About This Program This application is used to insure the inventory of retail, wholesale and manufacturers of jewelry. Required Documents The following documents are required to apply for coverage: This application Loss Runs from Prior Carrier Alarm Certificate Salesperson Schedule (for transporting > $25k) Shipment Declaration (for shipments > $25k or foreign shipments) Exhibition Schedule (for exhibiting items at shows) Fraud Statement Applicant Information Named Insured: Entity Type: Individual LLC LLP Corporation Non-Profit Country of Residency (if individual): Country of Registration (all others): Primary Address (no PO Box): Mailing Address (if different to primary): Contact Person: Phone / Fax: Email: Website: Year Business Established: Federal ID/Social Security #: Operations Primary Operations Retail Wholesale Manufacturing Description of Business/Operations Insurance History Any insurance declined or cancelled in the past 5 years? (not applicable in MO) If yes, provide details: Any prior insurance coverage? If yes, provide details below Policy Type Carrier Policy # Expiration Date Premium Yes No Any losses in the past 5 years? If yes, provide details below. Policy/Line Date of Loss Description of Loss Amount of Loss Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 1 of 10
Business Details Operational Data Annual Sales Number of Employees Minimum number of employees on premises during business hours Business Hours From: To: Estimated daily average value of property in the custody of jewelry dealers, including appraisers and repairers, or out on consignment or memorandum, during the past 12 months. Industry Associations Are you a member of any Jewelry Associations? If yes, provide name(s): Pawnbrokers Do you handle pawned property? If yes: What percentage of sales is related to jewelry? Amount loaned and unpaid plus accrued interest at legal rate on pledged property? Yes No 60% or more Less than 60% Shipments & Transporting Items Total value of property shipped during the last 12 months. Number of shipments the past 12 months. Maximum value of any one shipment. Owners Name (First and Last) Title Years of Experience Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 2 of 10
Locations, Inventory, Security and Location Specific Coverages Location Details Address (Street, City, State, Zip) Year Built Building Construction Fire Resistive Frame Joisted Masonry Masonry Non-Combustible Metal Non-Combustible Type of location Downtown (not mall) Enclosed Mall Freestanding (not downtown) Industrial park Strip Mall Number of Floors in Building Floor Location of Applicant Flood Zone A B C D E V X All Others Inventory Procedures Do you maintain a detailed record of inventory How often is inventory taken Last inventory date Value of inventory when last taken Maximum value of all inventory during the past 12 months Estimated average daily amount of other people s property in our custody or control during the last 12 months. Peak Season Do you have a peak season during which your inventory increases substantially Beginning of Peak Season End of Peak Season Maximum inventory limit during peak season Allocation of Stock at Last Inventory Loose diamonds (non-industrial) Pearls, natural and cultured (mounted & unmounted) Other unset precious stones Unset semi-precious and imitation stones Jeweler mounted with diamonds or other precious stones Other jewelry including costume jeweler & gold jeweler Watches, watch cases, watch bracelets mounted with diamonds or other precious stones Other watches, watch cases, movements, parts Clocks (including cases, movements, parts) Silverware, pewter, plate and stainless steel Jewelers findings, unset mountings and material for manufacture All other stock (Describe: ) Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 3 of 10
Security Premises Alarm Details Is the premises alarm system UL certified? Provide the UL Certificate number for the premises Central Station Alarm Monitoring Company Safe/Vault Details Manufacturer s name Fire/burglary rating Vault Safe No Vault UL TL 15 Class 1 TL 30 Class 2 TL 30 composite Class 3 TL 30 x 6 Class M TR TL 15 x 6 TR TL 30 x 6 Is safe located within a vault? Safe/Vault alarm company name Safe/vault alarm UL Certificate number Outside of business hours, percentage of property left out of safe/vaults None <10% <25% >25% Additional Security Details Do you have an armed uniformed guard? Controlled Entry Closed Circuit TV with DVR/VCR Double Door Security Vestibule Bullet Proof Package Receptacle Number of entrances Open to the general public Not open to the general public Showcases Are there any inside showcases? a) Number of inside show cases b) How are the interior showcase tops secured? c) Are all inside showcases equipped with key locks? d) Are the showcases kept locked during business hours except when the contents therein are actually being removed or replaced? Number of Show Window Displays / Outside Showcase displays a) Type of Glass Regular Plate Glass Minimum 8mm Glass Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 4 of 10
Location Specific Coverages The coverages indicated below are location specific and will thus apply only to the location indicated. Location: Coverage Limit Inland Marine (Indicates required coverages if Inland Marine is purchased) Stock Stock At Your Premises * Property in Safe Deposit Vault of Any Bank, Trust or Safe Deposit Company Property at Premises of Any Dealer, Processor, or Similar Bailee in the Jewelry Trade Show Windows & Outside Displays at Insured s Premises Regular Plate Glass 25,000 Minimum 8mm Glass Equals Inventory Limit at Premises Goods in the Custody of Others 25,000 included other Additional Coverage Options Office Contents, Furniture, Fixtures, Tools, Machinery, Fittings 25,000 included other Patterns, Mold, Models and Dies 25,000 included other Tenant Improvements and Betterments 25,000 included other Peak Season Coverage Include Exclude Earthquake (applicable only to earthquake zones, eligibility is based on construction type) 25,000 included other Flood (available for all zones other than A, V, E) Pages 3-5 must be completed separately for each Location. Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 5 of 10
