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Contact Information
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Name of Business |
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Contact Name: |
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Address: |
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Address 2: |
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City - St - Zip: |
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Phone Number: |
FAX |
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E-Mail Address: |
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Location for this quote.(Address) |
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Please answer
these questions based on your primary location and building. If you
have additional locations or buildings, please submit another copy
of this section and answer the questions for your other property.
Home based businesses should complete the following questions based
on the business portion of the home. |
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What is the desired
Property Deductible? |
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Is the business within 1,000
feet of a fire hydrant? |
YES
NO
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Is the business within 5
miles of a Fire Station?
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YES
NO
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What is the
100% replacement value of the business personal property (including
business contents, fine arts, value of all computer hardware and
software and laptops)? $
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| What is the construction
of the building where the business is located? |
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If the construction of the
building is not known, please provide details on the materials used
for the roof, floors and walls.
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What is the square footage
of the space occupied by the business? |
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Is the business the sole
occupant of a free standing building? |
YES
NO
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Does the building have an
automatic sprinkler system covering 100% of the premises? |
YES
NO
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Does the business have a
central station burglar alarm? |
YES
NO
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Is there any use of grills
or deep fat frying in your business operations or in any other businesses
in your building? (i.e. restaurant in the same building) |
YES
NO
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Please indicate
whether the following optional coverages are desired: |
| a) Earthquake Coverage (not
available in all areas): |
YES
NO
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b) Sprinkler Leakage - Earthquake
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YES
NO
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c) Flood Coverage (not available
in all areas): |
YES
NO
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d) Computer Mechanical Failure
and Computer Virus Coverage ($100,000 limit) |
YES
NO
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e) Systems Breakdown Coverage?
(i.e. boilers, pressure vessels, AC units, etc. |
YES
NO
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f) Mine Subsidence Coverage
(KY, IL, IN, WV only) |
YES
NO
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g) Business Income from Dependent
Properties ($10,000 limit) |
YES
NO
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h) Personal Property Off
Premises and Property in Transit Limited International Extension Endorsement |
YES
NO
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i) Business Income Sub-limit |
YES
NO
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| If yes, choose
limit option desired: |
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j) Business Income Waiting
Period Deductible (24 hours) |
YES
NO
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k) Business Income Off Premises
Power Failure ($10,000 limit) |
YES
NO
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Please indicate
whether any of the following exclusions are desired: |
| a) Business Income Exclusion |
YES
NO
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| b) Theft Exclusion |
YES
NO
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| c) Windstorm and Hail Exclusion |
YES
NO
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| d) Stock Exclusion |
YES
NO
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What is the total maximum
daily value of money and securities (i.e. checks) on the premises? |
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| The policy includes
limits of $10,000 inside the business and $2,000 while being delivered
to the bank. If higher limits are desired, choose one of the following
options: (Please note that in order to receive higher limits use of
a safe on premises is required.) |
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If loss of refrigeration
coverage is desired, please provide the total value of property subject
to refrigeration? |
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Many property
coverage forms provide for coverage similar to the limits below.
If you require higher limits than listed please list below. |
Separate Limits
for Each Coverage (unless you choose a blanket limit):
Fire Dept.
Service Charge/
Fire Extinguisher Recharge |
$2,500 |
Money Orders and Counterfeit
Currency |
$2,500 |
| Forgery and Alteration |
$2,500 |
Increased Construction Cost (after a
loss) |
$5,000 |
| Glass |
$2,500 |
Signs |
$2,500 |
| Customers’ Goods on Premises |
$10,000 |
Back-up of Sewer/Drains |
$2,500 |
| Personal Property Off Premises |
$5,000 |
Property In Transit |
$5,000 |
| Valuable Papers/Records on premises |
$10,000 |
Accounts Receivable at the premises |
$10,000 |
| Employees Dishonesty - ERISA |
$2,500 |
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| Indicate coverage area where
you will require limits higher than shown above: |
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Complete the
following questions only if interested in purchasing insurance for
the building. Home based businesses do not need to complete these
questions. |
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What is the 100% replacement
value of the building? |
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Are you interested in having
one blanket limit for both building and business personal property? |
YES
NO
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What is the square footage
of the entire building? |
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How many stories in the building?
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What is the original year
the building was built? |
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If the building(s)
is over 30 years old, indicate the year each of the following was
updated: |
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