EARTHQUAKE APPLICATION FORM
PERSONAL INFORMATION
Fields marked (
*
) are mandatory.
Quote Date
*
Choose Month
January
February
March
April
May
June
July
August
September
October
November
December
Choose Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Choose Year
2006
2007
First Name
*
Last Name
*
Mailing Address
*
City
*
State
*
Zip Code
*
Home No.
*
(
)
-
Cell No.
Businness No.
(
)
-
Ext.
E-Mail
*
Current Policy Expiration Date
Social Security No.
Location of Garage :
(if diff. from Above)
City
State
Zip Code
Choose from the Following
-- Select --
Individual
Partnership
Corporations
LLC
Subchapter "S" Corp.
Other
PREMISES INFORMATION
Location
City
State
Zip Code
Interest
-- Select --
Owner
Tenant
Nature of Businness/Description of Operations by Premises
STATUS OF TRANSACTION
Proposed EFF Date
-
-
Proposed EXP Date
-
-
NATURE OF BUSINESS
Description of Operation
-- Select --
Wholesale
Retail
Manufacturing
Apartment Building
Condo Association
Leasers Risk
Contractors
Other
If Other please specify
DBA
GENERAL INFORMATION
Please choose Yes or No for the following:
Is the applicant a subsidiary of another entity?
Yes
No
Does the applicant have any subsidiaries?
Yes
No
Is a formal safety program in operation?
Yes
No
Any exposure to flamables, explosives, chemicals?
Yes
No
Any catastrophe exposure?
Yes
No
Any other insurance with this company or being submitted?
Yes
No
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Yes
No
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
Yes
No
During the last 5 years (ten in RI), has any applicant been convicted of any degree of the crime or arson?
Yes
No
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Yes
No
Has business been placed in a trust?
Yes
No
Additional Comments :
PRIOR COVERAGE
COMMERCIAL GENERAL LIABILITY
Carrier
Policy Number
Proposed EFF Date
-
-
Proposed EXP Date
-
-
PROPERTY
Carrier
Policy Number
Proposed EFF Date
-
-
Proposed EXP Date
-
-
LOSS HISTORY
Enter all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior 5 years.
Click Here if None
Date of Occurrence
Line
Type/Description of Occurrence or Claim
Date of Claim
Amount Paid
Amount Reserved
Claim Status
-- Select --
Active
Inactive
-- Select --
Active
Inactive
COVERAGES
General Liability Limit
-- Select --
$300 k
$500 k
$1 Million
SCHEDULE OF HAZARDS
Annual Sales
Sq.Footage
# of Units
Payroll
# or Employees
PRODUCTS
Applicable to Wholesale and Manufacturing only
Products
Annual Gross Sales
# of Units
Time in Market
Epected Life
Intended Use
Principle Components
PROPERTY SECTION
PREMISES INFO
Premises #
Street Address
Building Description
Building #
Subject of Insurance
Amount
Deductible
Building
-- Select --
$500
$1000
$2500
$5000
Business
-- Select --
$500
$1000
$2500
$5000
Personal Property
-- Select --
$500
$1000
$2500
$5000
Loss of Income
-- Select --
$500
$1000
$2500
$5000
CONSTRUCTION TYPE
Choose type
-- Select --
Wood Frame
Brick
Concrete
Fire Resistant
Number of Stories
Number of Basements
Year Build
Total Sq ft
Building Improvement:
(Check all that apply)
Wiring
Renovated Year:
Roofing
Renovated Year:
Plumbing
Renovated Year:
Heating
Renovated Year:
Other
Renovated Year:
Roof Type
-- Select --
Tile
Shingle
Composition
Other
Security
Burglar Alarm Type:
-- Select --
None
Central Station
Local Station
Both
Premises Fire Protection:
Check all that apply
Sprinkler
Fire Extinguisher
Standpipes
CO2
Chemical Systems
% of Sprinkler System
Fire Alarm Type
-- Select --
None
Central Station
Local Station
Both
Comments & Remarks
Sales Agent
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