Services de gestion pour courtiers d'assurances ...
| [pic] |TSW Management Services Inc. |
| |International Insurance Wholesalers |
| |1177 West Hastings Street, Suite 200, |
| |Vancouver, BC V6E 2K3 |
| |Tel: 604 678-9833 Fax: 604 678-6882 |
| |Toll Free: 1 866 904-8146 |
PROPERTY INSURANCE APPLICATION
|Producer: | |
| | |
|Effective Date | |Quote required for : | |
APPLICANT
|Insured : | |
| | |
|Status: | |
|Operating Since : | |
|Name of Owners | |
|Experience of Owners | |
|Address: | |
| |Phone |Fax |
| |Website | | |
|Lienholders: | |
| | |
|Current Insurer: | |Policy No.: | |
|Policy cancelled by insurer? | |Reason: | |
| |Yes / No | | |
LOSSES - 5 years
|Date |Type |Description |Amount |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
TECHNICAL INFORMATION
| | | | |Location: |# 1 |
|Address : | |
|Lienholder: | |
|Occupancy: |By insured : |
| |Other occupants: |
|Adjoining risks: |Left: | |Distance: | |
| |Right: | |Distance: | |
| |Back: | |Distance: | |
|Year of construction: | |# Stories: | |Basement | |Floor Area | |
|Construction: |Walls |
|Alarm Systems: |Theft: |Wired |Type: |Central: | |
| |Fire: |Wired |Type: |Central: | |
|Other protection: |Sprinklers | |Smoke detectors: | |Extinguishers | |
|Safe: |Make & Model | |ULC : | |
|Updates? |Roof: |
| |Heating: |
| |Plumbing: |
| |Other? |
TECHNICAL INFORMATION
| | | | |Location: |# 2 |
|Address : | |
|Lienholder: | |
|Occupancy: |By insured : |
| |Other occupants: |
|Adjoining risks: |Left: | |Distance: | |
| |Right: | |Distance: | |
| |Back: | |Distance: | |
|Year of construction: | |# Stories: | |Basement | |Floor Area | |
|Construction: |Walls |
|Alarm Systems: |Theft: |Wired |Type: |Central: | |
| |Fire: |Wired |Type: |Central: | |
|Other protection: |Sprinklers | |Smoke detectors: | |Extinguishers | |
|Safe: |Make & Model | |ULC : | |
|Updates? |Roof: |
| |Heating: |
| |Plumbing: |
| |Other? |
SCHEDULE OF INSURANCE
|Only Complete Sections for coverage required | |Location |#1 |
|DESCRIPTION OF PROPERTY |Co-Ins |AR / NP |ACV or |
| | | |RC |
|DESCRIPTION OF PROPERTY |Co-Ins |
|CRIME |LIMIT |DEDUCTIBLE |PREMIUM |
|Dishonesty – Form A |$ |$ |$ |
|Theft Inside / Outside |$ |$ |$ |
|Money & Security– Broad Form |$ |$ |$ |
|(3D conventions II & III) | | | |
|Money Orders & Counterfeit Paper Currency ( IV ) |$ |$ |$ |
|Safe Burglary |$ |$ |$ |
|Night Deposit Box Burglary |$ |$ |$ |
|Damage to Premises by Burglary |$ |$ |$ |
|Credit Card Forgery |$ |$ |$ |
|LIABILITY |LIMIT |DEDUCTIBLE |RATE |PREMIUM |
|Commercial General Liability |$ |$ |$ |$ |
|Products and Completed Operations Aggregate |$ |$ |$ |$ |
|Tenant Legal Liability |$ |$ |$ |$ |
|Other Liability extensions required: |
|Revenue |Canadian |US |Foreign |Other |
|Last Complete Financial Year | | | | |
|Anticipated for Coming Financial Year | | | | |
|TOTALS: | | | | |
Other Coverages:
| |LIMIT |DEDUCTIBLE |RATE |PREMIUM |
|Pollution |$ |$ |$ |$ |
|Umbrella |$ |$ |$ |$ |
|Signature of Broker | |Date | |
|Signature of Applicant | |Date | |
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