Application for Coverage Building & Business Personal Property Insurance

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1 Application for Coverage Building & Business Personal Property Insurance Please type or print Please read this before filling out your application for Building & Business Personal Property insurance. You warrant and represent that the following statements are yours, and that you know the statements to be true. You know and intend that we will rely on the truth of the information you have provided in deciding to issue a policy to you, and that providing any false information in this application is grounds for us to deny you insurance. Desired Coverage Date: / / 1. I am applying as a(n): Individual Corporation Partnership Joint venture Other DBA (NAME OF BUSINESS ENTITY) CORPORATE NAME Name insured (List all owners): Mailing Address: Location Property Address, If Different than Mailing Address: Office Telephone Alternate telephone FAx address tax id/ssn Is TDIC your current professional liability insurer? Yes If no, please give the name of your current insurer. Deductible Chosen: $500 $1, Insured Location Building Information Occupant status: Building Owner Tenant Condominium Is the building currently occupied as a dental office? Yes Are renovations planned now or in the future? Yes If yes, when? Building Construction Material: Wood frame Masonry (concrete, brick with combustible frame, joist or roof) n-combustible fire resistive (steel frame, non-combstible roof) PAGE 1 OF 5

2 YEAR BUILT NUMBER OF UNITS BUILDING SQ. FEET NUMBER OF FLOORS YOur office SQ. Footage Do you provide lab services for other dental offices? Yes % LIST OCCUPANCIES IF OTHER THAN MEDICAL PROFESSION OFFICES PERCENTAGE OF VACANCIES IN THE BUILDING If the building is more than 30 years old, please advise if the following has been updated Electricity and roofing completed in the last 10 years Yes if no, when?. / / Alarm and protection systems: Sprinkler Yes Burglar Yes Are all operatories equipped with closed-end water units? Yes 3. Amount of Coverage Needed Building Replacement Cost (if you own the building and desire coverage) Business Personal Property Indicate the cost to replace with new equipment in the event of a total loss. Radiograph equipment... Dental operatories (furniture, equipment, supplies, chairs and disposable supplies)... Number of operatories All other dental equipment (excluding laboratory equipment)... Laboratory equipment... Equipment and supplies... Waiting room furniture... Tenants improvements and betterments... Nitrous oxide tanks and related equipment... Electronic Data Processing (EDP) or hardware/software... Computer backup? Yes Stored off-site? Yes Other (please describe)... Total BPP Limits Loss of income is included for $750 per day for 10 days/actual loss sustained, not to exceed 24 months. Other per-day limits available for loss of income (offered in increments of $100 up to $2,000 per day)... Gross Annual Income... Monthly Payroll... PAGE 2 OF 5

3 Coverage included at no additional cost Basic Limits Total Limits Desired (if more than basic limits) Signs...$10, Extra Expense (actual loss sustained)...up to $100,000 Valuble papers and records... $25,000 if backup is maintained (including radiographs, patient charts, records, negatives, prints, etc.) $10,000 if backup is not maintained Accounts Receivable...$100, Money and Securities...$10, Employee dishonesty including ERISA coverage...$25, (welfare/pension/profit sharing) Plan name (250,000 maximum) Gold and Other Precious Metals...$5, Fine Art...$5, Newly Acquired Buildings and Business Personal Property...$500,000 Personal Property Off-Premises/Personal Property in Transit... $25,000 Personal Effects...$10,000 Optional coverage (additional cost) Data Compromise ($500 deductible) If this coverage is desired, please select one of the following limits: $50,000 (proceed to step 4) $100,000 (answer questions 1-3 below before proceeding to step 4) $250,000 (answer questions 1-5 below before proceeding to step 4) 1. Has your organization suffered a breach of personal information in the last 12 months?...yes 2. Does your organization conduct background screens for prospective employees?...yes 3. Does your organization have a posted document retention/destruction policy in place?...yes 4. Does your organization maintain regularly updated computer security measures (e.g., firewall, secured wireless connectivity and virus protection)?...yes 5. Are your organization s employee, customer and other physical records maintained in a secure environment with limited access?... Yes PAGE 3 OF 5

4 4. Insurance History Prior carrier Policy No.: Has any carrier cancelled or refused renewal? Yes If yes, please explain. Is there any ongoing problem with your property that we or your current carrier should be aware of? Yes If yes, please explain. 5. Claims/Loss History Have you had any property losses in the last five years? Yes If yes, describe the loss. Date of Loss: / / Amount paid: Has the claim been closed? Yes Description of what has been done to to prevent further losses: 6. MortGagee/Loss Payee Information Attach separate sheet, if neccesary. Name Mortgagee Loss payee Description of INTEREST loan number Name Description of INTEREST loan number I authorize release and exchange of information between my past and present insurance carriers and The Dentists Insurance Company, involving past and future underwriting and claims matters. I have answered the questions on this application truthfully. I agree to notify of any change in the information contained in the application before and after a policy is issued and to supply such further underwriting information as may require. I further agree to be bound by the underwriting guidelines of. I understand the importance of requesting sufficient insurance equal to 100 percent of the replacement value of my property. If I have not requested sufficient coverage, I understand a loss I might have may affect my future insurability. Signature of ApplICANT Date PAGE 4 OF 5

5 Return this application by mail or fax. MAIL TO: FAX TO: P.O. Box 1582 Sacramento, CA Questions? Call your local broker: California , TDIC Insurance Solutions Hawaii , Jerry Hay, Inc. Illinois , TDIC Insurance Solutions Minnesota , TDIC Insurance Solutions, Inc. Nevada , TDIC Insurance Solutions New Jersey , Mid-Atlantic Insurance Resources Pennsylvania , PDAIS, Inc. All other states , TDIC FRAUD WARNINGS New Jersey Professional & Business Liability Application Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Pennsylvania Professional & Business Liability Application 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 insurance act, which is a crime and subjects such person to criminal and civil penalties. PAGE 5 OF 5

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