PERSONAL INLAND MARINE APPLICATION


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

POLICY STATUS :   New   Renewal, Prior Policy #:  Effective Date Of Coverage:  
Applicant's Name and Mailing Address:
Location of Property(if different from above):
Additional Interest - Name and Address:
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:
Dwelling - Location Of Property Description:
Construction: Frame Masonry
Protection Class:
ft from Hydrant miles to station
Occupancy:  Primary  Secondary  Rental
# of residents in household:  
# of families in dwelling:  
Dwelling Insurance Carrier:   
Dwelling Coverage A Limit: $  
Applicant Information:
Current Employer Name: 
Occupation: 
Years Employed: 
Previous Employer Name: 
Occupation: 
Years Employed: 
Marital Status:  
Social Security #  DOB: 
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:
Loss History: Any losses, whether or not paid by insurance, during the last 5 years, at this or at any other location? Describe:
Date Type Description Amount
$
$
$
$

NOTICE OF INSURANCE PRACTICES:


Personal information about you may be collected from persons other than you. Such information as well as other personal and privileged information collected by us or the agents may in certain circumstances be disclosed to third parties. You have the right to review your personal information in our files and can request corrections of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent/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 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.

Producer: How long have you known the applicant? Date agent last inspected property?


Please submit to my following underwriter
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I do not have an assigned underwriter
please assign me an underwriter