Transcription of COMMERCIAL INSURANCE APPLICATION DATE …
{{id}} {{{paragraph}}}
Example: confidence
COMMERCIAL INSURANCE APPLICATION DATE …
DATE (MM/DD/YYYY)NAIC CODEAGENCYUNDERWRITER:UNDERWRITER OFFICE:POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDCONTACTNAME:PHONE(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS:CODE:SUB CODE:AGENCY CUSTOMER ID:PROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMEPACKAGE POLICY PREMIUM: $NAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP+4 (of First Named Insured)FEIN OR SOC SEC #PHONE(of First Named Insured):(A/C, No, Ext):CR BUREAU NAME:DATE BUSSTARTEDID NUMBER:INSPECTION CONTACT:ACCOUNTING RECORDS CONTACT:PHONEE-MAILPHONEE-MAIL(A/C, No, Ext):ADDRESS:(A/C, No, Ext):ADDRESS:LOC #BLD #STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITSINTERESTYRBUILT%OCCUPIEDELECTRONIC DATA PROCTRUCKERS/MOTOR CARRIEREQUIPMENT FLOATERUMBRELLAACCOUNTS RECEIVABLE/VALUABLE PAPERSBOILER & MACHINERYGARAGE AND DEALERSVEHICLE SCHEDULEBUSINESS AUTOGLASS AND SIGNWORKERS COMPENSATIONINSTALLATION/BUILDERS RISKYACHTCOMMERCIALGENERAL LIABILITYCRIME/MISCELLANEOUS CRIMEOPEN CARGODEALERSPROPERTYDRIVER INFO SCHEDULETRANSPORTATION/MOTOR TRUCK CARGOQUOTEISSUE POLICYRENEWENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE (Give Date and/or Attach Copy):CHANGEAMDIRECT BILLCANCELPMAGENCY BILLLLCNO.
2. is a formal safety program in operation? 3. any exposure to flammables, explosives, chemicals? 4. any catastrophe exposure? 5. any other insurance with this company or being submitted? 6. any policy or coverage declined, cancelled or non-renewed during the prior three (3) years? (not applicable in mo) 7.
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: