Staffing Insurance - World Wide Specialty Progams, Inc
Package Policy Application
|Policy Effective Date: |
|Broker Name: |
|Insured Name (attach list of additional names): |
|Insured Location Address: |Insured Mailing Address (if different from location address): |
| | |
|Type Of Business: Corporation Partnership Sole Proprietorship LLC Other |
|General Liability (Direct Hire Only) |
|Requested Commercial Liability: | $1,000, 000 per occurrence/$1,000,000 aggregate |
|Limits, chose one: |$1,000, 000 per occurrence/$2,000,000 aggregate |
| |Other |
|Square Footage (insured location): | |
|Additional Locations |Location | Square Footage |
|(Attach list if additional | | |
|lines are need) | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|Auto-Hired & Non-Owned: | Yes No |
|Stop Gap Liability: |Yes No $ Payroll |
|(ND, OH, WA, WV & WY only) | |
|Employee Benefits Liability: |Yes No |
| |$1,000,000/$1,000,000 Number of Employees |
| |$1,000,000/$2,000,000 |
| |Other |
|Additional Insureds |
|(Attach list if additional lines are need) |
|Location | | | | |
|Name | | | | |
|Address | | | | |
|Interest | | | | |
|Crime |
| |$25,000 Employee Dishonesty |Optional Limits: |Optional Limits: |
|Optional |$25,000 Forgery and Alteration | | |
|Basket Endorsement |$10,000 Money and Securities on premises | | |
|Includes: |$5,000 Money and Securities off premises | | |
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Signature Date
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