Walterry Insurance: Association Businessowners Application Association Businessowners Application Organization Name: Contact Name Address1 Address2 City, State Zip Code Phone No. Fax No. Contact Email Date Operation Began 1. Is Association: Building Owner Tenant Lessor 2. Proposed Effective Date: 3. Location Address: Address2 City, State Zip Code 4. Deductible Requested: $250. $500. $1,000. $5,000. 5. Coverage Information: Property Replacement cost of building (if owner) Replacement cost Business Personal Property Computer Hardware Computer Data/Media Liability (Check applicable limits requested) $500,000 Each occurrence/$1,000,000 Aggregate $1,000,000 Each occurrence/$2,000,000 Aggregate 6. Current Insurance Information: Insurance Company Expiration Date Premium 7. Location Information: Square feet occupied by you Square feet rented to others Building Construction Number of Stories Sprinklered Yes No Central Station Alarm Yes No Building Age If over 30 years, advise year updated for Wiring, Heating, Plumbing & Roof Describe or list any manufacturing occupancies within the same building: County Protection Class Rating Territory Mortgagee Additional Insured Name Address City, State Zip Code 6. Describe all losses for the past 3 years: Date of loss Open/Closed Amount Description of loss Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance containing any false information, or, for the the purpose of misleading, conceals information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. WARNING: Any person who knowingly files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime and also punishable by civil penalties in certain jurisdictions. PENNSYLVANIA WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to criminal and civil penalties. Association Businessowners Application Supplimental Information 1. Optional Coverages $1,000,000 Employee Benifit Liability Does your organization have written procedures for the enrollment of employees? Yes No If answer is no, coverage for Employee Benifit Liability may not be available. 1,000,000 Hired and Non-Owned Auto Liability. If owned vehicles, complete auto application. Number of employees and/or volunteers who use a vehicle on behalf of the association $35,000 Hired Auto Physical Damage Estimated number of days that a vehicle is rented by the association 2. Describe any business activities conducted at any other location not listed in question #3 on the previous page. If none, please indicate as such and if so, please complete question 1-6 on th Convention Cancellation Application (even if no Convention Cancellation Coverage is requested). 3. Is there any revenue from distribution of products of others? Yes No If yes, Explain. 4. Is there any work subcontracted to others? Yes No If yes, What is the annual cost and type of work subcontracted? Copyright © 2005 Walterry Insurance Brokers [ Forms ] [ Contact Us ] [ Privacy Policy ] [ Home ]