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Customer Information |
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Name: |
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Business Start Date: |
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DBA Name: |
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Years in Business: |
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WebsiteURL: |
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Years of
Experience: |
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Business Type: |
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Full-time
Employees: |
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Industry Group: |
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Part-time
Employees: |
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Gross Receipts: |
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Business
Description: |
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Phone No. |
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Tax ID Number: |
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Cell No. |
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Fax No. |
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Email: |
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Physical Location: |
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Mailing Address: |
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Address: |
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Address: |
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City |
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City |
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State |
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State |
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Zip |
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Zip |
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Years at Location |
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BOP Customer Information |
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Effective Date |
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No. of
Additional Locations |
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Payroll |
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No of Losses |
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Class Code |
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Years Management
Exp. |
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BOP Policy Coverage |
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Eligibility |
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1 Total Property Value
combined building and contents at all locations |
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2 Maximum Contents Per Location
Range of
dollar value of the highest contents (Business Personal Property, etc)
in any one building. |
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3 Maximum Non-Contracting
Payroll (excluding officers, clerical & sales)
Range of dollar value of the
amount of payroll to employees of businesses not engaged in contracting
excluding officer, clerical, and sales payroll. |
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4 Maximum Contracting Payroll
Range of dollar value of
the amount of payroll to employees of businesses engaged in contracting
excluding officer, clerical, and sales payroll. |
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5 Total Annual Sales
Total income generated by the business after
costs. |
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Business Income |
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6 Gross Receipts / Annual sales receipts
Range of dollar value of the amount of Gross Receipts /
Annual sales receipts. |
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7 Annual Business Income
Total income generated by the business after costs.
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The Annual Business Income cannot be greater than
Gross Receipts / Annual sales receipts |
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8 Business Income - Dependent Property
Covers loss of business income
sustained when the suspension of the insured’s operations is caused by
direct loss or damage to described dependent property.
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9 Business Income -
Interruption of Computer Operations
Provides coverage for
Business Income & Extra Expense for loss due to interruption of computer
operations. |
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Liability Limits |
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10. Liability Per Occurrence/General Aggregate
The General Aggregate and the
Products-Completed Operations aggregate is automatically twice the
Liability Limit. |
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11. Amount of Business Income Covered
Desired amount of Business Income
to be covered against loss. |
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Building
& Contents |
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1.
Building Limit
Dollar amount for which
building is covered.
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2. Percentage of Area
Occupied
Area of building that is
occupied by the insured. |
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3.
Occupancy Type:
Describes the
relationship of the occupant to the building |
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4. Business Personal Property
Limit:
Dollar amount of the value of
the property of the business as contents of the building. |
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5.
Deductible
Dollar amount of loss
for which insured is responsible |
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6. No. Stories |
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7. Year Built: |
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8. Does Building have a
burglar alarm system with a monitoring service subscription? |
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9.
Square footage |
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10. Fire Protection Class
Designation of 1-10
indicating relative risk of loss due to fire. 10 being the highest risk.
Proximity to Fire Stations and fire hydrants, amount of brush and
foliage surrounding the structure, proximity to other buildings are
examples of criteria used by municipalities in determining the Fire
Protection Class. |
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11.
Sprinklered Percentage |
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12. Construction Type |
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13.
Enter year Plumbing last updated: |
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14. Enter year Electrical
last updated: |
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15.
Enter year Heating last updated |
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16. Enter year Roofing last
updated |
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17.
Cause of Loss:
Covers expenses to
extract pollutants from land or water at covered location caused by or
resulting from a specified cause of loss. |
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18. Valuation Method |
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Comments: |
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