JEWELLERS BLOCK APPLICATION

Transcription

1 45 Vogell Road, Suite 306, Richmond Hill, Ontario L4B 3P6 Tel: Toll: Fax: JEWELLERS BLOCK APPLICATION BROKERAGE: Broker contact: address: Phone No.: Fax No.: INSURED: Individual Partnership Corporation Joint Venture Full Legal Name of Applicant: Operating Name: Mailing Address: Risk Location: Describe Premises: Principal Owner(s): Website Address: Has the principal or any active partner filed for bankruptcy? Yes No If yes, provide details: Loss Payee / Mortgagee / Additional Insured (including name & address): INSURANCE EXPERIENCE: New Business Renewal Existing Insurer: Target Premium Required: Renewal Offered: Yes No If not, why? Have you had any insurance refused or cancelled within the past 5 years? Yes No If yes, please explain: LIST OF ALL LOSSES OR CLAIMS (Whether or not Insured Sustained during Past 5 Years on all operations): Date of Loss Details of Loss Amount Paid/Reserve Open/Closed Describe any insured and uninsured losses which have occurred in the past 5 years and state the date, type and value of each loss before the deductible (if any) was applied: If previous losses/claims have occurred, please advise the steps taken to prevent a re-occurrence? GroupOne Insurance Jewellers Block Application Form (2014) Page 1 of 8

2 GENERAL INFORMATION: Type of Business Based on Sales: Retails: % Wholesale: % Manufacturing: % Other: Name of Principals or Officers: Number of Years in Business: Years at Location: Give Names and Addresses of other jewellery locations or businesses owned or managed by the listed Principals or Officers: What is the least number of Employees, Officers or Owners customarily on your described premises at any time during business hours or when opening or closing for business: Number of Entrances: Open to Public: Not Open to the Public: Days of Business Open: Business Hours: Are all applicant s inside display cases equipped with key locks? Yes No Are all the display cases kept key locked during business hours except when stock is being removed or replaced? Yes No INVENTORY 1. Do you take a complete, written, annual physical inventory on all your stock at least once a year? Yes No Date Last Taken: Exact Total: 2. Prior to #1 above, Previous complete, written, physical inventory of all your stock was taken on: Exact Total: 3. The maximum value of all your during the last 12 months did not exceed: $ 4. The estimated average daily amount of other people s property in your custody or control during the last 12 months was: $ On Customer s property and $ Memorandum/Consignment Property Do you maintain detailed records of other people s property? Yes No 5. Do you handle pawned property? Yes No 6. The breakdown of property from your last complete written annual physical inventory is: a. Loose Diamonds and other Precious Stones % b. Unset Semi-Precious or Imitation Stones % c. Pearls % d. Jewellery mounted with Diamonds and other Precious Stones % e. Jewellery mounted with Semi-Precious Stones and Gold Jewellery % f. Watches, Watchcases and Watch Bracelets valued over $100 at cost % g. Other Watches, Watch Bracelets Clocks, Cases, Movements or parts % h. Fashion Jewellery including gold-filled, plated or Silver Merchandise % i. Jewellers Findings, unset Mountings, and material for manufacture % j. Jewellery Samples (plated brass or imitation) % k. Silverware, Pewterware, Plated ware or Stainless Stell % l. Giftware % m. Others, describe: % Total must equal 100% % GroupOne Insurance Jewellers Block Application Form (2014) Page 2 of 8

3 7. Is any non-jewellery inventory to be excluded from insurance? Yes No If yes, provide #6 item letters: 8. Is any non-jewellery inventory to be excluded from theft coverage? Yes No If yes, provide #6 item letters: PROPERTY AWAY FROM RISK LOCATION 1. Principals, Officers or Employees: a. Number of principals, officers or employees that carry total property valued at $5,000 or less: b. Principals, officers or employees that carry property valued at more than $5,000: Home City Travel: Name and Home City Number of Days Out Last 12 Months This Policy Amount Carried Individual Maximum Average Maximum Limit of Insurance Travel Elsewhere: 2. Commissioned salespeople or selling agents (not employee): Home City Travel: Name and Home City Number of Days Out Last 12 Months This Policy Amount Carried Individual Maximum Average Maximum Limit of Insurance Travel Elsewhere: 3. The estimated daily average value of property in the custody of jewellery dealers, including appraisers and repairers, or out on consignment or memorandum, during the last 12 months was: $ 4. The total value of property shipped during the last 12 months (above the shipper s limit of insurance and/or insurance deductible) is: a. Security Registered Mail $ b. Armored Car Service $ c. Specified private, paid delivery service or other contract or common carrier: $ (i) $ (ii) $ d. Unspecified private, paid delivery service or other contract or common carrier $ GroupOne Insurance Jewellers Block Application Form (2014) Page 3 of 8

