HO61 - SCHEDULED PERSONAL PROPERTY
SUPPLEMENTAL APPLICATION


All fields are required, otherwise enter 'n/a' for not applicable.
Producing Office:
Producer Name:
E-mail:
Address:
Phone #:
Fax #:

Applicant's Name:    Effective Date Of Schedule:   
Please indicate the total amount of coverage required by category:
# Property Limit Requested
1 Jewelry: $
Men's $
Women's $
In-Vault $
2 Furs $
3 Cameras $
Private Use $
Professional Use $
# Property Limit Requested
4 Musical Instruments $
Private Use $
Professional Use $
5 Silverware $
6 Golfer's Equipment $
7 Golf Carts $
8 Stamps $
9 Rare Coins $
# Property Limit Requested
10 Fine Arts $
Limited Breakage $
Full Breakage $
11 Guns/Firearms $
12 Bicycles $
Additional Rating Information:
General Information:
Explain all Yes responses in remarks section Y N Explain all Yes responses in remarks section Y N
Central Station Alarm System? Fire Burglar Dwelling occupied during the day?
Any Motion Detector Sensors? Dwelling up for sale or vacant?
Dwelling protected by sprinkler system? Travel for more than 30 days at a time? With any items?
Are all exterior doors protected by dead bolt locks? Are any items kept away from the listed premises?
Dwelling situated within Gated Community? Any scheduled items not worn by a household member?
Do you have a safe in residence? Specify Below: Any articles away at student's dorm/apartment? Value?
Wall Safe Freestanding
Underfloor Other 		- - Any Items loaned to museums or on exhibit?
Is property protected by any other means? Any in-vault items removed from the vault?
# Times?
Any part of the dwelling used professionally/commercially? Any jewelry with unset, damaged stones?
Any business conducted on premises?
Type? 		Have you or any member of the household had any: - -
Any Child Care or Day Care (paid or not) on premises? - foreclosures, repossessions or bankruptcies?
Dwelling/Unit within Downtown City Limits? - been convicted of arson, dishonesty, theft?
If apartment or condominium, 1st floor unit? - scheduled coverage cancelled or denied?
Is any professional equipment stored off premises? Dwelling within 1 mile of the coast?
Any paid or non-paid caretakers/housekeepers? Dwelling protected by Storm Shutters?
Remarks Section:
Prior Carrier For Scheduled Items:
 Exp Date:
 Expiring Premium:
# Provide a detailed description of each item, from whom purchased, etc. If additional space is required, use the schedule on the reverse side, be sure to attach all required appraisals/bills. Purchase/Appraisal Date Amount of Insurance
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Please submit to my following underwriter
- or-
I do not have an assigned underwriter
please assign me an underwriter