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Primary Property Owner Information
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| First Name: * |
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| Last Name: * |
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| Property Address Street 1: * |
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| Property Address Street 2: * |
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| City: * |
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| Zip Code: * |
(5 digits) |
| State: |
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| Mailing Addess (if different from above): |
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| Address Street 2:: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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Co-Applicant Information (if Joint Membership)
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| State: |
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| Last Name: |
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Contact Information - Primary Applicant
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| Daytime Phone: * |
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| Evening Phone: * |
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| Mobile Phone: * |
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| Email: * |
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| Fax: |
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Contact Information - Co-Applicant
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| Daytime Phone: |
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| Evening Phone: |
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| Mobile Phone: |
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| Fax: |
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| Email: |
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Membership Program Selection
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| Membership Program: * |
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Sales Representative Information
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| Sales Representative: * |
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Property Information
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| Property Type: * |
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| Insured Property Value: * |
(USD) |
| Property Insurance Deductible: * |
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| Insurance Company: * |
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| Mortgage Company: * |
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| Insurance Claim History: |
Please check all that apply |
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Wind claim |
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Hail claim |
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Water claim |
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Fire claim |
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Employment Information - Primary Applicant
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| Current Employer: * |
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| Employer Address: * |
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| City: * |
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| Employer Zip Code: * |
(5 digits) |
| State |
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| Phone: |
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| Fax: |
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| Email: |
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| How Long Employed: * |
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Employment Information - Co-Applicant
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| Current Employer: |
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| Employer Address: |
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| City: |
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| Zip Code: |
(5 Digits) |
| State: |
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| Phone: |
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| Fax: |
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| Email: |
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| How Long Employed: |
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Preferred Vendor Agreement
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By selecting "yes"
you may participate in the In-Network Program |
Yes, I agree and understand that the Preferred Vendor is the "In-Network" approved vendor in my service area and will perform the work in the event of an insurance claim, in which the Tru-Gap Protection Plan is used. I also agree to maintain "Replacement Cost Value" on my homeowner's insurance policy. I have read and understand the rules and guidelines of Tru-Gap Protection Plan. This is a separate agreement between myself and Preferred Vendor and is not related in anyway to an insurance policy. |
| By selecting "No" you may only participate in the Out-of-Network Program |
I do not agree to the Preferred Vendor Agreement |
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Referrals
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| List anyone who you think might benefit from the Tru-Gap Program, please provide contact information such as name, phone, and email: |
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Acceptance and Signature
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| Notice Correspondence: Member agrees to accept receipt of all notice correspondence from the Company on the date sent by one of the following: * |
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| Notice Email: |
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| Notice Address: |
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| Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Agreed & Accepted by Applicant: * |
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| Agreed & Accepted by Co-Applicant: |
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| Agreed & Accepted |
By checking the box, I understand and agree that it becomes my acceptance and electronic signature for submission of application into the Tru-Gap Program. I authorize Tru-Gap Protection to verify the information provided on this form and my credit and employment history. In addition, I have read and agree to the Out-of-Pocket Protection Agreement and the Protection Guidelines of the Tru-Gap Protection Program. I understand and agree that this application will be submitted to the Tru-Gap Protection Plan Corporate office for approval if any of the information provided on this application proves to be false at any time that the application and membership could be voided. |
