Towing V₃antage Towing and Recovery Application

Size: px
Start display at page:

Download "Towing V₃antage Towing and Recovery Application"

Transcription

1 Towing V₃antage Towing and Recovery Application to: GENERAL INFORMATION Proposed Policy Period: To Insured Name: DBA (if any): Location 1 Address: City: State: Zip: Location 2 Address: City: State: Zip: Mailing Address: City: State: Zip: Legal Entity: Corporation Partnership LLC Individual / Sole Proprietor FEIN or SSN: Website Address: Address: Businesss Phone: Other Related Entities (name, date started, describe operations): List all Owners Title Year Bus Started % Ownership Active? Years Managing 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 1 of 9

2 Coverage Requested A. Business Auto Type Symbols Limit-CSL Business Auto Liability 7,8,9 Uninsured Motorist 7 Medical Payments 7 PIP/-Fault 7 Type If Any n-owned Liability Cost of Hire Hired Liability Type Symbol Ded Business Auto Physical Damage 7 Comp/OTC 7 Collision Garagekeepers Legal Liability Direct Primary (n/a all states) Direct Excess Location Limit of Liability Deductible Deductible Comprehensive Collision B. General Liability (Occurrence Only) Type General Aggregate $ Each Occurrence $ Damage to Rented Premises $ Medical Expense $ Limit Driver Payroll: $ All other Towing payroll (including clerical, admin, officers and owners): $ Lot Size and Protection Loc Sq Feet of Loc Alarm Fully Fenced Camera Well Lit Sec Guard 24 hr Staff Animals V3 Insurance Partners LLC Towing Application (V3/13) Page 2 of 9

3 Sales/Revenues Both columns for percentage and annual dollar sales must be completed Desc Pct Sales Annual Sales Towing Tire Sales New* Roadside Assistance Tire Sales Used* Parking/Storage Tire Sales Recapped* Involuntary Repo Auto Sales (not lien) Voluntary Repo Service/Repairs- need ASR App Parts Sales Used/Salvage Body/Paint need ASR App Parts Sales - New Rental/Leasing Operations Trucking/Freight Hauling Other describe fully Mobile Home Transport TOTAL SALES 100% Desc Pct Sales Annual Sales * Are any tires sold by you manufactured in China? Towing 1. How many tows each month? 2. How many roadside assistance calls each month? 3. Show percentage of all types of your towing operations: Private Property (illegal parking) City/County/State Towing Highway/Turnpike Rotation Voluntary Repossesions Involuntary Repossesions Heavy Duty Commercial Tows Banks/Finance Companies Motor Club Towing Towing for your own business 4. Are your tow trucks equipped with scanners? 5. Do you do any chase or first on scene towing? 6. Are all tows required to be dispatched by your office dispatcher? Exposure History: Vehicles Employees Current 1 st Prior Yr 2 nd Prior Yr 3 rd Prior Yr 4 th Prior Yr 5 th Prior Yr 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 3 of 9

4 Employee List IMPORTANT Show all employees including those who drive company cars (including family members who use car) and employees who drive their personal vehicle on company business including ANYONE furnished a vehicle whether they are employed by insured or not. Use the Driver Supplemental Form for additional employees/drivers. Name Date of Birth Date of Hire Job Duties / Title CDL? Status Copies of MVR s required for each person who (1) drives a company owned vehicle, or (2) regularly drives their own personal vehicle on company business. A n-owned Supplemental Application must be completed for all employees who use their vehicle regularly on company business. Are all drivers covered by workers compensation insurance? Are any owners or employees furnished an auto? If furnished, provide name and vehicle: If yes, name of carrier: 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 4 of 9

5 Vehicle Schedule Mandatory for NY: Provide License Tag numbers Veh 1 Model Year Vehicle Make Body Type GVW Loc Nbr Value* VIN On-Hook Limit On-Hook Ded *Values provided are Original Cost New ACV or Stated Value Radius of Operations: Percent (0-50 miles) % miles? % over 200 miles? % Regulatory Filings 7. Do you require a Federal filing? 8. Do you require a State Filing? 9. Do you require a MCS-90 endorsement? 10. Do you ever perform secondary tows of hazardous materials? 11. Do you ever tow/move hazardous materials on a primary haul basis? 12. MC/DOT Number? 13. State Docket Number? 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 5 of 9

