I. General Information

Transcription

1 RPA INSURANCE SERVICES, LLC. 8 Wood Hollow Rd., Site 301, Parsippany, NJ Phone: (973) xext 100 United States Liability Insrance Company Commercial Package Application MCP017M25B8 Version 3 Yo or yor agent provided the information sed to complete the qestions below. Please answer all remaining qestions in the space provided. By signing this application yo are warranting that all information on this application is tre and correct. I. General Information Applicant's Name: Oregano Restarant Corporation Form Of Bsiness: Individal Corporation Partnership LLC Other: Mailing Address: City: State: Zip: Phone Nmber: Web Address: Fax Nmber: Address: Inspection Contact: Coverage Desired: Monoline Liability Monoline Property Monoline Liqor Package Policy Term: 3 Months 6 Months 9 Months Annal Has coverage been cancelled or non-renewed in the last 3 years (not applicable in the state of MO)? If Yes, provide complete details: What year did the bsiness start? 2018 Loss Information for the past 3 years: None or provide details below Please advise all entities reqesting to be added as Additional Insred on this policy: Not Applicable Complete Name Address Interest Description of Operations: bilders risk/renovation Are there past, pending or planned foreclosres and/or bankrptcies or jdgments for npaid taxes against the named insred or any officer, partner, member or owner, individally within the last five years? Has Insrance coverage been cancelled or non-renewed in the past three years? (not applicable in MO) II. Locations of Coverage and Corresponding Classifications Location #1 Address City 1694 Park Ave New York Years At Crrent Location: State NY Zip Page 1 of 3

2 Constrction: Masonry Non Combstible Protection Class: 4 No. of Stories: Year Bilt: 1900 Total Sqare Footage: 2,000 Years at this location: Roof Age: Roof Type: Flat Shingle Wood Shake Metal Tile Slate Plmbing: PVC Copper Lead Iron Galvanized Other Updates: Plmbing: Electrical: Heating: Other Protective Devices: Case of Loss: Fnctional & operational smoke detectors Brglar Alarm Fire Alarm Sprinkler System - Special Form Central Station Central Station % of the bilding Broad Form Basic Form Local Local Exclsions: Wind & Hail Sprinkler Leakage Theft Water Damage Dedctible: $500 $1,000 $2,500 $5,000 Other Coverage Limit Additional Information Eqipment Breakdown Inclded in Co-Insrance: 80% % Bilding and Personal Property Underwriting Information for Location 1 Classification Vacant Bildings - not factories - Other than Not-For-Profit - Leased Additional Insred - Mortgagee, Assignee or Receiver Contractors - sbcontracted work - in connection with renovating Vacant Bildings Code No. GL Class Code Premim Basis Exposre Total Area 2000 N/A Flat 1 Total Cost Applicable Sq. Ft. How many stories is this bilding? 5 Is the bilding crrently damaged by fire or otherwise? Is the bilding schedled for demolition dring or after the policy term (except incidental non-load bearing interior work)? Are there any strctral (load bearing) renovations ongoing or planned dring the policy term? Is the strctre a mobile home? Has any tenant been evicted in the past 60 days or is any tenant in the process of being evicted? Is the bilding locked and secred from nathorized entry? Is there a swimming pool on premises? Is the bilding located on an active farm? Is the bilding schedled for demolition dring the policy term (except incidental non-load bearing interior work)? How many total acres is the size of the plot of land the Vacant Bilding is located on? 0 What is the fll mailing address of the Additional Insred? 1710 First Ave Site 333 New York, NY What is the name of the Additional Insred? Orsipel LLC Page 2 of 3

3 III. Limits of Insrance COMMERCIAL GENERAL LIABILITY Each Occrrence $1,000,000 Personal Injry and Advertising Injry $1,000,000 Medical Expense (Any One Person) $5,000 Damage To Premises Rented to Yo $100,000 Prodcts/Completed Ops Aggregate Exclded General Aggregate $2,000,000 General Liability Dedctible $0 Classification Contractors - sbcontracted work - in connection with renovating Vacant Bildings Liability Are certificates of insrance reqired for all sbcontractors naming the applicant as an Additional Insred? V. Additional Eligibility Information Does the Applicant engage in any operations or have any classifications on their premise(s) other than those listed in Item II Locations of Coverage and Corresponding Classifications? Yes No New York Frad Statement: Any person who knowingly and with intent to defrad any insrance company or other person files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading, information concerning any fact material thereto, commits a fradlent insrance act, which is a crime and shall also be sbject to a civil penalty not to exceed five thosand dollars and the stated vale of the claim for each sch violation. Frad Statement: Any person who knowingly and with intent to defrad any insrance company or other person, files an application for insrance or statement of claim containing any materially false information, or conceals for the prpose of misleading, information concerning any fact material thereto, commits a fradlent insrance act, which is a crime and may sbject sch person to criminal and/or civil penalties and other sanctions. Applicant's Warranty Statement: I warrant that the information provided in this Application, and any amendments or modifications to this Application are tre and correct. I acknowledge that the information provided in this Application is material to acceptance of the risk and the issance of the reqested policy by Company. I agree that any claim, incident, occrrence, event or material change in the Applicant s operation taking place between the date this application was signed and the effective date of the insrance policy applied for which wold render inaccrate, ntre or incomplete, any information provided in this Application, will immediately be reported in writing to the Company and the Company may withdraw or modify any otstanding qotations and/or void any athorization or agreement to bind the insrance. Company may, bt is not reqired, to make investigation of the information provided in this Application. A decision by the Company not to make or to limit sch investigation does not constitte a waiver or estoppel of Company s rights. I acknowledge that this Application is deemed incorporated by reference in any policy issed by Company in reliance thereon whether or not the Application is attached to the policy. I acknowledge and agree that a breach of this WARRANTY STATEMENT is gronds for Company to declare void any policy or policies issed in reliance thereon and/or deny any claim(s) for coverage therender. Applicants Signatre*: Brokers Signatre: If yor state reqires that we have the name and address of yor (insred s) athorized Agent or Broker. Name of Athorized Agent or Broker: Address: (Mst be Owner, Officer or Partner) Title: (Reqired) Date: Date: (Reqired) SUBMITTING THIS APPLICATION DOES NOT BIND THE APPLICANT TO PURCHASE INSURANCE. ACCEPTANCE OF THIS APPLICATION DOES NOT BIND THE COMPANY TO ISSUE INSURANCE. Page 3 of 3