4 SECURITY INFORMATION 1. Are your described premises protected by an operating burglar alarm system? Yes No Central Station Monitoring Station Local Mercantile Other: If police station connected, is alarm monitored at all Times? Yes No Derived Channel Digital Communicator Direct Wire McCulloh Multiplex Radio Other: 2. Name of remises alarm service company: Is it a ULC listed alarm service company? Yes No If yes, provide copies of ULC Certificates Premises Alarm: ULC Certificate#: Expires: Extent: Guard Response: Line Security: Level I Level II Level III 3. Do you have motion detection? Yes No Does it cover the safe/vault area? Yes No 4. Is there a holdup alarm system? Yes No # Stationary Buttons: # Portable Buttons: 5. Do you maintain any of the following operating surveillance systems on your described premises while open to business? Cameras Yes No CCTV with monitors Yes No CCTV with VCR Yes No Others: 6. Other premise protection: e.g. buzz in-buzz out locking systems, interlocking double door, metal bars, gates, watchman 7. Safe/Vaults (all must be described) #1 #2 Make, Model and Number Details (size, weight, thickness etc.) Fire/Burglary Rating Composite Body Steel Composite Body Steel Inner Chest Yes No If yes, rating: % Yes No If yes, rating: % Relocking Device Yes No Number: Yes No Number: Time Lock Yes No Yes No Is Safe located within a Vault Yes No Yes No Alarm: Central Monitoring Station Central Monitoring Station Name of Alarm Company: ULC Certificate #: Expires: Other: Other: Extent: Partial Complete Partial Complete Line Security: Level I Level II Level III Level I Level II Level III The minimum proportion by value of property on premises when closed kept in this safe is: % % The minimum proportion by value of stock on premises kept in locked safe and vault, when described premises is closed: Complete if no Property reported in Complete if No Property reported in Inventory Section is to be excluded Inventory Section is to be excluded Protected by complete protection: % % GroupOne Insurance Jewellers Block Application Form (2014) Page 4 of 8

5 Protected by partial protection: % % Protected by relock device only: % % No Protection: % % The maximum proportion by value of property on premises including window displays) kept out of safes & vaults: % % The minimum proportion by value of property kept in safe or vault of a bank, trust or safe deposit company: LIMIT OF INSURANCE DESIRED On Described Premises: Total: % % a. Stock (including customer s and memorandum/consignment property and samples) $ Peak season additional stock limit of insurance: From: Through: $ b. Money and Securities safe burglary (on described premise)/robbery (on/off described premises) $ c. Your interest in tenants improvements $ d. Furniture, fixtures, safes, modular vaults, machinery, tools and their parts $ e. Patterns, molds, models and dies $ (items b. to e. to be covered standard property coverage forms) f. Show window//outside showcase: f.1) Number of show windows (opening into the interior of the premises): How are they protected against forcible entry? f.2) Number of outside showcases (not opening into the interior of the premises): How are they protected against forcible entry? f.3) The limit of insurance desired: No coverage is provided when premises are closed for business When premises are open to business * Protected Unprotected In all windows: $ $ In all outside showcases: $ $ In any one windows: $ $ In any one outside window: $ $ *Protected Property displayed in show windows and outside showcases is considered protected only when it is displayed behind swinging plateglass (or its equivalent) secondary to windowpane or behind metal bars or grille entirely across window or showcase, or behind burglary-resistant glazing material glass, or in a showcase within the window. Off Described Premises (refer to Section - Property Away from your Location): a. In transit by: Security registered mail $ Armored car services $ Specified private, paid delivery service or other contract or common carrier: $ $ GroupOne Insurance Jewellers Block Application Form (2014) Page 5 of 8