6 Safety Management 14. Describe your safety program: 15. How often do you hold safety meetings? 16. Describe your driver training program: 17. Describe your vehicle take home policy/procedures: 18. Describe your drug testing policy/procedures: 19. Describe your accident review procedures: 20. Name and title of person in charge of Safety program? Maintenance 21. Do you maintain maintenance logs on all vehicles? 22. How often is routine maintenance performed? 23. Do you perform the routine maintenance? 24. Is maintenance provided by professional certified mechanics? 25. Do your drivers perform daily maintenance checks on all vehicles? 26. Are your drivers responsible for any cost of the maintenance of the vehicles? 27. Are your vehicles subject to an annual state inspection? Driver Management 28. Do you obtain a MVR (Motor Vehicle Record) on all drivers before hiring? 29. How often do you obtain an MVR on your drivers? 30. Do you maintain driver files on all drivers including MVR s and copies of tickets? 31. Do all your drivers meet all local, state and federal license requirements? 32. Do you require job references? 33. Do you check job references? 34. Do you road test all drivers prior to hiring? 35. Desribe your disciplinary/termination procedures: 36. Do you issue a 1099 to any employees or independent contractors? 37. Describe how drivers are compensated: 38. How many drivers quit or were fired last year? 39. How many drivers were hired last year? 40. How many drivers do you expect to hire this year? 41. Are your drivers required to take internal or external training courses? 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 6 of 9

7 Repossesions 42. Who issues the assignment to pick up a car? 43. Are the debtors notified in advance and agree to the repossession? 44. What is your policy if the debtor changes their mind? 45. Do you perform involuntary repossessions? Truck / Freight Hauling 46. Do you have any contracts to haul cargo for specific clients? 47. Do all drivers have CDL Class A licenses? 48. What cargo or commodities do you haul? 49. Do you haul, transport, tow or set up mobile/modular housing? 50. What is the maximum distance traveled? 51. What is your average distance? Operations 52. Do you lease vehicles from other companies or individuals? 53. Do you lease vehicles to other companies or individuals? 54. Do you hire sub-contractors at any time? 55. Do you own or lease any cranes or forklifts? 56. Do you have any vehicles owned or leased by you that are NOT on this schedule? 57. Do you require the use of safety chains on every tow? 58. Do you require the use of wheel lift straps on every tow? 59. Do you require the use of vehicle towing lights on every tow? 60. How many lien sales per month? 61. Do you dismantle autos or have salvage/recycling operations? 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 7 of 9

8 1. Will lessor be added as add l insured? If yes, give name and address of lessor in narrative. 2. Will loss payee be added? If yes, give name and address of loss payee in narrative. Prior Insurance and Loss History Information (3 years) Policy Period Carrier Premium Loss Runs Required. Provide minimum of current plus two prior years loss history for all coverage requested. Has similar insurance ever been cancelled, declined or not renewed? (t applicable in Missouri) If yes, explain: Narrative / Other Coverage Wanted 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 8 of 9

9 Disclosures and tices COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (t applicable in all states, consult your agent or broker for your state's requirements.) NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (t applicable in CO, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied) IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS THE POLICY OF INSURANCE APPLIED FOR DOES NOT PROVIDE COVERAGE AS REQUIRED BY ENVIRONMENTAL PROTECTION AGENCY (EPA) 40 CFR PARTS 280 AND 281 FOR UNDERGROUND STORAGE TANKS. NO COVERAGE UNDER CERLA OR SIMILAR STATE OR FEDERAL ENVIRONMENTAL ACT(S). THIS POLICY EXCLUDES ALL COVERAGE FOR POLLUTION. SIGNATURE OF APPLICANT I have read this supplement and certify that the answers and information herein are true and correct to the best of my knowledge. Signature of Insured: Print Name: Date: The undersigned is an authorized representative of the applicant and represents that reasonable enquiry has been made to obtain the answers to questions on this application. He/she represents that the answers are true, correct and complete to the best of his/her knowledge. SIGNATURE OF PRODUCER Signature of Producer: Print Name of Producer: Name of Agency: Date: Need State Producers license Nbr (required in FL): 2013 V3 Insurance Partners LLC Towing Application (V3/13) Page 9 of 9

Cossio Insurance Agency 864-688-0121 Fax: 864-688-0138 PO Box 188 Simpsonville SC 29681

Cossio Insurance Agency 864-688-0121 Fax: 864-688-0138 PO Box 188 Simpsonville SC 29681 DIRECTIONS: 1. Complete the application (all pages) in full by filling in the blue fields. 2. Please fill in all the fields with the correct information. 3. Email the application to apps@cossioinsurance.com

More information

NON OWNED & HIRED AUTO

NON OWNED & HIRED AUTO 1. Applicant Information A) Name (First named insured and other named insureds) OWNED AUTO LIABILITY B) Do you own any vehicle (in your company s name)? If yes, who is the insurer of these vehicles? C)

More information

Commercial Automobile Insurance Application

Commercial Automobile Insurance Application COMMERCIAL AUTOMOBILE INSURANCE APPLICATION Application Requirements: 1. FULLY COMPLETED APPLICATIONS: 1. Our Supplemental; 2. Acord 125; and 3. Acord 127. If additional space is needed, please use your

More information

MOTOR CARRIER APPLICATION FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE

MOTOR CARRIER APPLICATION FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE MOTOR CARRIER APPLICATION FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE Applicant: _ City, State: Proposed Effective Date: Proposed Expiration Date: Date Quote

