HOG CONFINEMENT QUESTIONNAIRE
|
|
|
- Marilyn Stevens
- 5 years ago
- Views:
Transcription
1 HOG CONFINEMENT QUESTIONNAIRE Named Insured: Agency: PROPERTY Exposures: In addition to answering the following questions, please provide photos and a diagram of the complete complex, illustrating the dimensions and distances between the buildings. 1. Were the buildings originally constructed for the purpose of hog confinement? a. Is this a new entity? b. Is it under construction? 2. Who built the buildings and when were they constructed? Date Constructed: 3. What is the construction of the buildings? 4. Are heat sensors or fire alarms present? 5. Is there a back-up generator available to provide power in the event of a power outage? What make/model is it? _ 6. Is the back-up generator fixed/stationary or portable? 7. Must the generator be started manually or will it start automatically when power goes out?
2 8. Is there an alarm which will sound or automatically contact people in the event of a power outage? 9. If so, can this alarm reach employees on a 24 hour basis? 10. Are fire divisions (fire rated doors) separating the various buildings? 11. What type of insulation is being used? 12. What type material is covering the insulation and what is the thickness of this material? (e.g. ½ drywall, ¾ plywood?) 13. Are light bulbs and electrical fixtures moisture resistant? (e.g. Bulbs enclosed in sealed globes?) 14. Is the wiring exposed or in conduit (metal or plastic)? 15. Are the circuit breaker switches checked regularly to prevent them from locking? If yes, how often are they checked? 16. What type of heating system is being used? Give details. 17. Are any portable heaters being used? If yes, explain why and when they are used.
3 18. What type of manure removal system is being utilized? Provide details. 19. Is fuel stored on premises? If so, is it adequately protected? On Premises? Protected? 20. Are NO SMOKING signs posted? 21. What is the quality of housekeeping inside the buildings? Explain any exposures. 22. Is the area surrounding the building properly maintained and mowed? 23. Does the risk contain at least one fire extinguisher (rated 20A, 2OBC) every 75 feet (maximum distance traveled)? If not, explain. 24. Are fire extinguishers inspected monthly by insured and tagged annually by qualified service contractor? 25. Does the insured have a Fire Safety Plan in place with the employees being trained in exactly what to do in the event of a fire? GENERAL LIABILITY exposures:
4 26. Has the insured been subjected to complaints or nuisance lawsuits filed by neighbors due to odor arising from his premises? If yes, explain. 27. What measures does the insured take to control odor? 28. Is the confinement operation within 1 mile of residential development? 29. How many residences are within 1 mile of the confinement operation? 30. When were waste lagoons built and who designed them? 31. Were the lagoon plans approved by the state agency governing them? 32. Were permits obtained from the state to construct lagoons? 33. Are any lagoons diked (walls holding back waste water)? 34. Are lagoons within 1/2 mile of a stream or river? 35. Are lagoons lined with clay? With plastic? Clay?
5 Plastic? 36. Are lagoons pumped out at least twice a year? 37. Are the lagoons fenced? (Mandatory for Liner Coverage) 38. Describe waste management program. (attach additional pages if needed) 39. Has the insured ever been cited for an improperly functioning lagoon system? 40. Ownership:Who are the owners of the facility? 41. Who are the owners of the livestock? Please continue to next page.
6 To: Agent and Applicant Your application, quote, and policy does not offer coverage s for pollution. The definition of pollution is found in the coverage parts. Odors, manure, wastes, are part of the exclusion. Coverage for pollution is available through specialized markets. Agents should contact those markets for coverage, and applicants should contact the agent for the coverage request. Coverage for chemical drift from agricultural spray is covered up to $25,000 by an amendatory endorsement and is included on all policies. The coverage is applicable for damage to crops and animals only. Higher limits requests may be submitted to the Company. Agent Signature Date Applicant Signature Date
KENTUCKY FAIR PLAN APPLICATION FOR HOMEOWNERS COVERAGE FORM HO-8
KENTUCKY FAIR PLAN APPLICATION FOR HOMEOWNERS COVERAGE FORM HO-8 PRODUCER INSTRUCTIONS INCOMPLETE APPLICATIONS WILL BE DELAYED AND/OR RETURNED BY THE FAIR PLAN IMPORTANT Returned applications create an
CONVENIENCE STORE QUICK APPLICATION WITH AND WITHOUT GAS PUMPS
CONVENIENCE STORE QUICK APPLICATION WITH AND WITHOUT GAS PUMPS Binding subject to any additional information when required by IIC. Agency Agency Contact Email: Effective Date Expiration Date: Years in
THIS DOCUMENT IS FOR REFERENCE PURPOSES ONLY PLEASE COMPLETE AGENT CENTER APPLICATION TO SUBMIT
THIS DOCUMENT IS FOR REFERENCE PURPOSES ONLY PLEASE COMPLETE AGENT CENTER APPLICATION TO SUBMIT ** The Agent Center application requires further detail for any answers marked YES. ** AgriChoice Insurance
Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT P.O. Box 4439 Sandy, UT Fax
Salt Lake City Area Office 8722 S. Harrison St. Sandy, UT 84070 P.O. Box 4439 Sandy, UT 84091 800-257-5590 Fax 800-478-9880 Chicago Office 303 W. Madison Street Suite 2075 Chicago, IL 60606 800-456-4576
Surplus Insurance Brokers Agency Inc.
Surplus Brokers Agency Inc. GARAGE INSURANCE APPLICATION Call 800-342-5706 Fax 800-578-7758 www.surplusins.com Email quotes: submit@surplusins.com P O Box 749, South Bend IN 46624-0749 Section I General
T: W:
INSURANCE AGENCY ABOUT YOU TITLE FIRST NAMES SURNAME YOU YOUR PARTNER DATE OF BIRTH OCCUPATION POSITION YOU YOUR PARTNER ADDRESS OF BUILDINGS TO BE INSURED POSTCODE HOME TELEPHONE NUMBER WORK TELEPHONE
Service is our Hallmark.
A M E R I C A N Kansas New Business: 6/30/10 Renewal Business: 9/8/10 Dwelling Fire Program DP-1 Basic Form DP-2 Broad Form Special Form Service is our Hallmark. GENERAL RULES The Dwelling Fire program
MUSIC Condominium/Homeowners Association Supplemental Application
Applicant s Name DBA Agent Name Address Mailing Address Proposed Effective Date: Web Address From To (12:01 am Standard Time at the address of the Applicant) The Association is: Years of Experience years
THE HARTFORD LIVESTOCK DEPARTMENT (800) POULTRY AND HATCHERY APPLICATION
THE HARTFORD LIVESTOCK DEPARTMENT www.hartfordlivestock.com (800)-295-1815 POULTRY AND HATCHERY APPLICATION Producer s Name Applicant s Name Agency Code FEIN or SOC SEC # Mail Address Mail Address City,
Farm & Ranch Application
Farm & Ranch Application PO Box 4479, Houston Texas 77210 or 3131 Eastside #600, Houston Texas 77098 P. 713.351.8348 800:235:3817 F. 713.351.8492 800.294.0851 ncy Information Code: Address: Name: City:
CSE Safeguard Insurance Company
PO Box 1 PO Box 11660 303 Lennon Lane 2 nd Floor Salt Lake City UT 84147 Walnut Creek CA 94598 Ph: 888-273-1220 Ph: 925-947-2990 Fx: 801-363-0958 Fx: 925-947-3978 CSE Safeguard Insurance Company DWELLING
Service is our Hallmark.
A M E R I C A N Colorado New Business: 7/24/12 Renewal Business: 7/24/12 Dwelling Fire Program DP-1 Basic Form DP-2 Broad Form DP-3 Special Form Service is our Hallmark. GENERAL RULES The Dwelling Fire
CONTRACTORS PROTECTOR PROGRAM
CONTRACTORS PROTECTOR PROGRAM ITEM TABLE OF CONTENTS NSCO PAGE Applications... 1 Billing Procedures... 2 Eligibility and Underwriting Requirements... 1 Features and Coverages... 3 Inland Marine Coverages...
