we will assign a claim number to your claim with CFSIC, but your claim with CFSIC will remain "inactive" while any outstanding commercial insurance claim is pending.)

(Claim payments made by CFSIC will be offset by and will not be made prior to any claim payments made by a homeowner’s insurer or other source of insurance, whether such insurer claim payments were made pursuant to a claim process or as the result of litigation between or among the homeowner, acting individually or as part of a group, and an insurer.)
17(a). Please provide the name of your current homeowner's insurer.
Please provide your current homeowner's insurer policy number.
(PLEASE NOTE: Some commercial insurers provide direct financial assistance to their current or prior homeowner insureds who are in turn also CFSIC-approved claimants whose claims have been first fully adjusted and paid by CFSIC. For a complete list of those insurers, go to www.crumblingfoundations.org)
17(b). During your ownership of the residential building, have you been insured previously by any of the following homeowner's insurers: Travelers, The Hartford, or Liberty Mutual?
- Yes
- No
If "yes," please list all applicable insurer(s) and policy number(s) from insurer list in 17(b).
(If entering more than one insurer/policy number, please separate each entry with a comma. Example: Travelers policy 00002015, The Hartford policy 00002016, Liberty Mutual policy 00002017)
17(c). Do you agree that CFSIC can release information about your claim to any current or prior homeowner’s insurer, if that insurer participates in assisting CFSIC claimants with additional financial assistance?
- Yes
- No
PLEASE NOTE: By checking "yes" you authorize us to provide your current or prior homeowners insurer, as of the date such insurer agrees to collaborate with CFSIC, with the information contained in this application, a copy of your Participation Agreement, and a copy of the contract for the construction work undertaken, for the purpose of that collaborating insurer potentially providing you with an additional benefit outside the scope and structure of any claim paid by CFSIC.)
18. Prior to the replacement of the foundation, did you have a core test or other type of laboratory analysis done on the concrete foundation?*
- Yes
- No
- OR -
Did you have a visual examination done of the affected area, conducted by a Connecticut-licensed professional engineer or CFSIC-certified home inspector?*
- Yes
- No
(If "yes," please provide, as an attachment, the complete written report on the results of EITHER the test or the examination.)
19. Are you involved in a lawsuit either individually or collectively with a current or prior homeowner’s insurer?*
- Yes
- No
(PLEASE NOTE: If the answer to Question #19 is “yes,” you will be able to apply to CFSIC, but your claim will be placed in “inactive” status until such time as such lawsuit is settled or a settlement has been achieved.)
20. Do you understand that if your claim is accepted by CFSIC you will only receive a reimbursement payment from CFSIC as calculated using the replacement cost parameters found in the CFSIC underwriting and claims management guidelines, with the exception of any separate payment made by CFSIC at the request of a collaborating insurer, if any, and that such reimbursement will be paid to you over four quarterly installments?*
- Yes
- No
21. Do you understand that the maximum claim settlement reimbursement paid by CFSIC per residential building will not exceed $175,000 (or $70,000 with regard to any condominium unit) regardless of any other sources of indemnification or reimbursement available to you with respect to the claim in question, including your own funds or borrowed funds? (With the further understanding that the cap will increase for applications originally received on or subsequent to January 5, 2022 to $190,000 and $76,000 respectively.)*
- Yes
- No
The person signing this application represents and warrants that all information in this application is truthful and accurate.

In order for an application to be considered for reimbursement, it must be complete, with no questions left unanswered. It must be signed and dated.

In addition to the completed application, you must attach or include the following:

(a) Evidence of current ownership of the building in question, such as a local tax bill.

(b) If a core test or other type of approved laboratory analysis was done, a copy of the final laboratory report, OR

(c) If a visual inspection was done, a copy of the final written report;

(d) If you have made a claim to a current or prior homeowner’s insurer and the claim has been denied or is pending, evidence by way of a letter of denial, or evidence by way of a letter indicating that the claim has not been denied and is therefore under active consideration. (The term “current homeowner’s insurer” means the homeowner’s policy in force as of the date the claimant signs his or her CFSIC application; the term “prior homeowner’s insurer” means the homeowner’s policy that was in force at the time a claim was filed with a prior homeowner’s insurer.) Type 2 claimants will not have their claims be made active unless they can produce a claim denial or acceptance, with respect to the foundation in question, from a current or prior insurer.

(e) If you have made a claim to a current or prior homeowner's insurer and the claim has been paid, in whole or in part, evidence by way of a letter indicating the amount of the settlement made or the settlement to be made.

(f) Evidence that the building or structure in question was originally constructed during calendar year 1983 or subsequent.

(g) A Certificate of Completion signed by the building inspector of the town in which the residential building is located, which was provided at the time the foundation replacement was completed.

(h) Evidence in writing, obtained from the contractor who replaced your foundation, confirming the replacement work done to the foundation in question, itemizing all costs and expenses associated with the work done as that work relates to the replacement cost parameters specifically shown in these guidelines, and indicating how much of the work may have been covered by insurance and how much was covered by out-of-pocket private payment. This would be required even when the claimant litigated the claim with the insurer in question.