More information

MOTOR CARRIER QUESTIONNAIRE FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE

MOTOR CARRIER QUESTIONNAIRE FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE MOTOR CARRIER QUESTIONNAIRE FOR TRUCKERS INSURANCE FOR NON-TRUCKING LIABILITY AND VEHICLE PHYSICAL DAMAGE COVERAGE Applicant: _ City, State: Proposed Effective Date: Proposed Expiration Date: Date Quote

More information

UMBRELLA / EXCESS SECTION

UMBRELLA / EXCESS SECTION UMBRELLA / EXCESS SECTION DATE (MM/DD/YYYY) IMPORTANT - If CLAIMS MADE is checked in the POLICY INFORMATION section below, this is an application for a claims-made policy. AGENCY CARRIER NAIC CODE POLICY

More information

7 TOW TRUCK PROGRAM SUPPLEMENTAL APPLICATION

7 TOW TRUCK PROGRAM SUPPLEMENTAL APPLICATION LICATION Named Insured: Owner s Name: Web site Address: Address: Type of business Individual Corporation LLC Other Federal Tax ID: I. ELIGIBILITY 1. Are at least 50% of the operations derived towing? Yes

More information

FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA APPLICATION FOR PRODUCT LIABILITY INSURANCE

FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA APPLICATION FOR PRODUCT LIABILITY INSURANCE Proposed Effective Date FARM EQUIPMENT MANUFACTURERS ASSOCIATION - FEMA APPLICATION FOR PRODUCT LIABILITY INSURANCE Please answer all questions. If not applicable, please indicate N/A. I. Applicant information

More information

PROFESSIONAL LIABILTY APPLICATION

PROFESSIONAL LIABILTY APPLICATION DIRECTIONS: 1. Complete the application (all pages) in full by filling in the blue fields. 2. Please fill in all the fields with the correct information. 3. Email the application to apps@cossioinsurance.com

More information

Lenders Property Reporting Policy

Lenders Property Reporting Policy Lenders Property Reporting Policy Fidelity and Deposit Company of Maryland Colonial American Casualty and Surety Company Application Named Insured: Address: Type of Institution: Date of Application: Agent:

More information

COMMERCIAL AUTO APPLICATION

COMMERCIAL AUTO APPLICATION COMMERCIAL AUTO APPLICATION Dependent upon state authority, you are applying for insurance coverage provided by and underwritten by one of the following insurance companies of ARGO GROUP US: ARGONAUT-MIDWEST

More information

WORKERS COMPENSATION APPLICATION

WORKERS COMPENSATION APPLICATION DIRECTIONS: 1. Fill in the application by filling in the blue fields on all pages. 1. 2. Please Complete fill in the all application enrollment the fields with form (all the pages) (all correct pages)

More information

EQUINE CARE, CUSTODY AND CONTROL APPLICATION

EQUINE CARE, CUSTODY AND CONTROL APPLICATION EQUINE FARM OPERATIONS P.O. Box 3278 Ocala, Florida 34478 EQUINE CARE, CUSTODY AND CONTROL APPLICATION Great American Insurance Co. (01) Great American Insurance Company of New York (03) Great American

More information

COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION CARRIER

COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION CARRIER AGENCY COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION (MM/DD/YYYY) NAIC CODE COMPANY POLICY OR PROGRAM NAME PROGRAM CODE CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS:

More information

UMBRELLA / EXCESS SECTION

UMBRELLA / EXCESS SECTION AGENCY UMBRELLA / EXCESS SECTION APPLICANT (First Named Insured) DATE (MM/DD/YYYY) POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT FOR COMPANY USE ONLY AGENCY

More information

CAROLINA CASUALTY INSURANCE COMPANY P.O. BOX 2575 JACKSONVILLE, FLORIDA 32203 (904) 363-0900 (800) 874-8053 FAX (904) 363-8093

CAROLINA CASUALTY INSURANCE COMPANY P.O. BOX 2575 JACKSONVILLE, FLORIDA 32203 (904) 363-0900 (800) 874-8053 FAX (904) 363-8093 CAROLINA CASUALTY INSURANCE COMPANY P.O. BOX 2575 JACKSONVILLE, FLORIDA 32203 (904) 363-0900 (800) 874-8053 FAX (904) 363-8093 MISCELLANEOUS PUBLIC AUTO PROGRAM APPLICATION A. GENERAL INFORMATION PROPOSED

More information

EXTERMINATORS GENERAL LIABILITY APPLICATION

EXTERMINATORS GENERAL LIABILITY APPLICATION EXTERMINATORS GENERAL LIABILITY APPLICATION Applicant s Name: Agency Name: Agent No.: Mailing Address: Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address

More information

RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World CONTRACTORS AND CONSULTANTS LIABILITY APPLICATION

RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World CONTRACTORS AND CONSULTANTS LIABILITY APPLICATION RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World CONTRACTORS AND CONSULTANTS LIABILITY APPLICATION INSTRUCTIONS: Please print or type clearly. If any questions do not apply, print

More information

Property/Casualty Insurance Renewal Survey Multi-State

Property/Casualty Insurance Renewal Survey Multi-State Property/Casualty Insurance Renewal Survey Multi-State P.O. Box 5670 Cortland, New York 13045 Phone (800) 822-3747 Fax: (607) 758-9028 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date

More information

Alarm Installation, Servicing, Monitoring or Repair General Liability Application

Alarm Installation, Servicing, Monitoring or Repair General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance

More information

RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World

RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World SITE SPECIFIC ENVIRONMENTAL LIABILITY APPLICATION RLI ENVIRONMENTAL INSURANCE Environmental Solutions for a Greener World INSTRUCTIONS: Please print or type clearly. Please answer all questions completely.

More information

COMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION

COMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION National Casualty Company Home Office: Madison, Wisconsin Adm Office: 8877 Gainey Center Dr. Scottsdale, Arizona 85258 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215

More information

Alarm Installation, Servicing, Monitoring or Repair General Liability Application

Alarm Installation, Servicing, Monitoring or Repair General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide

More information

Roush Insurance Services, Inc.

Roush Insurance Services, Inc. Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone (800) 752-8402 Fax (317) 776-6891 Email: quote@roushins.com www.roushins.com AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING

More information

Movie Boat Application

Movie Boat Application About This Program This application is used to insure watercraft and related activities as they relate to a production. Required Documents The following documents are required to apply for coverage: This

More information

Small Business Insurance Application

Small Business Insurance Application 3660 N Lake Shore Dr, Suite 2602, Chicago 60613 General Information Named Insured: Select Entity Type: Country of Residence: Country of Registration: Primary Address, City, State, Zip: Mailing Address,

More information

Caterers and Halls General Liability and Miscellaneous Articles Application

Caterers and Halls General Liability and Miscellaneous Articles Application Caterers and Halls General Liability and Miscellaneous Articles Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-Mail: Phone: Web site Address: PROPOSED EFFECTIVE

More information

Short Term Productions Application

Short Term Productions Application About This Program This application is used to insure a single production with a maximum budget of $1,000,000 and a maximum duration of 60 days within a 60 day consecutive period. Required Documents The

More information

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL) Surplus Call 800-342-5706 Insurance Fax 800-578-7758 www.surplusins.com Email quotes: submit@surplusins.com Brokers Agency Inc. P O Box 749, South Bend IN 46624-0749 AUTOMOBILE APPLICATION FOR INSURANCE

More information

FTP INC 131 WHITE OAK LANE OLD BRIDGE,NJ 08857 732 679 3700 FAX 732 679 6928

FTP INC 131 WHITE OAK LANE OLD BRIDGE,NJ 08857 732 679 3700 FAX 732 679 6928 FTP INC 131 WHITE OAK LANE OLD BRIDGE,NJ 08857 732 679 3700 FAX 732 679 6928 Auto Service Risks Application Applicant s Name Agency Name Agent Mailing Address Address Web site Address E-mail Phone PROPOSED

More information

WORKERS COMPENSATION SUPPLEMENTAL APPLICATION

WORKERS COMPENSATION SUPPLEMENTAL APPLICATION WORKERS COMPENSATION SUPPLEMENTAL APPLICATION NAMED INSURED: EFFECTIVE DATES: OWNERS Active Absentee Delegate Through Supervisors Years in Business: Years of Experience Same Industry: Other currently owned

More information

OFF-ROAD CLUB EVENT LIABILITY INSURANCE COVERAGE

OFF-ROAD CLUB EVENT LIABILITY INSURANCE COVERAGE OFF-ROAD CLUB EVENT LIABILITY INSURANCE COVERAGE Coverage Information General Liability Coverage for Car Club Social Events We offer affordable general liability protection for limits of $1 million for

More information

Artisan Contractors Application

Artisan Contractors Application Agency Name: Address: Contact Name: Phone: Fax: Email: Artisan Contractors Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent

More information

BUSINESS AUTO FLEET SUPPLEMENTAL APPLICATION

BUSINESS AUTO FLEET SUPPLEMENTAL APPLICATION GENERAL INFORMATION Date: Applicant Name: RISK PROFILE BUSINESS AUTO FLEET SUPPLEMENTAL APPLICATION 1. Years in business: 2. Does the applicant engage in interstate commercial trade? 3. Does the applicant

More information

CTP 5037 (11/11) Page 2 of 6

CTP 5037 (11/11) Page 2 of 6 COMMERCIAL AUTO APPLICATION New Business Renewal Expiring Policy # PO Box 2575 Jacksonville, Florida 32203 904-363-0900 800-874-8053 Fax 904-363-8093 1. GENERAL Applicant s Name: Mailing Address: Garaging