CONTRACTORS PROTECTOR PROGRAM
CONTRACTORS PROTECTOR PROGRAM ITEM TABLE OF CONTENTS NSCO PAGE Applications... 1 Billing Procedures... 2 Eligibility and Underwriting Requirements... 1 Features and Coverages... 3 Inland Marine Coverages...
Service is our Hallmark.
A M E R I C A N Indiana New Business: 12/10/12 Renewal Business: 12/10/12 Homeowners Program HO-2 Broad Form Homeowners HO-3 Special Form Homeowners HO-4 Contents Broad Form-Renters HO-6 Unit-Owners Form-Condo
Homeowner Application
Homeowner Application Applicant s Name: Mailing Agent Name: Agency Code: PROPOSED EFFECTIVE DATES: General Information: From To 12:01 A.M., Standard Time, at the address of the Applicant Billing Method:
Agent Name: Agent Address: Agent City: State: Zip Code: Agent Phone: Fax:
Builders Risk Quick Quote All QUESTIONS MUST BE ANSWERED! AGENT INFORMATION Agent Name: Agent Address: Agent City: State: Zip Code: Agent Phone: Fax: E-mail: INSURED INFORMATION Insured Name: Insured Mailing
SECURITY & FIRE PROTECTION COMPANIES PROPOSAL FORM UNDERWRITTEN BY
SECURITY & FIRE PROTECTION COMPANIES PROPOSAL FORM UNDERWRITTEN BY P1 PROPOSAL FORM FOR THE SECURITY & FIRE PROTECTION INDUSTRY DISCLOSURE: In completing this Proposal Form it is very important that you
BUILDERS RISK PROGRAM APPLICATION
BUILDERS RISK PROGRAM APPLICATION Applicant s Name: Mailing Address: Agency Name: Agent: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the
TRANSFLO MOTOR CARRIER OPERATING PROVISIONS
Purpose The purpose of this document is to establish operating and safety requirements, policies and procedures for motor carriers conducting operations within a TRANSFLO terminal. Motor Carrier Access
PROPOSAL FORM. Property All Risk
PROPOSAL FORM Property All Risks Guidelines to Fill the Form 1. Please use BLOCK CAPITALS and tick YES or NO where appropriate and initial any amendments. 2. Please answer all the questions completely.
Construction E & O Application
1550 Bedford Highway, Suite 815 Bedford, NS B4A 1E6 t: 1-877-343-8224 f: 1-877-432-9822 e: accounts@agileuw.ca agileuw.ca Construction E & O Application Whoever fills out the form must be a principal,
Dwelling & Habitational Fire Application
Home Office: One Nationwide Plaza Columbus, OH 43215 Adm. Office: 8877 N. Gainey Ctr. Dr. Scottsdale, AZ 85258 1-800-423-7675 Fax (480) 483-6752 NOTICE TO AGENT BILLING INSTRUCTIONS Indicate below how
Property Inspection Guidelines
Property Inspection Guidelines www.tridentinsurance.net Lines of Business: Property, General Liability, Worker s Compensation, Public Official Liability Risk Control Strategy/Key Issues: Provide a tool
Building works questionnaire
Building works questionnaire Policyholder Policy number Answers to the following questions and any additional information supplied to us on your behalf assist us in the assessment of the risk. All material
New Beginnings. How Claims Put Peoples Lives Back Together
New Beginnings How Claims Put Peoples Lives Back Together What is the claims process? This is a common question as there are many people, companies, and steps involved. Common Questions from the Insured:
Proposal form. Personal Information Name of the Proposer: Telephone: Fax:
Commercial Fire Insurance Proposal form Completing the Proposal form 1. This proposal must be fully complete including all the required documents 2. It is a duty of prosper to disclose all the material
MID-VALUE HOMEOWNER S APPLICATION
The following must be submitted with the application: -Replacement Cost Estimator or Building Information Sheet -Woodstove Questionnaire, if applicable -Diligent Search Letter, if applicable MID-VALUE
Residential Unoccupied Property Owners Proposal Form
Residential Unoccupied Property Owners Proposal Form Disclosure The proposer must take care in answering all of the following questions which are relevant to the Insurer in providing this insurance and
WASTE & RECYCLING COMMERCIAL COMBINED
Please fill out this form using the latest version of adobe reader Download the latest version here: http://get.adobe.com/uk/reader/ WASTE & RECYCLING COMMERCIAL COMBINED TELEPHONE 020 7977 4800 WWW.LONDONMARKETBROKING.CO.UK
NJR Home Services General Terms and Conditions Residential Interior Electrical Service Contract
NJR Home Services General Terms and Conditions Residential Interior Electrical Service Contract This is your official agreement with NJR Home Services (NJRHS) and provides a detailed description of the
Property Owners Insurance Proposal Form
Property Owners Insurance Proposal Form This proposal form is NOT for use by Commercial Customers If you do not answer any questions honestly, accurately or withhold information we may refuse to pay your
Alabama Manufactured Home Program Manual
American Reliable Insurance Company Alabama Manufactured Home Manual 02/01/2016 New 02/01/2016 Renewal A####M#### A4435M0116 Quoting Procedure Binding Restrictions All quoting and issuance of policies
Ontario Pharmacists Association
Application Information a) Membership no. (must be current) OCP Accreditation no: b) Name of pharmacy c) Name of legal entity d) Mailing/billing address e) Contact person: Tel Fax f) Pharmacy address ii)
FARM APPLICATION. Postal Cod. Address Website Address Broker Number
FARM APPLICATION Applicant s Full Name Broker - Mailing Address Postal Home Phone # Work Phone # Mobile # Fax # Email Address Website Address Broker Number Policy Period From, 20 12:01 a.m.; to, 20 12:01
HOME OCCUPATION PERMIT APPLICATION Town of Apex, North Carolina
HOME OCCUPATION PERMIT APPLICATION Town of Apex, North Carolina Last updated February 2014 Submittal Date: Application Number: Fee Paid: Check # Hard Copy Submittal Requirements Submit to Planning Department
Lesson 2: The Homeowners Policy
Lesson 2: The Homeowners Policy Homeowners Insurance: ISO Policy Forms Covered Property to Identify and Address Residential Property and Liability Loss Exposures Four Methods for Managing Personal Residential
Building contract works questionnaire
Building contract works questionnaire Policyholder Policy number You have a duty to present us with a fair presentation of the risks to be insured and must disclose every material circumstance which you
INSURANCE APPLICATION FORM
INSURANCE APPLICATION FORM Insurance coverage under Illinois Drycleaner Environmental Response Trust Fund is available to qualified drycleaning facilities actively engaged in drycleaning operations for
UTICA FIRST INSURANCE COMPANY. Application For Convenience Stores or Automobile Service or Repair Stations
See below and check one: Convenience Store with gasoline (or related product) with Full or Self service pump sales and including car washes in connection therewith. Not including automobile service stations
RESIDENTIAL STRATA PROPOSAL BROKER INFORMATION
NAME OF BROKING FIRM NAME PHONE CONTACT DETAILS FAX EMAIL WEBSITE BROKER INFORMATION YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with an insurer, You have a duty, under
Georgia Dwelling Program Manual
United National Insurance Company Georgia Dwelling Manual 04/01/2017 New 04/01/2017 Renewal A####M#### U6021M0417 Quoting Procedure Binding Restrictions All quoting and issuance of policies for these programs
PRO PRO. ProSurance TM. Application Form INSURANCE FOR PROFESSIONALS
PRO INSURANCE FOR PROFESSIONALS ProSurance TM PRO Application Form This is an application for an errors and omissions package policy aimed at a wide range of small and medium-sized professionals. As well
