ALL QUESTIONS MUST BE ANSWERED IN FULL AND …



CONVENIENCE STORESAPPLICATION SUPPLEMENT1.Proposed First Named Insured & Other Named Insured(s): FORMTEXT ?????2.Mailing AddressStreetCityCountyStateZIP Code FORMTEXT ?????3.Location AddressStreetCityCountyStateZIP Code FORMTEXT ?????4.Contact Name: FORMTEXT ?????Web Site Address: FORMTEXT ?????Contact for Inspection/Audit:Name: FORMTEXT ?????Phone No.: FORMTEXT ?????5.Applicant is: FORMCHECKBOX Individual FORMCHECKBOX Partnership FORMCHECKBOX Corporation FORMCHECKBOX LLC FORMCHECKBOX Joint Venture FORMCHECKBOX Other (specify): FORMTEXT ?????6.Proposed Effective Date: From: FORMTEXT ?????To: FORMTEXT ?????BUSINESS INFORMATION7.Number of Years in Business: FORMTEXT ?????Number of Years Experience: FORMTEXT ?????8.Hours of Operation: Monday through Thursday FORMTEXT ?????to FORMTEXT ?????Friday FORMTEXT ????? to FORMTEXT ?????Saturday FORMTEXT ????? to FORMTEXT ?????Sunday FORMTEXT ????? to FORMTEXT ?????YesNo9.Are you in compliance with all applicable laws and ordinances pertaining to licensing or codes? FORMCHECKBOX FORMCHECKBOX 10.Do you have any firearms on site or have armed security?If yes, prohibit. FORMCHECKBOX FORMCHECKBOX 11.Do you provide any delivery services? FORMCHECKBOX FORMCHECKBOX 12.Do you provide any drive-thru services? FORMCHECKBOX FORMCHECKBOX 13.Is there a security system connected to a central station? FORMCHECKBOX FORMCHECKBOX 14.Have there been any assault or battery incidents within the past three years? FORMCHECKBOX FORMCHECKBOX If yes, provide details including dates: FORMTEXT ?????15.Receipts: Total $ FORMTEXT ?????Liquor $ FORMTEXT ?????Gas $ FORMTEXT ?????Other $ FORMTEXT ????? 16.Operating Hours: FORMTEXT ?????17.Number of Days Opened: FORMTEXT ?????18.Is store open 24 hours? FORMCHECKBOX Yes FORMCHECKBOX No19.Describe safety controls: e.g., security camera, panic alarms and alarms that are received at a central station: FORMTEXT ?????20.Square footage of building: 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 occurrence that may give rise to claims for the past 3 years:YearCarrierPolicy NumberPremiumLossesPaidLossesReservedDescription of Loss FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21.Does applicant have any other business ventures for which coverage is not requested? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, explain and advise where insured: FORMTEXT ?????COOKING HAZARDS1.Is any type of cooking or food preparation done on premises? FORMCHECKBOX Yes FORMCHECKBOX No2.Type of cooking equipment used:Grill FORMTEXT ?????Fryer FORMTEXT ?????Other FORMTEXT ????? YesNo3.Automatic gas or electric shut-off for cooking with manual pull? FORMCHECKBOX FORMCHECKBOX 4.Are hoods and ducts equipped with filters? FORMCHECKBOX FORMCHECKBOX 5.Are filters cleaned at a MINIMUM of every six months? FORMCHECKBOX FORMCHECKBOX 6.Are hoods and ducts cleaned at a MINIMUM of every six months? FORMCHECKBOX FORMCHECKBOX 7.Are portable fire extinguishers mounted and accessible to cooking areas? FORMCHECKBOX FORMCHECKBOX 8.Semi-annual service contract for auto extinguishing system? FORMCHECKBOX FORMCHECKBOX GASOLINE SALES AND OTHER AUTOMOBILE EXPOSURES1.Number of pumps: FORMTEXT ?????YesNo2.Emergency automatic shut-off accessible to employees and customers? FORMCHECKBOX FORMCHECKBOX 3.Is there a car wash on premises? FORMCHECKBOX FORMCHECKBOX If yes, describe: FORMTEXT ?????4.Is there any auto repair on premises? FORMCHECKBOX FORMCHECKBOX If yes, separate supplemental application required.LIQUOR SALESYesNo1.Do you sell alcohol? FORMCHECKBOX FORMCHECKBOX a.If yes, do you sell it for on premises consumption? FORMCHECKBOX FORMCHECKBOX b.If yes, do you provide employees with written policies and procedures regarding non-service to minors and intoxicated persons? FORMCHECKBOX FORMCHECKBOX c.Has your license to sell alcohol ever been suspended or revoked or restricted in any way due to failure to comply with licensing standards or codes? FORMCHECKBOX FORMCHECKBOX d.Do you ever sell over the internet? FORMCHECKBOX FORMCHECKBOX If yes, estimated internet sales. $ FORMTEXT ?????2.Estimated AnnualClass DescriptionClass CodeExposureConvenience Store Sales13673Sales - $ FORMTEXT ?????Gasoline Stations – Full Service13453Gallons: FORMTEXT ?????Gasoline Stations – Full & Self Service Combined13455Gallons: FORMTEXT ?????Car Washes – Self Service10368Sales - $ FORMTEXT ?????Car Washes – Other Than Self Service10367Sales - $ FORMTEXT ?????Liquor Sales59211-002Sales - $ FORMTEXT ?????LPG Gas Sales From Tank Filling13412Sales - $ FORMTEXT ?????LPG Gas Sales From Tank Swap Program13412Sales - $ FORMTEXT ?????FRAUD STATEMENTSFLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim of 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 PPLICATION 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 SignatureDateAgent Name and Address ................
................

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

Google Online Preview   Download