More information

Auto Service and Repair Insurance Application

Auto Service and Repair Insurance Application Auto Service and Repair Insurance Application Section I General Information Policy Period Desired From to 1. d Insured Type of Entity: Corp Partnership Individual LLC Other 2. For inspection purposes:

More information

HOME MEDICAL EQUIPMENT DEALER O&P INSURANCE SURVEY. (please include all organizations that are to be included as insureds)

HOME MEDICAL EQUIPMENT DEALER O&P INSURANCE SURVEY. (please include all organizations that are to be included as insureds) HOME MEDICAL EQUIPMENT DEALER O&P INSURANCE SURVEY P.O. Box 5670 Cortland, NY 13045 Phone: (800) 822-3747 Fax: (607) 756-5051 General Information Date of survey: Legal Name of Organization: Mailing Address:

More information

APPLICATION FOR TRUCK BROKER INSURANCE

APPLICATION FOR TRUCK BROKER INSURANCE APPLICATION FOR TRUCK BROKER INSURANCE I. Applicant Proposed Effective Date: Applicant Name: Street Address: Mailing Address: Applicant Phone: Email: Website # Years in Business: MC # DOT # Applicant operates

More information

Individual LLC Partnership Corporation Joint Venture Trust Principal or Majority Owner (please include all principals)

Individual LLC Partnership Corporation Joint Venture Trust Principal or Majority Owner (please include all principals) Insurance Indemnity Sections 1 through 6 must be completed for a quote indication. Sections 7 through 9 must be completed in order to bind. 1. General Information Applicant Legal Name Company Name (DBA)

More information

Commercial Insurance Applying - A Technical Analysis

Commercial Insurance Applying - A Technical Analysis Investigator Liability Insurance Application Application Requirements: FULLY COMPLETED APPLICATION: If additional space is needed, please use your firm's letterhead. Application must be Dated and Signed

More information

Primary Commercial Liability Insurance Application

Primary Commercial Liability Insurance Application Name of Insured:(Attach separate sheet if necessary) Address of Insured: Provide names of any subsidiaries or affiliated company(s) to be covered: 1. 2. 3. List all additional insureds to be named with

More information

CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE INSURANCE

CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE INSURANCE 370 West Park Avenue, P. O. Box 9004, Long Beach, NY 11561-9004 Tel: (516) 431-4441 Fax:(516) 889-9872 CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE

More information

HOTEL QUESTIONNAIRE/SURVEY FAX TO: 866-756-3037

HOTEL QUESTIONNAIRE/SURVEY FAX TO: 866-756-3037 HOTEL QUESTIONNAIRE/SURVEY FAX TO: 866-756-3037 Owner Information: Expiration Date: / Target Premium: $ Current Carrier: Business Name: Owner Name: ABVI#: Address: City: State: Zip: Business Phone: Business

More information

Individual LLC Partnership Corporation Joint Venture Trust Principal or Majority Owner (please include all principals)

Individual LLC Partnership Corporation Joint Venture Trust Principal or Majority Owner (please include all principals) Canal Truck Insurance Application Insurance Indemnity Sections 1 through 6 must be completed for a quote indication. Sections 7 through 9 must be completed in order to bind. 1. General Information Applicant

More information

Rental House Insurance Application

Rental House Insurance Application 3660 N Lake Shore Dr, Suite 2602, Chicago 60613 Rental House Insurance Application General Information Named Insured: Select Entity Type: Country of Residence: Country of Registration: Primary Address,

More information

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ).

BY COMPLETING THIS APPLICATION THE APPLICANT IS APPLYING FOR COVERAGE WITH THE INSURANCE COMPANY INDICATED ABOVE (THE INSURER ). Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Markel Insurance Company Associated International Insurance Company

More information

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE

More information

Landscaping General Liability Application

Landscaping General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 1-800-423-7675 Fax (480) 483-6752

More information

Exterminators General Liability Application

Exterminators General Liability Application Exterminators General Liability Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Web site Address: E-mail: Phone: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at

More information

Individual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.:

Individual Partnership D/B/A (if applicable): Corporation 2. P.O Box: Phone No.: Whenever used in this Application, the term Applicant means the Named Insured and any other entity proposed for coverage. ENDURANCE AGENCY ADVANTAGE APPLICATION THIS IS AN APPLICATION FOR INSURANCE WRITTEN

More information

Automobile Service Operations Application

Automobile Service Operations Application Automobile Service Operations Application NATIONAL INDEMNITY COMPANY OF THE SOUTH NATIONAL LIABILITY & FIRE INSURANCE COMPANY Administrative Office Omaha, Nebraska Desired Policy Term From: To: 1. Named

More information

Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION

Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers 1 st Choice REAL ESTATE SERVICES PROFESSIONAL LIABILITY COVERAGE APPLICATION Travelers Casualty and Surety Company of America Hartford, Connecticut IMPORTANT NOTE: This is an application for

