WAREHOUSEMAN LIABILITY INSURANCE PROPOSAL

COMPLETE A SEPARATE PROPOSAL FOR EACH LOCATION

Name of Applicant: ______

Mailing Address: ______

Contact Name: ______Telephone: ______

Location Address: ______

Years in Business: ______Policy Term: ______to ______

Description of Operations: ______

______

Insured is: ______Individual ______Partnership ______Corporation ______Joint Venture.

1.  Description of Premises:

a.  What is ground floor area? ______

b.  Height in stories? ______

c.  Total area (or cubic capacity) of premises available for storage? ______

d.  Identify and describe area(s), if any, occupied by tenant(s) or lessees: ______

______

e.  Any basement(s)? ______If “Yes”, is basement protected by automatic sump pump? ______

And stored property on shelves or pallets? ______

f.  Construction of walls? ______

Construction of Roof? ______

g.  Year built? ______If recently remodeled, when? ______

2.  PROTECTION OF PREMISES

a.  Is location sprinklered? ______If “Yes”, describe: ______

(1)  Wet or dry system? ______

(2)  Manufacturer’s name and when installed: ______

(3)  How often serviced? ______By Whom? ______

(4)  Is system equipped with a Sprinkler Alarm? ______

b.  List any other private fire protection: ______

c. (1) Are your premises protected by an operating Premises Alarm System? ______

Central Station? ______Local Alarm? ______

(2)  Extent of Protection (1-2-22-3): ______

Name of Protective Company: ______

(3)  Underwriters’ Laboratories Certificate No.: ______

Date of Expiration: ______

d. (1) State number of watchmen employed exclusively by you and maintained on duty within your premises at all times when not regularly open to business: ______

(2)  Do they signal to a Central Station and how often? ______

(3)  How many clock stations on premises? ______

(4)  How many pull boxes for Central Stations Signals? ______

3.  Are there any cold storage facilities? ______If so, complete Cold Storage Supplement and attach.

4.  Estimated values in storage during previous year: Maximum: ______Average: ______

5.  Give percentage (by weight) of goods or commodities stored (dry storage):

a.  Canned Foods: ______

b.  Other Foodstuffs: ______

c.  Furniture: ______

d.  Industrial Chemicals: ______

e.  Cloth Products: ______

f.  Paper Products: ______

g.  Home Appliances (other than radio or TV equipment): ______

h.  Radio/Television/Electronic Equipment: ______

i.  Liquor, wines, spirits: ______

j.  Tobacco Products: ______

k.  Tires: ______

l.  Other (Describe): ______

6.  Total number of employees? ______

If any employee(s) bonded, give details: ______

7.  List annual gross receipts for each of the last five years (excluding any cold storage operations):

Date / Amount / Date / Amount
a. / $______/ Storage / d. / $______/ Storage
$______/ Handling / $______/ Handling
b. / $______/ Storage / e. / $______/ Storage
$______/ Handling / $______/ Handling
c. / $______/ Storage
$______/ Handling

8.  What are the estimated gross receipts (excluding cold storage operations) for the next twelve months?

Storage: $______Handling: $______

9.  Give details of all previous losses, insured or not insured, occurring during past five years, which would have been recoverable under this type of insurance: ______

______

10.  Name trade associations in which membership is held: ______

11.  ATTACH A COMPLETE COPY OF THE WAREHOUSE RECEIPT USED (AGREEMENT USED TO STORE GOODS)

12.  WHAT POLICY LIMIT IS DESIRED: $______WHAT DEDUCTIBLE: $______

13.  Has any company cancelled, denied or declined to renew coverage? ( ) Yes ( ) No

If yes, please explain ______

______

Present Carrier: ______Expiring Premium: ______

Rate: ______Deductible: ______

14. Losses past 3 years: Date of Loss Details Carrier

______

______

______

This application does not constitute a binder and insurance shall only become effective as of the date advised by the company.

The Proposer agrees that the statements contained in this proposal are true and that, if insurance is affected, material misrepresentation or concealment of any information voids this insurance.

Date: ______Signed by Insured: ______

By: ______

Agency: ______

Address: ______

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