ORIGINAL YEAR OF CONSTRUCTION NUMBER OF BUILDING STORIES 2/15/2013 BUILDING SURVEY DATE
0807 3502 SOUTH FIRST STREET CHAMPAIGN, ILLINOIS SYSTEM CONDITION INDEX.771 PRIMARY BUILDING USE BUILDING SURVEY TEAM BUILDING SYSTEM REPLACEMENT COST $ 347,400 LABORATORY BUILDING GROSS SQUARE FEET 16,986
Instructions for Completing TRANSFLO s Motor Carrier Access Agreement
Instructions for Completing TRANSFLO s Motor Carrier Access Agreement Prior to accessing a TRANSFLO terminal, all motor carriers must sign (at the corporate level) and return TRANSFLO s Motor Carrier Access
Farm/Ranch Insurance Quote Questionnaire. Full Name: Farm Name: Mailing Address: Property Address (If different):
Farm/Ranch Insurance Quote Questionnaire Full Name: Farm Name: Mailing Address: Property Address (If different): Home Ph: Cell: Work Ph: Fax: Email: Website: Name of Closest Fire Depart: Distance From
BUILDING SUBCODE FEES:
Building Sub-code PERMIT FEES TOWNSHIP OF PENNSVILLE 2011 (A 4-2011) 1. Plan review shall be 20% of the amount to be charged for a construction permit. a. The fee for plan review for elevator devices in
Builders Risk Plan Coverage Application
Builders Risk Plan Coverage Application Thank you for your interest in Zurich s Builders Risk Plan. To provide you the most accurate and timely service, please be sure to read these directions carefully
TECH. Esurance TECH Application Form INSURANCE FOR TECHNOLOGY COMPANIES
TECH INSURANCE FOR TECHNOLOGY COMPANIES Esurance TECH Application Form Esurance TECH is an insurance package designed specifically for the technology sector. The policy includes Professional Indemnity,
Demolition Contractors (Per Job Basis) General Liability Application
Demolition Contractors (Per Job Basis) General Liability Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: Location Address: E-mail: Phone: Web site Address: PROPOSED EFFECTIVE
COMMERCIAL FINE ARTS APPLICATION
COMMERCIAL FINE ARTS APPLICATION 1. Name of Applicant: 2. Web site Address: 3. Location Address: 4. Proposed Policy Term: From: To: 5. Applicant s Business: Number of Years in Business: 6. Contact for
A&E. Inter-Pacific Insurance Brokers, Inc. APPLICATION FORM INSURANCE FOR ARCHITECTS & ENGINEERS
A&E INSURANCE FOR ARCHITECTS & ENGINEERS APPLICATION FORM INTRODUCTION The purpose of this application form is for us to find out who you are and to obtain information relevant to the cover provided by
The Brethren Mutual Insurance Company 149 North Edgewood Drive, Hagerstown, Maryland Telephone: (800) Fax: (301)
The Brethren Mutual Insurance Company 149 North Edgewood Drive, Hagerstown, Maryland 21740-6599 Telephone: (800) 621-4264 Fax: (301) 733-1794 FARM APPLICATION NAMED INSURED AND MAILING ADDRESS: PRODUCER:
BUILDERS RISK PROGRAM APPLICATION
BUILDERS RISK PROGRAM APPLICATION Applicant s Name: Mailing Address: Agency Name: Agent: Address: Location Address: E-mail: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the
Service is our Hallmark.
A M E R I C A N I N S U R A N C E Mississippi New Business: 9/23/12 Renewal Business: 9/23/12 Dwelling Fire Program DP-1 Basic Form DP-2 Broad Form DP-3 Special Form Service is our Hallmark. GENERAL RULES
GENERAL INFORMATION. Lift Kit (suspension) Installation/Sales
Automobile Service s Application COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY OF
** Please write N/A in spaces provided if Not Applicable to any questions
Americana Insurance Group Inc. Travel Agency Fact Finding Questionnaire ** Please write N/A in spaces provided if Not Applicable to any questions ** If any lists can be provided instead of writing everything
Condominium. Travelers Condominium Pac SM and Condominium Pac Plus SM are designed for owners of buildings used exclusively as condominiums.