More information

Lexington Insurance Company

Lexington Insurance Company BURGLAR & FIRE ALARM, AND TELECOMMUNICATIONS PROPERTY Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant

More information

PERSONAL UMBRELLA APPLICATION

PERSONAL UMBRELLA APPLICATION AGENCY PERSONAL UMBRELLA APPLICATION APPLICANT'S NAME AND MAILING ADDRESS (include county & ZIP+4) DATE (MM/DD/YYYY) CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS: CODE: SUBCODE: DATE

More information

AGENT NAME: NAME AND ADDRESS OF PERSON APPLYING FOR INSURANCE:

AGENT NAME: NAME AND ADDRESS OF PERSON APPLYING FOR INSURANCE: Owners / Contractors Protective Liability Application All questions must be answered in full. Application must be signed and dated by the Proposed Policyholder or their Authorized Representative NAME AND

More information

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)

AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL) National Casualty Company Home Office: Madison, Wisconsin Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza

More information

COMMERCIAL GENERAL LIABILITY INSURANCE APPLICATION - AIRPORT TENANTS (FBO)

COMMERCIAL GENERAL LIABILITY INSURANCE APPLICATION - AIRPORT TENANTS (FBO) QBAV-3019 (07-11) COMMERCIAL GENERAL LIABILITY INSURANCE APPLICATION - AIRPORT TENANTS (FBO) (Check which is desired) A QUOTATION INSURANCE POLICY RENEWAL POLICY Name of Applicant Address Applicant is:

More information

COMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION

COMMERCIAL AUTOMOBILE/TRUCKERS APPLICATION National Casualty Company Home Office: Madison, Wisconsin Adm Office: 8877 Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215

More information

INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION

INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION NOTICE: The insurance coverage for which you are applying is written on a claims-made and reported policy form. Subject to policy provisions,

More information

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY AND PREMISES LIABILITY INSURANCE APPLICATION THIS IS AN APPLICATION FOR CLAIMS-MADE AND REPORTED INSURANCE PROVIDED THROUGH HORIZON RISK INSURANCE, LLC. IT IS IMPORTANT

More information

PRODUCT LIABILITY SUPPLEMENTAL APPLICATION

PRODUCT LIABILITY SUPPLEMENTAL APPLICATION Note: This application must be completed in addition to the ACORD Applicant Information Section and the Commercial General Liability Application. Please attach the following information about your products

More information

Exterminator Liability Application

Exterminator Liability Application P.O. Box 440549 Local Telephone (678) 290-2100 Kennesaw, GA 30160 FAX (678) 290-2200 WATS 800-476-4940 Visit Our Website at www.thomcoins.com Exterminator Liability Application Instructions: This entire

More information

Garage and Garagekeepers Supplemental Application TEXAS

Garage and Garagekeepers Supplemental Application TEXAS Garage and Garagekeepers Supplemental Application TEXAS McNeil & Company, Inc. P.O. Box 5670 Cortland, New York 13045 Phone (800) 822-3747 Fax: (607) 758-9028 General Information Date of survey: Insurance

More information

COMMERCIAL AUTOMOBILE APPLICATION

COMMERCIAL AUTOMOBILE APPLICATION Home Office: One Nationwide Plaza Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 A STOCK COMPANY COMMERCIAL AUTOMOBILE

More information

GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application

GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application GREAT AMERICAN ASSURANCE COMPANY Real Estate Professional Liability Insurance Application NOTICE: This is an application for a Claims-Made policy. Coverage for prior acts and claims made after termination

More information

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application NOTICE: This is an application for a Claims-made policy. Coverage for prior acts and claims made after

More information

COMMERCIAL AUTO APPLICATION

COMMERCIAL AUTO APPLICATION Acceptance Indemnity Insurance Company Acceptance Casualty Insurance Company Occidental Fire & Casualty of North Carolina Wilshire Insurance Company Harco National Insurance Company Transguard Insurance

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE

More information

1. Insured Name: 2. Insured Address: 3. Insured Contact: Phone: A B C Location

1. Insured Name: 2. Insured Address: 3. Insured Contact: Phone: A B C Location Chubb Group of Insurance Companies 202 Hall s Mill Road, Whitehouse Station, NJ 08889 SOLAR ENERGY APPLICATION SUPPLEMENT APPLICANT INFORMATION 1. Insured Name: 2. Insured Address: 3. Insured Contact:

More information

St. Paul Fire and Marine Insurance Company GENERAL INFORMATION

St. Paul Fire and Marine Insurance Company GENERAL INFORMATION INTERNATIONAL INSURANCE APPLICATION St. Paul Fire and Marine Insurance Company GENERAL INFORMATION Named Insured Effective Date Mailing Address (Street, City, State, Zip Code) Website: Business of Insured:

