DATE APPLICATION FOR BASIC PROPERTY & LIABILITY INSURANCE
77 HARTLAND STREET BOX 280200, EAST HARTFORD, CT 06128-0200TEL (860) 528-9546, FAX (860) 282-0070CONNECTICUT FAIR PLANTHIS IS NOT A BINDER OF INSURANCECONNECTICUT FAIR PLANAPPLICATION FOR BASIC PROPERTY & LIABILITY INSURANCEDATEFAIR PLAN USEUND INITIALS:DATE:APPROVEDREJECTEDQUOTATION #3. TAX ID # (if Corporation)2. MAILING ADDRESS (INCLUDE ZIP CODE)1. APPLICANT (NAME AS IT SHOULD APPEAR ON POLICY):PLEASE COMPLETE EVERY ITEM WITH ANSWERS TYPEWRITTEN OR PRINTED LEGIBLY IN INK. IF AN ITEM IS NOT APPLICABLE, WRITE 'S SIGNATURE IS REQUIRED ON PAGE INSTRUCTIONS ON PAGES 3 AND 4PRODUCER E-MAIL ADDRESSPRODUCER NAMEPRODUCER FAX (A/C, NO)PRODUCER PHONE (A/C, NO, EXT)PRODUCER ADDRESSI HEREBY CERTIFY THAT I AM A LICENSED PRODUCER OF CONNECTICUT.
remarks have you had any losses to this property within the past three years? if yes, complete below 18. describe the date, cause, amount paid and
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