25 Condominium Travelers Condominium Pac SM and Condominium Pac Plus SM are designed for owners of buildings used exclusively as condominiums. Eligibility Up to $10 million Total Insured Values per building,
Propane and Fuel Oil Dealers Supplemental
Propane and Fuel Oil Dealers Supplemental Applicant Name: Requested Effective Date:_ Insured s Website: Section I Summary of Operations Please provide a narrative of the Insureds operations (Include all
CAMPGROUND APPLICATION
J. D. Smith Insurance Brokers 2-105 West Beaver Creek Rd. Richmond Hill, Ont., L4B 1C6 1-800-917-SAVE (7283) Fax: 905-764-9618 www.jdsmithinsurance.com CAMPGROUND APPLICATION Broker: Address: Applicant:
Insurance Application & Proposal
Business Insurance Property Owners - Vacant Insurance Application & Proposal Intermediary Policy. The Proposer Insured Name Business / Trading Name Are You registered for GST purposes? What is Your ABN?
SITE SPECIFIC POLLUTION LIABILITY APPLICATION
SITE SPECIFIC POLLUTION LIABILITY APPLICATION SECTION A: APPLICANT INFORMATION APPLICANT MAILING ADDRESS CITY STATE ZIP CODE PHYSICAL ADDRESS IF DIFFERENT CITY STATE ZIP CODE CONTACT NAME CONTACT E-MAIL
Residential Care or Skilled Nursing Facility Application
NeitClem WHOLESALE INSURANCE BROKERAGE, INC. 7442 North Figueroa St. Los Angeles, CA 90041 Phone (323)-258-2600 Fax (323)-258-2676 License #OA71853 www.neitclem.com Residential Care or Skilled Nursing
A&E. Application Form INSURANCE FOR ARCHITECTS & ENGINEERS
A&E INSURANCE FOR ARCHITECTS & ENGINEERS Application Form This is an application for an errors and omissions package policy designed specifically for architects and engineers. As well as errors and omissions
Convenience, Delicatessen, Grocery and Liquor Stores Product
Convenience, Delicatessen, Grocery and Liquor Stores Product CONVENIENCE, DELICATESSEN, GROCERY AND LIQUOR STORES WARRANTY APPLICATION To receive a quote, please complete the General Information Section
Homeowners Insurance Application
HOH265710 Policy Effective Date: 3/20/2017 Policy Expiration Date: 12:01 AM Date/Time Printed: 3/13/2017 1:08:15PM Policy Form: HO3 Risk ID: HOH265710 Phone: (888)254-5014 Fax: (866)776-8320 Agent: Brightway
CONTRACTORS EQUIPMENT APPLICATION
CONTRACTORS EQUIPMENT APPLICATION 1. Name of Applicant: 2. Mailing Address: Location Address: Website Address: 3. Proposed Policy Term: From: To: 4. Annual Income Last Year: Estimated Current Year: 5.