More information

HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION

HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION HEATING, VENTILATION AND AIR CONDITIONING CONTRACTORS GENERAL LIABILITY APPLICATION Please note: This application is intended to be used for HVAC contractors with under $1,000,000 in receipts. On accounts

More information

PERSONAL UMBRELLA APPLICATION

PERSONAL UMBRELLA APPLICATION AGENCY PERSONAL UMBRELLA APPLICATION CARRIER DATE (MM/DD/YYYY) NAIC CODE APPLICANT'S NAME AND MAILING ADDRESS (include county & ZIP+4) CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS:

More information

Travelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION

Travelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION Miscellaneous Professional Liability Plus+ SM Travelers Casualty and Surety Company of America Hartford, Connecticut 06183 APPLICATION Policy NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES, SUBJECT

More information

APPLICATION FOR PRIMARY COMMERCIAL LIABILITY INSURANCE

APPLICATION FOR PRIMARY COMMERCIAL LIABILITY INSURANCE 3633 E. Broadway Long Beach, Ca. 90803-6035 800.272.4594 562.439.9731 Fax. 562.439.4453 danrod@hmbd.com www.hmbd.com APPLICATION FOR PRIMARY COMMERCIAL LIABILITY INSURANCE General Information Name of Insured:(Attach

More information

PERSONAL UMBRELLA APPLICATION

PERSONAL UMBRELLA APPLICATION AGENCY PERSONAL UMBRELLA APPLICATION CARRIER DATE (MM/DD/YYYY) NAIC CODE APPLICANT'S NAME AND MAILING ADDRESS (include county & ZIP+4) CONTACT NAME: PHONE (A/C, No, Ext): FAX (A/C, No): E-MAIL ADDRESS:

More information

Home Business Insurance Application

Home Business Insurance Application ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT RLI Insurance Company Peoria, Illinois Home Business Insurance Application Agency Name Address City State Zip RLI Administrator/Brokering

More information

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110

Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 Lexington Insurance Company Administrative Offices 100 Summer Street Boston, Massachusetts 02110 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE

More information

APPLICATION FOR UMBRELLA POLICY FOR INSURANCE AGENTS

APPLICATION FOR UMBRELLA POLICY FOR INSURANCE AGENTS Policy number Effective date Submitted by APPLICATION FOR UMBRELLA POLICY FOR INSURANCE AGENTS Instructions: (A) Answer all questions. If the answer is none, state none. (B) If space is insufficient to

More information

Property Managers Professional Package Product

Property Managers Professional Package Product COMMITTED TO A MAKING DIFFERENCE Property Managers Professional Package Product PROPERTY MANAGERS PROFESSIONAL PACKAGE PRODUCT APPLICATION All questions must be answered and application must be signed

More information

Cossio Insurance Agency 864-688-0121 Fax: 864-688-0138 PO Box 188 Simpsonville SC 29681

Cossio Insurance Agency 864-688-0121 Fax: 864-688-0138 PO Box 188 Simpsonville SC 29681 DIRECTIONS: 3. Email the application to apps@cossioinsurance.com of Fax it to 864-688-0138. Section 1: Applicant Information Applicant s Name (First, Middle,Last): Applicant s Mailing Address: Date of

More information

AVIATION GENERAL LIABILITY INSURANCE APPLICATION

AVIATION GENERAL LIABILITY INSURANCE APPLICATION AVIATION GENERAL LIABILITY INSURANCE APPLICATION Applicant s Name: Mailing Address: Name of Airport: Applicant is Individual Partnership Joint Venture Corporation Other: Type of Business is: FBO FAA Certified

More information

ERRORS & OMISSIONS INSURANCE APPLICATION

ERRORS & OMISSIONS INSURANCE APPLICATION ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: Indian Harbor Insurance Company 505 Eagleview Blvd. Suite 100 Dept: Regulatory Exton, PA 19341-1120 Telephone: 800-688-1840 THIS IS AN APPLICATION

More information

Greenwich Insurance Company

Greenwich Insurance Company REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION tice: This is an application for a policy that contains Claims-made liability protection. Coverage for prior acts and claims made after

More information

ACE Advantage. Employed Lawyers Professional Liability Application

ACE Advantage. Employed Lawyers Professional Liability Application ACE American Insurance Company Illinois Union Insurance Company Westchester Fire Insurance Company Westchester Surplus Lines Insurance Company ACE Advantage Employed Lawyers Professional Liability Application

More information

Auto Dealers Application

Auto Dealers Application P.O. Box 14770, Scottsdale, AZ 85267-4770 8475 E. Hartford Dr., Scottsdale, AZ 85255 (480) 991-7889 WATS (800) 848-8860 Fax (480) 948-1394 Toll Free (866) 240-8807 P.O. Box 571770, Murray, UT 84157-1770