6 Unspecified private, paid delivery service or other contract or common carrier $ b. In the safe or vault of a bank, trust or safe deposit company $ c. In the custody of jewellery dealers not included in d. below. This does not include property covered while entrusted to another jewellery dealer for safe keeping by someone covered in d. below. $ d. In the custody of principals, officers, employees, commissioned salespeople, or selling agents away from any described premises for individual maximum limit of insurance. This limit of insurance will not be less than the highest individual maximum limit of insurance, but no more than two times the highest individual maximum limit of insurance. $ DEDUCTIBLE / COVERAGE SELECTION 1. Deductible Amount: $1,000 $2,500 $5,000 $10,000 $ 2. Specific coverage deductible: BROKER DECLARATION Is this account NEW to your office? Yes No If no, how long have you known the applicant? Is the applicant financially sound? Yes No Have you personally seen this property? Yes No Do you recommend this applicant? Yes No Is the property for sale? Yes No Comments: I/We hereby declare that the statements and particulars contained in this application are true and that I/we have not suppressed or mis-stated any material facts and I/we agree that should a policy be issued then this application shall be the basis of the contract with Underwriters. This application must be signed by the Producer/Account Executive. Signature of Producer/Account Executive: Date: Print Name of Broker/Producer & Brokerage: GroupOne Insurance Jewellers Block Application Form (2014) Page 6 of 8

7 DISCLAIMER Consumer and previous insurer reports containing personal, credit, factual, or investigate information about the applicant may be sought in connection with this Application for insurance or any renewal, extension, or variation thereof. All provisions contained in the various forms issued under this contract shall be deemed to be contained in the present Application of insurance. The policy may be deemed to be void and claims may be denied where: 1. An applicant for a contract: a) Provides false or erroneous information to the prejudice of the insurer; or b) Knowingly misrepresents or fails to disclose in the Application any fact required to be stated therein; or 2. The insured contravenes a term of the Contract or commits a fraud; or 3. The insured willfully makes a false statement in respect of a claim under the Contract. I CERTIFY THAT ALL STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND ACCURATE AND APPLY FOR A CONTRACT OF INSURANCE BASED UPON THE TRUTH OF THE STATEMENS. I AM IN AGREEMENT THAT THIS DECLARATION SHALL HEREBY FORM PART OF THE INSURANCE CONTRACT BETWEEN THE INVOLVED PARTIES. Signature of Applicant: Date: Title of Applicant: Broker s Signature: Date: GroupOne Insurance Jewellers Block Application Form (2014) Page 7 of 8

8 SUPPLEMENTARY INFORMATION ON PREMISES (To be completed by Agent or Broker) Year Built: Number of Stories: Are you responsible for building insurance? Yes No Total Area: sq ft Area Occupied By Applicant: sq ft Occupies Basement? Yes No Adjacent Exposure: Occupied by Applicant as: Occupied by Other as: Any portion of this building: Vacant or Unoccupied? Yes No Under Renovation? Yes No If yes, please explain: Structure Type: Industrial Plaza Strip Plaza Stand-Alone Building Commercial/Residential Commercial Condo Other: Walls: Frame Brick Veneer Masonry HBC Non-Combustible Stucco Alum. Siding Fire Resistive Others: Floor: Concrete Wood Joist Wood Others: Roof: Wood Joist Steel Deck Concrete Patent Others: Heating: Gas Electric Oil Combination Furnace Wood Stove Others: Electrical: Fuses: Circuit Breakers: Year Updated: Heating: Plumbing: Electrical : Fire Protection: Fire hydrant within 300 metres/1000 feet Fire Hall within 8km Unprotected Roof: Paid Volunteer Distance to Responding Fire Department: Sprinklers: Yes % No Smoke Detectors: Yes No Dust Collection System: Yes No Approved Spray Booth: Yes No Does the building have a ULC Automatic Fire Extinguishing System? Yes No Has the system been independently tested within the last 12 months? Yes No Do you have any flammable/combustible liquids on premises? Yes No If yes, how much: On premises and how is it stored: Miscellaneous Information: GroupOne Insurance Jewellers Block Application Form (2014) Page 8 of 8