Insurance Applica on & Proposal
Business Insurance Property Owners Insurance Applica on & Proposal Intermediary Interim Cover. The Proposer Insured Name Business / Trading Name Are you registered for GST purposes? What is your ABN? Postal
Pollution Legal Liability Questionnaire
INSTRUCTIONS Pollution Legal Liability Questionnaire A. This questionnaire requires that contact persons be provided for each location. The applicant is responsible for obtaining and reviewing whatever
PROPOSAL FORM FOR WASTE & RECYCLING ISR
PROPOSAL FORM FOR WASTE & RECYCLING ISR IMPORTANT NOTICE TO THE PROPOSER ON COMPLETION OF THIS PROPOSAL FORM 1. DISCLOSURE Any material change must be disclosed to Insurers.. A material change is any information
Used Auto and Motorhome Dealer Application
Used Auto and Motorhome Dealer Application COLUMBIA INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL LIABILITY & FIRE INSURANCE COMPANY NATIONAL INDEMNITY
BULLETIN 3/1/ This is a redistribution of the 2/9/10 Bulletin (no changes)
GET THERE TOGETHER Contract P&C BULLETIN 3/1/2010 - This is a redistribution of the 2/9/10 Bulletin (no changes) TO: All Contract Agents We are pleased to announce an up-date to the ISO Commercial Property,
A. The confined feeding of animals for foods, fur, or pleasure purposes on lots, pens, ponds, sheds, or buildings where:
216 CONFINED FEEDING / INTENSIVE LIVESTOCK Definitions and Regulations Article 2 Sections 216.2(2) & 216.3(2) amended 11/24/2014 Ordinance # 2014-07 216 CONFINED FEEDING / INTENSIVE LIVESTOCK DEFINITIONS
A UNIQUE AND COMPREHENSIVE INSURANCE SCHEME FOR THE ELECTRICAL INDUSTRY
.. A UNIQUE AND COMPREHENSIVE INSURANCE SCHEME FOR THE ELECTRICAL INDUSTRY PROPOSAL FORM Camberford Law plc Innovative Insurance solutions Since 1958 Insurance Brokers Underwriting Agents Authorised and
Jewellers Block Proposal Form
Jewellers Block Proposal Form Period of Insurance From: To: Company Details Full Name of Proposer(s): Company Name: Trading Name: Business Address: Postal Address Telephone: Email: Fax: Website: Mobile:
PROPOSAL FORM (The issue of this form is not to be taken as an admission of liability)
- ALLIANZ INSURANCE LANKA LIMITED Company : PB 323 46/10,Nawam Mawatha, Colombo 02 Tel: +9411 2300400 Fax: +9411 2304404 E-mail: info@allianz.lk Web site: www.allianz.lk PROPERTY ALL RISK INSURANCE PROPOSAL
Proposal for Jewelers Block Policy
Proposal for Jewelers Block Policy Please type or complete in ink. Answer all questions. If the answer to any question is none, state NONE. If the answer is left blank or if you fail to sign and date this
INSURANCE FOR ALLIED HEALTH & MEDICAL PROFESSIONALS
A&M INSURANCE FOR ALLIED HEALTH & MEDICAL PROFESSIONALS APPLICATION FORM INTRODUCTION The purpose of this application form is for us to find out who you are and to obtain information relevant to the cover
California and Nevada Property/GL/Liquor Liability application for establishments serving liquor and requesting Liquor Liability
California and Nevada Property/GL/Liquor Liability application for establishments serving liquor and requesting Liquor Liability coverage Name of Applicant Mailing Address Bars/Restaurants/Taverns Insurance
Cossio Insurance Agency Fax: PO Box 5987 Greenville SC 29606
DIRECTIONS: 1. Complete the application (all pages) in full by filling in the blue fields. 2. Please fill in all the fields with the correct information. 3. Email the application to apps@cossioinsurance.com
National Flood Insurance Program. Summary of Coverage
National Flood Insurance Program Summary of Coverage FEMA F-679 / November 2012 This document was prepared by the National Flood Insurance Program (NFIP) to help you understand your flood insurance policy.
Thatched Home Quotation Request Form
Thatched Home Quotation Request Form tes 1. Please complete all questions fully. You must take reasonable care to answer all questions honestly and to the best of your knowledge, and if you volunteer any
Property Owners Insurance Proposal Form
Property Owners Insurance Proposal Form It is essential that you make fair presentation of the risk that should include a full and unrestricted disclosure including every material fact and circumstance
APPLICATION FOR PHARMACY PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR PHARMACY PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis) APPLICANT S INSTRUCTIONS: 1. Answer all questions. If the answer requires detail, please attach a separate sheet. 2. Application
Underwriting Guidelines
Underwriting Guidelines 125 S. Wacker Drive Suite 2300 Chicago, IL 60606 P: 800.310.3351 F: 312.705.4289 A member of Global Indemnity plc Page 1 of 17 BASIC RULES CAUSES OF LOSS Basic form CP 10 10 1.
