STATEMENT OF VALUES DATE (MM/DD/YYYY) …

ACV/RCRATE ORLOSS COST13 date (MM/DD/ yyyy )PHONE(A/C, No, Ext):AGENCYCOMPANYPAGENAIC CODE:FAX(A/C, No): policy NUMBERINSURED / APPLICANTEFFECTIVE DATEHEADQUARTERS ADDRESSCOINS %APPLICABLE CAUSES OF LOSSCODE:SUBCODE:AGENCY CUSTOMER IDAPPLICABLE FORM NUMBERS (Attach completed forms and endorsements that require completion to provide necessary information affecting rates or loss costs)CLASS CODELOC# DESCRIPTION AND ADDRESS OF PROPERTYSUBJECT100% VALUESPREMIUMBLDG#N/AALL VALUES AND LOCATION INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGEAND BELIEFOFSPECIFIC AVERAGE RATEREQUESTED80%BASICEARTHQUAKE COV90%BROADFLOODBLANKET RATE REQUESTEDSPRINKLERLEAKAGE EXCL100%SPECIALVANDALISM EXCLDESC:ADDRESS:DESC:ADDRESS:DESC:ADDRE SS:DESC:ADDRESS:DESC:ADDRESS:DESC:ADDRES S:DESC:ADDRESS:DESC:ADDRESS:DESC:ADDRESS :DESC:ADDRESS:DESC:ADDRESS:ACV (Actual Cash Value) or RC (Replacement Cost): If other valuation basisapplies, provide necessary ' :B = Building S = Stock F = Furniture & Fixtures M = MachineryBPP = Your Business Personal Property PPO = Personal Property of Others BI = Business Income R = Rental Income Other - :RATE OR LOSS

acv/ rc rate or loss cost 1 3 date (mm/dd/yyyy) phone (a/c, no, ext): agency company naic code: page fax (a/c, no): insured / applicant policy number effective date

Loading..

Tags:

  Policy, Date, Effective, Number, Applicants, Insured, Yyyy, Insured applicant policy number effective date

Information

Related search queries