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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