Valuable Papers - Limit Unspecified $
Limit Specified $
4. Mini-Computer - Limit Unspecified $
5. Heating and Cooling Systems: Heating System Cooling System Both
(Type of System: Steam & Hot Water Heat Hot Air Heat)
6. Higher Property Deductible: $250 $500 $1000
7. Exterior Building Glass (Already included for owner-optional for tenant)
LOC. NO. : BLDG. NO. TOTAL WIDTH OF GRADE FLOOR GLASS:
8. Elimination of Standard $100 glass deductible
9. Non-owned and hired auto liability
10. Umbrella Coverage - Limit $

Walterry Insurance: National Newspaper Association Insurance Policy Application Please fill out form completely, and click 'Done' at the bottom when you are finished. APPLICANT'S NAME: MAILING ADDRESS (NO, STREET, CITY, COUNTY, STATE, ZIP CODE): APPLICANT'S PHONE NUMBER: APPLICANT'S EMAIL ADDRESS: TYPE OF BUSINESS Proprietorship Partnership Corporation Other POLICY PERIOD EFFECTIVE FROM: TO: PREMIUM TO BE PAID: Annually Semi-Annually Quarterly Monthly WHERE WILL INSURANCE APPLY? Address (If different from mailing address): Owner/Tenant: Type of Occupancy: Percent occupied by insured: PROPERTY CONSTRUCTION AND VALUES - REQUIRED RATING DATA - COMPLETE BOTH SECTIONS SECTION 1 BUILDINGS (list all structures at each location): Loc. No. Bldg. No. CONSTRUCTION Frame, Joisted Masonry, Non- Combustible Fire Resistive No. Stories Total Sq. Ft. Repl. Cost SECTION 2 PERSONAL PROPERTY: Stock Furn. Fixt. Improvements & Betterments Replacement Cost Printing Equipment Total + +- =$ + +- =$ + +- =$ Mortgagee ( Indicate if other than first mortgagee ) Loc. No. Bldg. No. Name and Address: Complete All Questions - Explain Yes Answers in Space Provided 1. Have there been more than 2 covered Property, Liability losses or a single loss in excess of $2,500 within th past 3 years? Yes No 2. Any evidence of financial difficulty within the past 3 years? Yes No 3. During the past 3 years has any coverage been canceled, declined or non-renewed? Yes No 4. Are buildings over 25 years old? If yes, give age: years. Yes No 5. Have plumbing, heating and electrical systems been renewed within past 10 years? Yes No 6. Does owner have less than 3 years management experience in this line of business? Yes No Remarks OPTIONAL COVERAGES Workers' Compensation Estimated Annual Payroll: Newspaper Publishing *4304 $ Salespeople Outside *8742 $ Clerical Office *8810 $ Other Classification $ Experience Modification (If Applicable) : *Subject to State Variations HAVE YOU HAD ANY LOSSES OR ANY TYPE OF EMPLOYEE INJURIES IN THE PAST THREE YEARS? Yes No Please describe and list amount of loss (If known): OPTIONAL COVERAGES 1. Contingent Extra Expense Limit: $ - up to 40% of Limit applies each month. Indicate monthly revenue from newspapers printed off premises. Name and address of printing firm: 2. Accounts Receivable - Limit $ 3.

Automobile Information for Umbrella Coverage
	Private Passenger	Commercial
A. Number of Business Autos. Type:
B. Automobile Policy Number
C. Limits
D. Insuring Company
E. Annual Premium

Coverage	Present Insurer	Policy No.	Eff./Exp. Dates	Lim. of Liab.	Premium