4 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Yo are hereby notified that nder the Terrorism Risk Insrance Act ("the Act"), as amended yo have a right to prchase insrance coverage for losses arising ot of acts of terrorism. As defined in Section 102(1) of the Act: The term act of terrorism means any act or acts that are certified by the Secretary of the Treasry, in consltation with the Secretary of Homeland Secrity, and the Attorney General of the United States, to be an act of terrorism; to be a violent act or an act that is dangeros to hman life, property, or infrastrctre; to have reslted in damage within the United States, or otside the United States in the case of certain air carriers or vessels or the premises of a United States mission; and to have been committed by an individal or individals, as part of an effort to coerce the civilian poplation of the United States or to inflence the policy or affect the condct of the United States Government by coercion. Yo shold know that any coverage for losses cased by certified acts of terrorism is partially reimbrsed by the United States nder a formla established by federal law. Under this formla, the United States reimbrses 85% throgh 2015; 84% beginning on Janary 1, 2016; 83% beginning on Janary 1, 2017; 82% beginning on Janary 1, 2018; 81% beginning on Janary 1, 2019 and 80% beginning on Janary 1, 2020, of covered terrorism losses exceeding the stattorily established dedctible paid by the insrance company providing the coverage. The premim charged for this coverage is provided below and does not inclde any charges for the portion of loss covered by the federal government nder the Act. Coverage for "insred losses, as defined in the Act, is sbject to the coverage terms, conditions, amonts and limits in this policy applicable to losses arising from events other than acts of terrorism. Yo shold know that the Act, as amended, contains a $100 billion cap that limits U.S. Government reimbrsement, as well as insrers' liability, for losses reslting from certified acts of terrorism, when the amont of sch losses in any one calendar year exceeds $100 billion. If the aggregate insred losses for all insrers exceed $100 billion, yor coverage may be redced. Yo shold also know that, nder federal law, yo are not reqired to prchase coverage for losses cased by certified acts of terrorism. REJECTION OR SELECTION OF TERRORISM INSURANCE COVERAGE Please X one of the boxes below and retrn this notice to the Company. I decline to prchase Terrorism Coverage. I nderstand that I will have no coverage for losses arising from acts of Terrorism. I elect to prchase coverage for certified acts of Terrorism for a premim of $. Applicant Name (Print) Athorized Signatre Named Insred Date TRIADN NY (02-15) Page 1 of 1

5 Vacant Bilding Prodct As an owner of a vacant property, do yo have the right coverage? Local children enter yor bilding and fall throgh the floor A fire begins in yor vacant bilding and spreads to srronding properties While having renovations completed on the property, constrction materials fall on a passerby The following are important featres; make sre yo have them all: COVERAGE FEATURES USLI COMPETITORS No restriction on the length of vacancy No minimm earned premim or a 25% minimm earned premim even on 3, 6 and 9 month policy terms 3, 6 and 9 month poliy terms Can consider bildings ndergoing renovations Special form and replacement cost available for some risks Contents coverage available No liability dedctible Vandalism is inclded with property coverage for commercial bildings Independent contractors coverage available for risks with renovations A.M. Best rated A ++ Carrier A prod member of the Berkshire Hathaway Grop Policyholders have access to many services throgh or Bsiness Resorce Center that will assist in growing and protecting their bsinesses This docment does not amend, ext end or alter the coverage afforded by the policy. F or a complete nderstanding of any insrance yo prchase, yo mst first read yor policy, declaration page and any endorsements and discss them with yor agent. A sample policy is available from yor agent. Y or actal policy conditions may be amended by endorsement or affected by state laws. Vacant Bilding PO S 5/ 1 5