Claim Type 1: Indemnification Application1. Name of Claimant* First Last 2. Address of Claimant* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 NoAddress of Foundation Claim Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3. Contact Phone Number*4. Contact Email* 5(a) Is the affected building a single-family dwelling?* Yes No5(b) A multiple-family dwelling? (Up to and including four families) Yes No5(c) A condominium? Yes No5(d) A planned unit development? Yes No6. In each case noted above, are you the owner?* Yes No7. If you are not the owner, state your relationship to the owner:(Note: you will be required to provide as an attachment to this application a letter signed by the owner stating that you may act as the owner's representative for purposes of making a claim.)8. How long have you (or the owner) occupied this dwelling?*9. When was this building built (year)?*10. Is this building within a 20-mile radius of the J.J. Mottes Concrete Company in Stafford Springs, CT?* Yes NoIf "No", have you received a written waiver from the Connecticut Department of Housing? Yes No11. Have you replaced the foundation of the dwelling in question?* Yes NoNOTE: Before answering question #12 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 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; any work done to garages, unless the garage is connected to the foundation of the main dwelling and the work was performed to remediate or replace the garage’s foundation; • 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.12. What was the total cost of the foundation replacement?*13. What was the total cost of the foundation replacement less all ineligible costs and expenses as shown above?*14. Did you pay for the foundation replacement on the dwelling in question using your own funds or through funds provided in whole or in part through a loan?* Yes NoIf "no", please indicate below in the spaces provided all other sources of funds, including any payment by an insurer, and provide the amount of that payment.(i) SourceAmount $(ii) SourceAmount $(iii) SourceAmount $15. Prior to the replacement of the foundation, did you have a core sample laboratory analysis done of the concrete foundation?* Yes NoIf "yes" please provide, as an attachment, the complete report on the results of that test.16. Prior to the replacement of the foundation, did you have a visual inspection done of the affected area, conducted by a Connecticut licensed professional engineer?* Yes NoIf "yes" please provide, as an attachment, the complete report on the results of that test.17(a) Did you make a claim for a damaged foundation to your current or any homeowner's insurer before you replaced your foundation?* Yes No17(b) If "yes", was this claim accepted in whole or in part by an insurer? Yes No18. If any such claim was paid in whole or in part, please provide the amount of the total claim settlement:19. Please provide the name of the insurer paying the claim:20. If the answer to question #17(a) is "no", do you currently have an active claim pending with a prior or current homeowner's insurer with respect to the foundation in question? Yes No(Whether the answer to the active claim question above is “yes” or “no” you will be required to provide evidence, as part of this application, that you applied to an insurer to have the foundation claim paid before your application will be considered as an active claim by CFSIC, regardless of whether that claim made to an insurer was denied, in whole or in part, or is still pending, and you will be required to provide evidence of either the denial by the insurer or the pending status of that claim.) 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.21. Are you involved in a lawsuit either individually or collectively with a current or prior homeowner’s insurer?* Yes No22. Do you understand that if your claim is accepted by CFSIC you will receive no more than 75% of the value of the foundation construction contract you entered into, in accordance with CFSIC’s claims management guidelines and all terms, conditions, and limitations of those guidelines?* Yes No23. Do you understand that the maximum claim settlement reimbursement paid by CFSIC per eligible dwelling will not exceed $175,000 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?* Yes No24. Do you currently have a mortgage on the property in question?* Yes NoIf "yes", please provide the name(s) of the mortgage holder(s):The person signing this application represents and warrants that all information in this application is truthful and accurate. In order to be considered for indemnification, it must be complete, with no questions left unanswered. It must be signed and dated. In addition to the completed application, you must attach (upload) or include the following: (a) In the case of someone completing an application on behalf of a homeowner, a letter certifying that the person signing the application is authorized to act on the homeowner's behalf. (b) Evidence of current ownership of the building in question, such as a local tax bill. (c) If a core sample has been taken, a copy of the final laboratory report. (d) If a visual inspection has been done, a copy of the final written report. (e) 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. (f) If you have made a claim to a current or prior homeowner's insurer and the claim has been honored in whole or in part, evidence by way of a letter indicating the amount of the settlement made or the settlement to be made. (g) Evidence that the building or structure in question was originally constructed during calendar year 1983 or subsequent. (h) An attestation by way of answer to question #10 that the building in question is within a 20-mile radius of J.J. Mottes Concrete Company in Stafford Spring, CT; OR, if outside that radius, a copy of the waiver received from the Connecticut Department of Housing extending that radius. (i) A Certificate of Occupancy signed by the building inspector of the town in which the dwelling is located, which was provided at the time the foundation replacement was completed. NOTE: Please note that reimbursement will only be made to the current owner of the dwelling 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 will delay the processing of your claim. Therefore, it is in your interest to only submit your claim if your claim is complete in all respects. By signing this application, or authorizing a representative to sign on their behalf, the claimant agrees, to the extent the application is approved for indemnification, 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. All Participants approved for indemnification under this application acknowledge and agree that all claim payments made by CFSIC will be remitted directly to the contractor or contractors providing foundation remediation or replacement services and not to Participants directly or to any other intermediary on behalf of Participants.Signature of Claimant or Claimant's Representative:*Date* MM slash DD slash YYYY “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).”Attach Claim DocumentsSelecting this will allow you to upload your claim documents.