BUSINESS OWNERS PACKAGE INSURANCE APPLICATION

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1 BUSINESS OWNERS PACKAGE INSURANCE APPLICATION Progrm ville through: CAMICO Insurnce Services Tel:

2 Prt 1: Generl Informtion 1. Firm Nme: 2. Contct Person: (Person designted nd uthorized y the Firm to receive ny nd ll notices concerning this insurnce.) 3. Contct Person Title: 4. Contct Person E-mil: 5. Primry Miling Address: Miling Address City Stte Zip 6. Telephone: 7. Fx: 8. Entity Type: Sole Proprietorship Prtnership / LLP Corportion LLC PC Other (list): (If prtnership, plese provide list of ll prtners on seprte sheet) 9. Yer Estlished (yyyy): 10. We Site: 11. Do you hve more thn 50% ownership interest in ny other usiness? Yes No If Yes, plese list: Prt 2: Coverge Options Business Owners Pckge Property & Liility Complete Prt 3 (elow) Business Umrell (optionl) Complete Prt 5 (pge 2) Prt 3: Business Owners Pckge Coverge Property & Liility 12. Effective Dte: 13. Numer of office loctions: Plese complete the ttched Additionl Loction Supplement for ech dditionl loction (Pge 4.) 14. Primry Building Address: (If different from #5) Street Address City County Stte Zip 15. Building vlue: $ 16. Business personl property (*contents) vlue: $ (if owner) * Office furniture, copiers, fcsimile mchines, etc. 17. Tennts improvements & etterments vlue: $ (Instlled fixtures, e.g. cuicles, kitchen etc.) 18. Computers & medi vlue: $ 19. Construction Type: Frme Joisted msonry Non-comustile Msonry, non-comustile Fire resistive 20. Yer Built: 21. Fully sprinklered? Yes No 22. Are occupied t this loction (sq.ft.): 23. Annul revenue t this loction: $ 24. Numer of stories: 25. Numer of property or liility losses in lst 3 yers: If there hve een ny losses plese complete the ttched Property Loss History Supplement (Pge 5) nd loss runs on seprte sheet of pper. CIS - BOP (rev. 03/11) CAMICO Insurnce Services

3 Prt 4: Bsic Coverge Requested 26. Liility Limit: $1,000,000 per occurrence / $2,000,000 ggregte $2,000,000 per occurrence / $4,000,000 ggregte 27. Fire Legl Limit: $300,000 $500,000 $1,000,000 (minimum) 28. Property Deductile: $500 $1000 $2500 $ Do you currently hve Business Auto Policy? Yes No If, Yes, plese complete the ttched Business Owned Auto Supplement (Pge 5). 30. Do ny of your employees regulrly (more thn 3 times per week) use their personl utos s prt of their jo requirements? If Yes, plese complete the ttched Hired Non-Owned Auto Supplement (Pge 5). Yes No Prt 5: Business Umrell (optionl) 31. Umrell coverge in ddition to the primry liility limits: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Prt 6: Prior Crrier Informtion 32. Hve you hd ny prior usiness owners insurnce in the lst 4 yers? Yes No If Yes, plese list crriers, policy numers, expirtion dtes, premium if ville. Crrier Policy Numer Expirtion Dte Premium Prt 7: Business Owned Auto Supplement (optionl for Corp. & L.L.C. Entities) 33. If you hve usiness uto policy, wht is your effective dte? 34. If you hve usiness owned vehicles, plese list ll drivers: Nme License Numer Stte DOB 35. Plese list ny vehicles registered to your usiness: Vehicle VIN Yer Mke Model Body Type Vehicle Grge Zip Rdius (Truck) GVW (Truck) Cost New Comp. Ded Coll Ded 36. Numer of usiness owned uto losses in lst 3 yers: If ny losses, plese complete the ttched Business-Owned Auto Loss Supplement (Pge 5). CIS - BOP (rev. 03/11) CAMICO Insurnce Services

