EARTHQUAKE APPLICATION FORM
PERSONAL INFORMATION
Fields marked (*) are mandatory.  
Quote Date *
First Name *
Last Name *
Mailing Address *
City *
State * Zip Code *
Home No. * ( ) -
Cell No.
Businness No.
E-Mail *
Current Policy Expiration Date
Social Security No.
Location of Garage :
(if diff. from Above)
City State Zip Code
Choose from the Following
 
PREMISES INFORMATION
Location
City State Zip Code
Interest
Nature of Businness/Description of Operations by Premises
 
STATUS OF TRANSACTION
Proposed EFF Date - -
Proposed EXP Date - -
 
NATURE OF BUSINESS
Description of Operation
If Other please specify
DBA
 
GENERAL INFORMATION
Please choose Yes or No for the following:  
Is the applicant a subsidiary of another entity?
Does the applicant have any subsidiaries?
Is a formal safety program in operation?
Any exposure to flamables, explosives, chemicals?
Any catastrophe exposure?
Any other insurance with this company or being submitted?
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
During the last 5 years (ten in RI), has any applicant been convicted of any degree of the crime or arson?
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?
Has business been placed in a trust?
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
 
COVERAGES
General Liability Limit
 
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
Business
Personal Property
Loss of Income
CONSTRUCTION TYPE
Choose type
Number of Stories
Building Improvement:
(Check all that apply)
Roof Type
Security
Premises Fire Protection:
Check all that apply
% of Sprinkler System
Fire Alarm Type
Comments & Remarks
Sales Agent
 
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