| Location for this Quote(Address) |
|
| Please answer these questions based on your primary location and building. If you have additional locations or buildings, please submit another copy of this section and answer the questions for your other property.
Home based businesses should complete the following questions based on the business portion of the home. |
| What is the desired Property Deductible? |
$500 |
$1,000 |
$5,000 |
$10,000 |
| Is the business within 1,000 feet of a fire hydrant? |
Yes
No
|
| Is the business within 5 miles of a Fire Station? |
Yes
No
|
| What is the 100% replacement value of the business personal property (including business contents, fine arts, value of all computer hardware and software and laptops)? |
$
|
| What is the construction of the building where the business is located? |
Frame
(wood) |
Joisted masonry
(brick) |
Non-combustible
(steel) |
Masonry non-combustible
(tilt-up concrete) |
Fire resistive |
| What is the square footage of the space occupied by the business? |
|
| Is the business the sole occupant of a free standing building? |
Yes
No
|
| Does the building have an automatic sprinkler system covering 100% of the premises? |
Yes
No
|
| Does the business have a central station burglar alarm? |
Yes
No
|
| Is there any use of grills or deep fat frying in your business operations or in any other businesses in your building? (i.e. restaurant in the same building) |
Yes
No
|
| Please indicate whether the following optional coverages are desired: |
| a) Earthquake Coverage (not available in all areas): |
Yes
No
|
| b) Sprinkler Leakage - Earthquake |
Yes
No
|
| c) Flood Coverage (not available in all areas): |
Yes
No
|
| d) Computer Mechanical Failure and Computer Virus Coverage ($100,000 limit) |
Yes
No
|
| e) Systems Breakdown Coverage? (i.e. boilers, pressure vessels, AC units, etc... ) |
Yes
No
|
| f) Mine Subsidence Coverage (KY, IL, IN, WV only) |
Yes
No
|
| g) Business Income from Dependent Properties ($10,000 limit) |
Yes
No
|
| h) Personal Property Off Premises and Property in Transit Limited International Extension Endorsement |
Yes
No
|
| i) Business Income Sub-limit |
Yes
No
|
| If yes, choose limit option desired: |
|
$100,000 |
$200,000 |
$300,000 |
$400,000 |
$500,000 |
| j) Business Income Waiting Period Deductible (24 hours) |
Yes
No
|
| k) Business Income Off Premises Power Failure ($10,000 limit) |
Yes
No
|
| Please indicate whether any of the following exclusions are desired: |
| a) Business Income Exclusion |
Yes
No
|
| b) Theft Exclusion |
Yes
No
|
| c) Windstorm and Hail Exclusion |
Yes
No
|
| d) Stock Exclusion |
Yes
No
|
| What is the total maximum daily value of money and securities (i.e. checks) on the premises? |
|
The policy includes limits of $10,000 inside the business and $2,000 while being delivered to the bank.
If higher limits are desired, choose one of the following options:
(Please note that in order to receive higher limits use of a safe on premises is required.) |
|
$20,000 / $4,000 |
$30,000 / $6,000 |
$40,000 / $8,000 |
$50,000 / $10,000 |
| If loss of refrigeration coverage is desired, please provide the total value of property subject to refrigeration? |
|
| Many property coverage forms provide for coverage similar to the limits below. If you require higher limits than listed please list below. |
| Fire Dept. Service Charge/Fire Extinguisher Recharge |
$2,500 |
Money Orders and Counterfeit Currency |
$2,500 |
| Forgery and Alteration |
$2,500 |
Increased Construction Cost (after a loss) |
$5,000 |
| Glass |
$2,500 |
Signs |
$2,500 |
| Customers’ Goods on Premises |
$10,000 |
Back-up of Sewer/Drains |
$2,500 |
| Personal Property Off Premises |
$5,000 |
Property In Transit |
$5,000 |
| Valuable Papers/Records on premises |
$10,000 |
Accounts Receivable at the premises |
$10,000 |
| Employees Dishonesty - ERISA |
$2,500 |
|
|
| Indicate coverage area where you will require limits higher than shown above |
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