4 Prt 8: Signtures The undersigned proprietor, uthorized prtner of the prtnership, or uthorized stockholder of the corportion represents tht the following sttements re understood nd greed to y the pplicnt: By signing this ppliction, the undersigned represents tht he or she hs mde inquiries of ll Firm memers s pproprite nd tht ll Firm memers re ound y the representtions mde on this ppliction, ny supplementl ppliction, nd ny supplementl dt nd documents provided. Signing this ppliction or tendering premium does not ind the pplicnt or the compny to issue insurnce coverge, ut it is greed tht this ppliction shll e the sis of the contrct should policy e produced. Nme: (Plese Print) Signture: Dte: Position/Title: Applicnt/Firm: Plese send completed ppliction nd pproprite supplementl forms to: Sles Deprtment Cll: CAMICO Insurnce Services E-mil: 1800 Gtewy Drive, Suite 300 Fx: Sn Mteo, CA WARNING Residents of Arizon, Arknss, Colordo, District of Columi, Florid, Georgi, Kentucky, Louisin, Mine, New Jersey, New Mexico, North Crolin, Ohio, Oklhom, Oregon, Pennsylvni, Tennessee, Virgini, Wshington nd West Virgini Any person who knowingly nd with intent to defrud ny insurnce compny or other person files n ppliction for insurnce or sttement of clim contining ny mterilly flse informtion or concels for the purpose of misleding, informtion concerning ny fct mteril thereto commits frudulent insurnce ct, which is crime nd sujects such person to criminl nd civil penlties, including ut not limited to fines, denil of insurnce enefits, civil dmges, criminl prosecution nd imprisonment. (For Arizon, Florid, Georgi, North Crolin, nd Oregon residents only: All sttements nd descriptions in this ppliction for insurnce nd in ny negotitions therefore, y or ehlf of the insured, shll e deemed to e representtions nd not wrrnties. For CO residents only: Any insurnce compny or gent of n insurnce compny who knowingly provides flse, incomplete, or misleding fcts or informtion to policyholder or climnt for the purpose of defruding or ttempting to defrud the policyholder or climnt with regrd to settlement or wrd from insurnce proceeds shll e reported to the Colordo Division of Insurnce within the Deprtment of Regultory Agencies.) CIS - BOP (rev. 03/11) CAMICO Insurnce Services

5 Additionl Loction Supplement Supplements 1. Office loction 2: Street Address City County Stte Zip 2. Building vlue: $ 3. Business personl property (*contents) vlue: $ (if owner) * Office furniture, copiers, fcsimile mchines, etc. 4. Tennts improvements & etterments vlue: $ (Instlled fixtures, e.g. cuicles, kitchen etc.) 5. Computers & medi vlue: $ 6. Construction Type: Frme Joisted msonry Non-comustile Msonry, non-comustile Fire resistive 7. Yer Built: 8. Fully sprinklered? Yes No 9. Are occupied t this loction (sq.ft.): 10. Annul revenue t this loction: $ 11. Numer of stories (if owned): 1. Office loction 3: Street Address City County Stte Zip 2. Building vlue: $ 3. Business personl property (*contents) vlue: $ (if owner) * Office furniture, copiers, fcsimile mchines, etc. 4. Tennts improvements & etterments vlue: $ (Instlled fixtures, e.g. cuicles, kitchen etc.) 5. Computers & medi vlue: $ 6. Construction Type: Frme Joisted msonry Non-comustile Msonry, non-comustile Fire resistive 7. Yer Built: 8. Fully sprinklered? Yes No 9. Are occupied t this loction (sq.ft.): 10. Annul revenue t this loction: $ 11. Numer of stories: CIS - BOP (rev. 03/11) CAMICO Insurnce Services

6 Property Loss History Supplement 1. Plese complete for ny losses in the lst 3 yers. Attch loss runs or descrie elow if not ville. Dte of Loss Description Loss Amount Business Owned Automoile Supplement 1. Plese complete for ny losses in the lst 3 yers. Attch loss runs or descrie elow if not ville. Vehicle Dte of Loss Drive Nme At Fult (y/n) Incurred Amount Vehicle Liility Uninsured Motorist Physicl Dmge Description Hired/Non-owned Automoile Insurnce-Drivers Informtion Supplement 1. Include ll ccountnts nd ny employees, in the course of their usiness dy who drive their own vehicles for usiness utilized more thn 3 times week. Nme Drivers License # Stte Licensed CIS - BOP (rev. 03/11) CAMICO Insurnce Services

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