140 Property Section
Applicant (first named insured)
*
Proposed effective date
*
Proposed expiration date
*
Premises Information:
Premises number
*
Building number
*
Street address
*
Building/BPP
Amount ($)
Percent coinsurance
Valuation
Causes of loss
Deductible ($)
Blanket coverage
Business income
Amount ($)
Percent coinsurance
Valuation
Causes of loss
Deductible ($)
Blanket coverage
Improvements/Betterments
Amount ($)
Percent coinsurance
Valuation
Causes of loss
Deductible ($)
Blanket coverage
Additional information- business income/extra expense
Business income without extra expense?
Select
Yes
No
Extra expense?
Select
Yes
No
Type of business
Select
Non Mfg
Mfg
Mining
Percent coinsurance
Ordinary payroll
Select
Exclude
Include
90days
180days
Power/Heat deductible ($)
Electronic media (days)
Ord or law (days)
Tuition fees
Select
Yes
No
Student tuition fees ($)
Other educational service inc ($)
Off premium power?
Select
Yes
No
Name for off premium power or dependent property
Address for off premium power or dependent property
City for off premium power or dependent property
State for off premium power or dependent property
Zip for off premium power or dependent property
Power?
Select
Yes
No
Water?
Select
Yes
No
Comm (describe if YES)?
Select
Yes
No
Describe
Dependent property?
Select
Yes
No
Percent coinsurance
Cont location?
Select
Yes
No
Rec location?
Select
Yes
No
Mfg location?
Select
Yes
No
Ldr location (describe if YES)?
Select
Yes
No
Describe
Extra expense?
Select
Yes
No
Days period res
Limit loss pay percentage 1
Limit loss pay percentage 2
Limit loss pay percentage 3
Limit loss pay percentage 4
Additional coverages, options, restrictions, endorsements, and rating information
Construction type
*
Distance to fire hydrant (feet)
*
Distance to fire department (miles)
*
Fire district code number
Prot Cl
Number of stories
*
Number of basements
*
Year built
*
Total area
*
Building improvements if 20+ years
Wiring improved?
*
Select
Yes
No
Roofing improved?
*
Select
Yes
No
Plumbing improved?
*
Select
Yes
No
Heating improved?
*
Select
Yes
No
Other improved (explain)?
*
Select
Yes
No
Explain
Building code grade
Tax code
Roof type
Other occupancies
Wind class
Select
Resistive
Semi-resistive
Other
Right exposure and distance
Left exposure and distance
Rear exposure and distance
Burglar alarm type
Certificate number
Expiration date
Extent
Grade
Select
Central Station
With Keys
Burglar alarm installed and serviced by
Number of guards/watchmen
Do guards clock hourly?
Select
Yes
No
Premises fire protection (sprinklers, standpipes, CO2/chemical systems)
Percent sprinklers
Fire alarm manufacturer
Fire alarm type
Select
Central Station
Local Gong
Additional Interests:
Interest 1
Rank
Interest
Select
Loss Payee
Mortgagee
Interest name
Address
City
State
Zip
Evidence
Select
Certificate
Policy
Interest 2
Rank
Interest
Select
Loss Payee
Mortgagee
Interest name
Address
City
State
Zip
Evidence
Select
Certificate
Policy
53 Loveton Circle, Suite 120 • Sparks, MD 21152
Phone • 1.800.926.8085 • 410.472.1620 • Fax • 410.472.1897
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