Named Insured:
Mailing Address:
Effective Date:
Current Carrier:
Underwriting
Information
Location: (if different from above)
Is this a home office?
Construction of building:
Choose One
Frame
Masonry
Fire-Resistive
Other
Year Built:
# of Stories:
Any previous claims?
Yes
Central Station Monitor Alarm System?
Is there an operating sprinkler system?
Are you the owner of building or tenant?
Owner
If owner, what is square foot of building?
Coverage
Information
Coverage Type
Limits
Money and securities:
Choose One
$2,500
$10,000
Employee Dishonesty:
Choose One
$5,000
$10,000
Pension / Welfare Plan (ERISA):
Choose One
$10,000
$15,000
$20,000
General Liability
Occurrence Limit:
Choose One
$300,000
$500,000
$1,000,000
$2,000,000
Hired & Non-owned Auto Liability
Choose One
$300,000
$500,000
$1,000,000
Employee Benefits Liability
Other:$
Number of Additional Insureds:
Policy Deductible:
Choose One
$250
$500
$1,000
$2,500
Whom should we contact with the Indication?
Contact Person:
Comments:
