MISCELLANEOUS APPLICATION



STATE OF FLORIDA

INSURANCE APPLICATION

In accordance with Chapter 284 of the Florida Statutes, the Florida Property Insurance Trust Fund insures all eligible property owned by the State of Florida, and the Florida Casualty Insurance Risk Management Trust Fund insures eligible exposures for liability, auto, and workers compensation benefits. These Trust Funds should be the primary source for insurance unless the exposure is ineligible for coverage, or unless unique circumstances require private insurance.

An insurance application is one of the first steps used to establish a contract for private insurance. Applications for insurance require complete and accurate information. 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 civil penalties. Misrepresentation, omission, and/or concealment of facts may prevent recovery under the policy. (Refer to Section 627.409 of the Florida Statutes.)

The Insurance Application is a generic form used by State of Florida agencies to describe the exposures to be insured and indicates the terms acceptable by the Agencies. The Insurance Company may request additional information, depending on the exposure. Premium quotes will be provided prior to policy issuance. Important or unique exposure information should be submitted with the Application.

All questions and inquires should be directed to the Department of Management Services, Division of State Purchasing at (850) 487-0417 or Suncom 277-0417.

INSURANCE APPLICATION

THIS IS A GENERIC FORM USED BY THE STATE OF FLORIDA; THE INTENT OF THIS FORM IS TO PROVIDE INFORMATION FOR INSURANCE COVERAGE. ADDITIONAL INFORMATION MAY BE REQUIRED.

APPLICANT INFORMATION

DEPARTMENT NAME

CONTACT INFORMATION INSPECTION CONTACT

State Purchasing (850) 488-8855

POLICY INFORMATION

INSURANCE COVERAGE

( PROPERTY ( LIABILITY

( AUTO ( WORKERS’ COMPENSATION

( INLAND MARINE ( OTHER

EFFECTIVE DATE

FROM TO

PREMISES INFORMATION

MAILING ADDRESS

4050 ESPLANADE WAY, TALLAHASSEE, FL 32399

LOCATION INFORMATION (Physical address)

DESCRIPTION (include dimensions and construction) AGE PURPOSE

VALUE DEDUCTIBLE

STORAGE ADDRESS (if different that physical address)

PROTECTION (fencing, guards, alarms etc)

ADDITIONAL COVERAGE

VEHICLE INFORMATION (including driver name, license number)

WATERCRAFT INFORMATION (including copy of survey, crew information)

TRANSIT INFORMATION (including Moving Company and experience, date of move, destination and packing details)

GENERAL INFORMATION

REMARKS

COMPLETED BY (Sign and Print name and phone number)

DMS/100

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download