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 business: What are the hours of operations? Ineligible - 24-hour operations APPLICANT INFORMATION: Applicant dba: Email: Phone #: Mailing Inspection contact: Phone #: Legal Entity: ( ) Individual ( ) Corporation ( ) Partnership ( ) Other PROPERTY: Location #: Building #: Ineligible roofing materials: Wood shingles, Tile, Slate, SPF (Sprayed Polyurethane Foam), and Tin Physical Building Limit: $ ( ) RC ( ) ACV ( ) Special Deductible: $ BPP Limit: $ ( ) RC ( ) ACV ( ) Special Deductible: $ Occupancy: Sq Feet: Year Built: Roof Type: Roof Age: Construction: PPC: Distance to fire dept: FT / MI Central Station Alarm: ( ) Yes ( ) No Roof - please answer this question regardless of the age of the building. a. When was the last time roof was repaired? Replaced? b. Roof material? ( ) Metal ( ) Composition Tar & Gravel ( ) SPF - Sprayed Polyurethane Foam ( ) Other 1
Update information must be provided for any building 25 years or older to bind and for best quote. 1. Wiring a. When was wiring updated? b. All wiring in conduit? ( ) Yes ( ) No c. All fuses replaced by circuit breakers? ( ) Yes ( ) No d. Any aluminum wiring? ( ) Yes ( ) No 2. Plumbing a. When was the last time the sewer lines were replaced? b. When was the last time the water lines were replaced? c. Type of water pipes: ( ) Galvanized ( ) PVC ( ) Other (Explain in the comments sections) 3. Heating a. When was heating system modernized? b. Type of system: ( ) Central ( ) Space Heaters ( ) Hot Water ( ) Air ( ) Other c. Type of fuel: 4. Asbestos a. Has the building been inspected for existence of asbestos? ( ) Yes ( ) No Date: What was the outcome? (Reply in comments section) b. Any friable asbestos? ( ) Yes ( ) No If yes, what is friable? c. Has any asbestos abatement been done? ( ) Yes ( ) No If yes, when? Losses: ( ) No ( ) Yes - If yes show if claim is open or closed and the amount paid and describe type of each loss: Additional Interest: ( ) Loss Payee ( ) Mortgagee PROPERTY: Location #: Building #: Physical Building Limit: $ ( ) RC ( ) ACV ( ) Special Deductible: $ BPP Limit: $ ( ) RC ( ) ACV ( ) Special Deductible: $ Occupancy: Sq Feet: Year Built: Roof Type: Roof Age: Construction: PPC: Distance to fire dept: FT / MI Central Station Alarm: ( ) Yes ( ) No 2
Roof - please answer this question regardless of the age of the building. a. When was the last time roof was repaired? Replaced? b. Roof material? ( ) Metal ( ) Composition Tar & Gravel ( ) SPF - Sprayed Polyurethane Foam ( ) Other Update information must be provided for any building 25 years or older to bind and for best quote. 1. Wiring a. When was wiring updated? b. All wiring in conduit? ( ) Yes ( ) No c. All fuses replaced by circuit breakers? ( ) Yes ( ) No d. Any aluminum wiring? ( ) Yes ( ) No 2. Plumbing 2. Plumbing a. When was the last time the sewer lines were replaced? b. When When was was plumbing the last system time the modernized? water lines were replaced? Tc. pe Types of water of water pipes: pipes: ( ) Galvanized ( ) Galvanized ( ) PVC ( ) PVC ( ) Other ( ) Other (Explain (Explain in in the the comments section) secti 3. Heating a. When was heating system modernized? b. Type of system: ( ) Central ( ) Space Heaters ( ) Hot Water ( ) Air ( ) Other c. Type of fuel: 4. Asbestos a. Has the building been inspected for existence of asbestos? ( ) Yes ( ) No Date: What was the outcome? (Reply in comments section) b. Any friable asbestos? ( ) Yes ( ) No If yes, what is friable? c. Has any asbestos abatement been done? ( ) Yes ( ) No If yes, when? Losses: ( ) No ( ) Yes - If yes show if claim is open or closed and the amount paid and describe type of each loss: Additional Interest: ( ) Loss Payee ( ) Mortgagee 3
Request Liability Coverage By Completing The Below Information LIABILITY: Occupancy: ( ) Lessors Risk Only % ( ) Owner % Per Occurrence Limits: General Aggregate Limits: Medical Expense: $5,000 Fire Damage Limits: Personal & Advertising Injury Limit: Hired/Non-owned Auto: ( ) Yes ( ) No Does the business or business owner have a commercial auto policy? ( ) Yes ( ) No Location #: Building #: Class code: Description/Class: Description of Operation Gasoline Total Gallons Grocery & grocery related items Liquor / Alcohol Annual Receipts Additional Interest: ( ) Additional Insured ( ) Loss Payee ( ) Mortgagee ( ) Lienholder Location #: Building #: Class code: Description/Class: Description of Operation Gasoline Total Gallons Grocery & grocery related items Liquor / Alcohol Annual Receipts Additional Interest: ( ) Additional Insured ( ) Loss Payee ( ) Mortgagee ( ) Lienholder 4
Liability Losses: ( ) No ( ) Yes - If yes show if claim is open or closed and the amount paid and describe type of each loss: Does the insured have any of the following operations? Description of Operations Yes No Prems Refilling or dispensing of LPG tanks? Sale of fireworks or any other similar novelty items? Automotive services, towing or repair work? Car Wash Facilities? ATM located outside the building? Check cashing facilities? Is there cooking on the premises? Is there a working automatic (Ansul) dry chemical fire suppressant system? Are barriers in front of store? (To prevent cars from running to building.) Video game machines? Number of machines? 8 Liner type video machines? Number of machines? Security System - Required for theft coverage. Description of equipment Yes No Prems Is there a UL Certified Alarm System? Is the system local? Is the system Central Station Are there dead bolts on all exterior doors? Are Hold Up alarms present? Are there frequent bank deposits? Are there signs posted that employees have limited cash? Are there any above ground fuel storage tanks? If yes, number of tanks and type fuel? Propane tank exchange on premises? If yes, average number held for exchange? Protective devices: Are tanks in a cage? Barriers used to stop cars? Type of barrier? Does insured own tanks? Do you refill propane tanks on premises? Who owns tanks? Insured? Maximum amount of money on premises at any one time is $ Maximum amount of money kept on premises overnight is $ 5
Is there a safe on the premises? What type? Is there a time delay? A Drop Safe? Is it alarmed? Do sidewalks, parking lots or floor areas present any slip and fall exposures? If yes describe: Is there a documented floor inspection program? If so, how often inspected? Are shopping carts available for customers use? Are they provided with seat belts? Are there any trip and fall exposures presented from stock in aisles? If yes, describe: Carrier Name, Policy #, Limits & Expiration Date of Pollution Liability for the Underground Tanks: Note: The Texas Petroleum Tank Fund expired in 1998. *Acord forms are not required unless specifically requested by underwriting. Additional Comments: 6