Coverage Options The coverages indicated below apply across all scheduled locations. Dates of Coverage Effective: (12 month coverage term) Coverage Limit Deductible Inland Marine Deductible 2,500 5,000 10,000 25,000 50,000 100,000 Base Limit (included) Increase Options Ded Additional Coverage Options Transit to and From the US Postal Service 125,000 n/a 1,000 Money and Securities 5,000 10,000 15,000 25,000 Electronic Data Processing Equipment 25,000 50,000 75,000 100,000 150,000 200,000 250,000 Registered Buyer 25,000 n/a Accounting Expense 1,500 n/a Theft Damage to Buildings 25,000 50,000 75,000 100,000 Travel * 25,000 35,000 50,000 60,000 75,000 100,000 Off Premises Coverage Included included Property Worn by You or Your Employees (at Shows only) Included Included Registered Buyer Included included 1,000 Shipping Limit ** 500 Express Carriers 25,000 First Class Registered/Express Mail 25,000 Schedule Shipments Armored Car 25,000 on Page 8 Merchants Parcel Delivery Service 25,000 Air Freight 25,000 Exhibition Coverage As Declared Schedule Exhibitions on page 9 * For increases in the travel limit above the blanket limit, please complete the Salesmen, Owners & Employees Schedule on page 8 ** Increases to the shipping limit are handled on a per shipment basis. To declare a shipment above $25,000 in value or a foreign shipment, complete the Shipments Schedule on page 9 Applicant Signature: Date: To be completed by your Insurance Broker: Insurance Company(s) Applied to: Insurance Agency/Agent: License Number: NOTE: Coverage availability will vary based on individual risk characteristics and the State in which insured is located. Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 6 of 10
Salesmen, Owners & Employees Schedule The policy includes coverage for the transport of up to $25,000 of merchandise for any salesman, owner, or employee. Salesmen, owners or employees transporting items with a value greater than $25,000 at any one time are required to be scheduled. The blanket limit of 25,000 may be increased to 100,000. To select the increase, indicate such on the Coverage Options on Page 7. Salesman Details Full Name Classification Salesman Owner Employee Date of Birth Drivers License Number / State Home Address Country of Citizenship United States Canada Years experience in jewelry industry Years experience as traveling jewelry salesperson in the US States in your territory Number of Travel Days Per Year a) Local (In same city as insured s premises) b) Non-Local (Elsewhere in the US) Average amount carried Maximum amount carried Limit of Insurance required Where are goods kept during non-business hours? When you carry merchandise, do you use: A container strapped to your body Inside Pocket Wheeled Container Any losses over the past 5 years? If yes, describe Other Brands Do you carry other lines? If yes, provide: Value (at cost) Company Name Address, City State Classification Signature Signature Date Signed This page must be completed separately for each scheduled Owner, Salesperson or Employee. Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 7 of 10
Shipments Schedule The policy includes coverage for the shipping of up to $25,000 of merchandise in any one shipment by and between the United States, Canada, their territories and possessions. Shipments that must be scheduled are those: a) Values exceeding $25,000 or b) Shipping overseas or being shipped from overseas. STEP 1: Shipment Details Shipping Method Name of Shipping Company Shipping Date Express Carrier First Class Registered/Express Mail Armored Car Merchants Parcel Delivery Service Air Freight Tracking # (assigned by shipping company) Shipping From Address Shipping To Address STEP 2: Item to Include in Shipment If multiple items will be included in the shipment, duplicate this section for each item. Category of Item being shipped Detailed Description of Item Loose Diamonds (non-industrial) Pearls, natural and cultured (mounted & unmounted) Other unset precious stones Unset semi-precious and imitation stones Jeweler mounted with diamonds or other precious stones Other jewelry including costume jeweler & gold jeweler Watches, watch cases, watch bracelets mounted with diamonds or other precious stones Clocks Value of Item This page must be completed separately for each scheduled shipment. Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 8 of 10
Exhibition Coverage The exhibition of stock at industry shows must be scheduled to the policy. Complete the items below for each that you will be exhibiting your stock and desire coverage. Name of Show Location of Show (Address, City, State, Zip) Dates of Show Start/End Limit of Insurance Transit Coverage * Include Exclude Include Include Include Include Exclude Exclude Exclude Exclude * Transit Coverage indicates that the transit of property to and from the scheduled Show by armored carrier is included for the limited indicated for a single loss. Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 9 of 10
FRAUD STATEMENT Please read the statement applicable to your state, and the final statement. Then sign, date and return with your application. COLORADO: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. DISTRICT OF COLUMBIA: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FLORIDA: Any person who knowingly and with intent to defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MICHIGAN: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of a fine of up to $5,000.00. MINNESOTA: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW YORK NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim of each such violation. OHIO: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT THEY ARE FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact, may be violating state law. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 such person to criminal and civil penalties. RHODE ISLAND: In Rhode Island this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? YES NO UTAH: For your protection, Utah law requires the following to be included in this application: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. ALL OTHER STATES: 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." (Not applicable in CO, HI, NE, OH, OK, OR, VT, ) In DC, LA, ME, TN and VA, insurance benefits may also be denied. THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER, BUT IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED. THE APPLICANT REPRESENTS THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE TIME THE POLICY IS ISSUED, THE APPLICANT WILL PROVIDE WRITTEN NOTIFICATION OF SUCH CHANGES. SIGNATURE OF APPLICANT DATE Jewelers Block Application (07/2011). Please email to service@productioninsurance.com or fax to (626) 844-6403. Page 10 of 10