More information

Small Fleet Truckers (6-19 Revenue Units) Underwriting Checklist

Small Fleet Truckers (6-19 Revenue Units) Underwriting Checklist Small Fleet Truckers (6-19 Revenue Units) Underwriting Checklist Fleet: City, State: Insured s Email Address: Expiration Date: Proposed Effective Date: Date Quote Required: Broker: Producer(s): Producer

More information

Condominium or Homeowners Association General Liability Application

Condominium or Homeowners Association General Liability Application Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide

More information

F. Schedule of Covered Autos (Dealers only) List any owned tow truck, car hauler, or service vehicle to be insured.

F. Schedule of Covered Autos (Dealers only) List any owned tow truck, car hauler, or service vehicle to be insured. GARAGE APPLICATION General Information Effective Date: 1. Your Name Phone No. (dba) 2. Mailing Address 3. Your Web site address 4. Location #1 Address 5. Location #2 Address Is there work done elsewhere?

More information

Workers Compensation - What You Need to Know

Workers Compensation - What You Need to Know 3250 Interstate Drive, Richfield, Ohio 44286-9000 800-929-1500 Fax: 330-659-8905 www.natl.com National Interstate Insurance Company National Interstate Insurance Company HI Triumphe Casualty Company WORKERS

More information

Insurance Agents and Brokers E&O Application

Insurance Agents and Brokers E&O Application Capitol Indemnity Corporation Capitol Specialty Insurance Corporation I. APPLICANT INFORMATION Insurance Agents and Brokers E&O Application 800 West 47 th Street, Suite 515 Kansas City, MO 64112 Phone:

More information

CONDOMINIUM OR HOMEOWNERS ASSOCIATION GENERAL LIABILITY APPLICATION

CONDOMINIUM OR HOMEOWNERS ASSOCIATION GENERAL LIABILITY APPLICATION P.O. Box 14770, Scottsdale, AZ 85267-4770 8475 E. Hartford Dr., Scottsdale, AZ 85255 (480) 991-7889 WATS (800) 848-8860 Fax (480) 948-1394 Toll Free (866) 240-8807 P.O. Box 571770, Murray, UT 84157-1770

More information

BUSINESS OWNERS SECTION

BUSINESS OWNERS SECTION AGENCY NAME BUSINESS OWNERS SECTION CARRIER DATE (MM/DD/YYYY) NAIC CODE POLICY NUMBER EFFECTIVE DATE FIRST NAMED INSURED POLICY TYPE PERSONAL PROPERTY LIABILITY OPTIONAL S 1. STANDARD MINIMUM GENERAL INFORMATION

More information

NON PROFIT MANAGEMENT LIABILITY APPLICATION

NON PROFIT MANAGEMENT LIABILITY APPLICATION NON PROFIT MANAGEMENT LIABILITY APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY. "CLAIMS" MUST BE FIRST MADE AGAINST AN "INSURED PERSON" DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED REPORTING

More information

DUMP & READY MIX/CEMENT TRUCK APPLICATION

DUMP & READY MIX/CEMENT TRUCK APPLICATION DUMP & READY MIX/CEMENT TRUCK APPLICATION Dependent upon state authority, you are applying for insurance coverage provided by and underwritten by one of the following insurance companies of ARGO GROUP

More information

OIL & GAS CONTRACTORS SUPPLEMENT (Must be fully completed and attached to the application)

OIL & GAS CONTRACTORS SUPPLEMENT (Must be fully completed and attached to the application) SEND SUBMISSIONS TO: submissions@coverx.com www.coverx.com Producer: Producer Is: Wholesaler Retailer Address: Telephone: Fax: Excess & Surplus Lines License No.: Email: Proposed Effective Date: If Renewal,

More information

6. Number of employees including principals: Full-time Part-time Seasonal Total

6. Number of employees including principals: Full-time Part-time Seasonal Total Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED

More information

Inspectors General and Professional Liability Application

Inspectors General and Professional Liability Application Inspectors General and Professional Liability Application ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE Please provide the following information along with this application: 1. Resume

More information

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application

Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application Navigators Insurance Company Real Estate Professionals Errors and Omissions Insurance Application Herbert H. Landy Insurance Agency Inc. 75 Second Avenue, Suite 410 Needham MA 02494 Phone: (800) 336-5422

More information

Personal Lines Insurance Agents Professional Liability

Personal Lines Insurance Agents Professional Liability Personal Lines Insurance Agents Professional Liability PART I - AGENCY DETAILS P.O. Box 2909 Jacksonville, FL 32203-2909 Phone: 800-342-2498 Fax: 904-355-7611 www.shellyins.com INSURANCE AGENTS AND BROKERS

More information

UMBRELLA / EXCESS SECTION

UMBRELLA / EXCESS SECTION AGENCY UMBRELLA / EXCESS SECTION DATE (MM/DD/YYYY) IMPORTANT - If CLAIMS MADE is checked in the POLICY INFORMATION section below, this is an application for a claims-made policy. Read all provisions of

More information