Home Performance with Energy Star Loan Policy
Home Performance with Energy Star Loan Policy The Home Performance with Energy Star Loan will help residential electric customers finance energy efficiency improvements that might be suggested for customers
The Commonwealth of Massachusetts. Town of Northborough. Board of Health. Horse and Stable Regulations
The Commonwealth of Massachusetts Town of Northborough Board of Health Horse and Stable Regulations A) Authority The Board of Health, Town of Northborough, Massachusetts, acting under the authority of
Hire of the Ground Floor of Aiming Higher Central.
Hire of the Ground Floor of Aiming Higher Central. Dear Hirer, Please find enclosed a Request for Hire form together with a Terms and Conditions of Hire Agreement. I would like to bring to your attention
INSURANCE APPLICATION FORM
INSURANCE APPLICATION FORM Company Name Business/ Trading Name Business address Postal address Contact Name Telephone phone Mobile phone Email address Nature of Business Number of years in business House
DEALERS OPEN LOT / GARAGEKEEPERS PROPOSAL FORM
DEALERS OPEN LOT / GARAGEKEEPERS PROPOSAL FORM DEALERS OPEN LOT INSURANCE ) Specify ) Coverage GARAGE KEEPERS LEGAL LIABILITY ) Required POLICY PERIOD: To 1) Name of Assured Address of Assured 2) Location(s)
GOLFsure Proposal Form Golfsure
GOLFsure Proposal Form Golfsure Address : Broker : Inception Date : Insured: 1 Are they're any unreported claims or potential claims? If, please advise details: 2 Material Damage Section Advise the following:
MOBILE HOME PARK APPLICATION. All questions must be answered in full and application must be signed and dated by the insured.
MOBILE HOME PARK APPLICATION All questions must be answered in full and application must be signed and dated by the insured. APPLICANT INFORMATION 1. Named Insured 2. Mailing Address Street City County
Automobile Service Operations Application
Automobile Service Operations Application COLUMBIA INSURANCE COMPANY NATIONAL FIRE & MARINE INSURANCE COMPANY NATIONAL INDEMNITY COMPANY NATIONAL INDEMNITY COMPANY OF MID-AMERICA NATIONAL INDEMNITY COMPANY
ACCIDENT PREVENTION POLICY Signature Page Assign, Sign, & Return this page only to DiFiore Construction
To all Subcontractors: ACCIDENT PREVENTION POLICY Signature Page Assign, Sign, & Return this page only to DiFiore Construction Excellence in safety and loss prevention is an objective of all operations
APPLICATION FOR PHARMACY PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR PHARMACY PROFESSIONAL LIABILITY INSURANCE (Claims Made Basis)APPLICANT S INSTRUCTIONS: 1. Answer all questions. If the answer requires detail, please attach a separate sheet. 2. Application
APPLICATION FOR SHIP REPAIRER S LIABILITY INSURANCE
APPLICATION FOR SHIP REPAIRER S LIABILITY INSURANCE 1. Name and address of applicant 2. Address (s) of ship repair yard (s) 3. Number of years in ship repair business under present management 4. Number
INSURANCE FOR RECRUITMENT, EMPLOYMENT & STAFFING AGENCIES
RES INSURANCE FOR RECRUITMENT, EMPLOYMENT & STAFFING AGENCIES APPLICATION FORM INTRODUCTION The purpose of this application form is for us to find out who you are and to obtain information relevant to
APPLICATION FOR VETERINARY SERVICES PROFESSIONAL LIABILITY INSURANCE
APPLICATION FOR VETERINARY SERVICES PROFESSIONAL LIABILITY INSURANCE NOTICE: The policy for which application is made provides coverage on a CLAIMS MADE basis. Please read the policy carefully. If space
COMMERCIAL INLAND MARINE APPLICATION (Animal Floater, Golf Carts, Signs)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
3. Program Underwriting Requirements
NATIONAL INSURANCE COMPANY 1. General Requirements: A. All business placed by the agent with the Company must originate from persons licensed for the agency by the Company. Brokered business is not acceptable