FUNERAL DIRECTORS/CEMETERY - Travelers



FUNERAL DIRECTORS/CEMETERYAPPLICATION SUPPLEMENTProposed First Named Insured & Other Named Insured(s): FORMTEXT ?????Mailing Address StreetCityCountyStateZIP Code FORMTEXT ?????Location Address StreetCityCountyStateZIP Code FORMTEXT ?????Telephone: FORMTEXT ?????Fax: FORMTEXT ?????Website: FORMTEXT ?????5.Contact person/phone #:Inspection: FORMTEXT ?????Accounting/Records: FORMTEXT ?????6.Business Type: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX LLC FORMCHECKBOX Trust FORMCHECKBOX Other (specify): FORMTEXT ?????7.Operating as: FORMCHECKBOX For Profit FORMCHECKBOX Nonprofit FORMCHECKBOX Other: FORMTEXT ?????8.Interest of Named Insured in premises: FORMCHECKBOX Owner FORMCHECKBOX General Lessee FORMCHECKBOX Tenant FORMCHECKBOX Other: FORMTEXT ?????9.Part occupied by Named Insured: FORMCHECKBOX Entire FORMCHECKBOX Portion ( FORMTEXT ?????%) FORMCHECKBOX Other (Lessor’s Risk Only)10.Date Business Established: FORMTEXT ?????If new venture, provide prior experience: FORMTEXT ?????11.Effective Date Desired: From: FORMTEXT ?????To: FORMTEXT ?????Term Desired: FORMTEXT ?????PREVIOUS INSURER & LOSS HISTORY – Attach separate sheet if necessary FORMCHECKBOX See Loss Runs AttachedMissouri Applicants: DO NOT answer this question.Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years? FORMCHECKBOX No FORMCHECKBOX Yes – If Yes, give name of company, date, and reason: FORMTEXT ?????Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the past 3 years:PolicyDatesCarrierPolicy NumberPremiumCoverageCheck ifClaims-MadeDescription of Loss FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????BUSINESS INFORMATION1.Indicate Gross Receipts: Estimated Next 12 Months: $ FORMTEXT ?????Last 12 Months: $ FORMTEXT ?????Prior 12 Months: $ FORMTEXT ?????2.During the past 5 years, has your name been changed or has any other business been purchased, merged or consolidated with you? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, provide details: FORMTEXT ?????3.Is the business in compliance with licensing standards or safety codes? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AIf yes, provide details: FORMTEXT ?????FUNERAL DIRECTORS1.Describe all business operations conducted by you: FORMTEXT ?????2.Partners and StaffNumber ofPartners and StaffLicensedYes Noa.Principals/Partners FORMCHECKBOX FORMCHECKBOX b.Funeral Directors FORMCHECKBOX FORMCHECKBOX c.Embalmers FORMCHECKBOX FORMCHECKBOX d.Interns FORMCHECKBOX FORMCHECKBOX e.Other Employees (describe): FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX YesNo3.Do you subcontract any services?If yes, provide subcontracted details and costs of subcontracted work: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 4.Does the funeral home offer any of the following:a.Sale of caskets or urns?If yes, indicate receipts from sales: $ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX b.Sale of headstones, including engraving?If yes, indicate receipts from sales: $ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX If yes, provide details: FORMTEXT ?????c.Do you perform cremations?If yes, are you operating the crematory?If yes, provide details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d.Do you perform eye enucleation (the removal of eyes from a deceased person for transplants)? FORMCHECKBOX FORMCHECKBOX e.Do you provide counseling services?If yes, % of receipts from this service: FORMTEXT ?????% FORMCHECKBOX FORMCHECKBOX If yes, provide details of counseling services offered: FORMTEXT ?????5.Do you lease/rent caskets?If yes, indicate receipts from this service: $ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 6.Do you lease/rent chairs?If yes, indicate receipts from this service: $ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 7.Do you ship the deceased to or from other locations?If yes, indicate receipts from this service: $ FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX If yes, provide details: FORMTEXT ?????8.Do you offer prepaid funeral services or sales of “special” life insurance policies?If yes, provide details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 9.Do you offer limousine rental/service?If yes, provide details of services: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Confirm coverage is in force and indicate automobile carrier information: FORMTEXT ?????CEMETERIES1.Number of plots in cemetery: FORMTEXT ?????2.Total number of acres: FORMTEXT ?????3.Annual Burials:Estimated Next 12 Months: FORMTEXT ?????Past 12 Months: FORMTEXT ?????Prior Year: FORMTEXT ?????YesNo4.Do you require a burial contract?If no, provide details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX 5.Indicate who is responsible for site preparation, burial and maintenance: FORMTEXT ?????6.7.Does the cemetery perform cremations?Is there a mausoleum on-site? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 8.Number of disinterments in the past 12 months: FORMTEXT ?????9.Are the following approvals required for disinterments:a.State Cemetery Control Boardb.Municipal Authorityc.Next of KinExplain procedures followed to locate the next of kin if they are not found: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 10.Hours cemetery is open to the public: FORMTEXT ?????11.Securitya.Does the cemetery have a fence and gates?b.Are the gates locked after business hours?c.Does the cemetery use guards to patrol the premises?If yes, provide details including if the security guards are employees or subcontractors: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX d.Are security guards armed?If yes, provide details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX e.Does the cemetery use dogs for security?If yes, provide details: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX Provide copies of all contracts utilized for services provided.FRAUD STATEMENTSFLORIDA: Any person who knowingly and with intent to injure, 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.LOUISIANA and 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 include imprisonment, fines, and denial of insurance benefits.Refer to the Core Application for all Fraud Statements. IMPORTANT NOTICEDECLARATIONI DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided.SIGNATURESApplicant SignatureTitleDateProducer SignatureDateProducer Name and Address ................
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