(To the extent your application is accepted for participation in the CFSIC program and you are not the owner of the residential building in question by virtue of your response to question #8, you will be provided with a Power of Attorney form and instructions for its completion. The Power of Attorney must be completed and received by CFSIC prior to any further consideration of your claim.)

[PLEASE NOTE: Reimbursement will only be made to the current owner (or with respect to a Legacy Claimant, the former owner) of the residential building in question who, in addition, was also responsible for the payment of the replaced foundation, whether such payment was made in whole or in part.]
```
Please be aware that applications not accompanied by each and every required piece of evidence noted above are permitted, 
but with the understanding that for a claim to be deemed as “active” and therefore potentially eligible for funding, 
all points of evidence required must eventually be submitted.
```
By signing this application, or authorizing a representative to sign on their behalf, the claimant agrees, to the extent the application is approved for reimbursement, to become a “Participant,” among any other claimants, in the indemnification and reimbursement program facilitated by CFSIC’s unincorporated protected cell. Claimants shall not, by virtue of their participation in the CFSIC indemnification and reimbursement program, have any ownership interest or voting rights in CFSIC or its protected cell. The claimant acknowledges that funds available to pay the CFSIC claims shall be limited to assets contributed to the protected cell by the State of Connecticut and other available funding sources, if any, for the purpose of funding such claims, excluding those claims involving collaborating insurers, if any. All Participants approved for reimbursement under this application acknowledge and agree that all claim payments made by CFSIC will be remitted directly to the owner of the residential building. Participants further agree that they acknowledge and understand that CFSIC will have no responsibility in any way, directly, indirectly, or vicariously, for the quality of a chosen contractor's workmanship. All Participants will be required to enter into a Participant Agreement upon acceptance to their claim prior to any claim payment being made.
“In Connecticut, a person is guilty of insurance fraud when, with the intent to injure, defraud, or deceive any insurance company, he knowingly presents false, incomplete, or misleading information in support of an insurance application, claim, or other benefit. The offense includes conspiracy. Insurance fraud is a class D felony, which subjects a person to a fine up to $5,000, up to five years imprisonment, or both (C.G.S. § 53a-215).”
APPENDIX 1
The Board of Directors of CFSIC has determined that the eligibility of claimants with respect to both Type 1 and Type 2 claims is affected by the date on which the affected residential building was purchased. With respect to such eligibility:

• For any residential building purchased on or after February 1, 2019, if the buyer of such residential building is aware that the building or any addition(s) to the building, inclusive of any garage, was constructed in 1983 or subsequent, such buyer will only be eligible to apply to CFSIC as a Type 1 or Type 2 claimant if the buyer or seller of the building has tested for pyrrhotite, or has conducted a visual exam for evidence of pyrrhotite conducted by a Connecticut-licensed professional engineer or CFSIC-certified home inspector, prior to the date of sale;

This Appendix is a material part of the application. A claimant signing this application acknowledges his or her understanding of the terms and conditions of this Appendix, and agrees to be bound by those terms and conditions.

Next Steps

There are two “Next-Step” options, based on your progress in completing the above application.

Option #1: You have completed all the questions on the application.

You are now ready to sign, date and submit the application before uploading your attachments.
In the boxes below, please sign your name (with your mouse), then type your name, and add today’s date.
Then, click the CAPTCHA checkbox to confirm you are human (and not a robot). At that point, click the
“Submit” button, a new page will appear showing you how to upload all your attachments.

Option #2: You require more time to complete the application.

If you need more time to complete your application, go directly to the “Save and Continue Later”
button below.  This option will save your answers and provide a clickable link for you to return to,
within 30-days, to complete your application.

The person signing this application acknowledges that this is an application to become a Pending claimant of CFSIC as that term is defined by CFSIC’s Underwriting and Claims Management Guidelines; and the applicant acknowledges that as a Pending claimant the claim may never be eligible for payment.

Signature of Claimant or Claimant's Representative:*
(to re-attempt signature, click the circle symbol above to clear and re-sign)
Type or Print Your Name*
Signature Date*
MM slash DD slash YYYY
This field is hidden when viewing the form
Attachment: Evidence of Ownership (i.e., local tax bill)
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Core Test or Other Lab Analysis Final Report
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Visual Inspection Report
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Letter from Current (or Prior) Homeowner's Insurer on Pending or Denied Claim
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Letter from Current (or Prior) Homeowner's Insurer on Paid Claim (in-whole or in-part) with Settlement Amount
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Evidence of Original Construction During Calendar Year 1983 or Subsequent
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Certificate of Completion (signed by building inspector) Provided Upon Completion of Foundation Replacement
Max. file size: 20 MB.
This field is hidden when viewing the form
Attachment: Written Evidence of Replacement Work Completed (itemize all costs and expenses, per questions #14 and #15)
Max. file size: 20 MB.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.