WAREHOUSE & LOGISTICS INSURANCE PROGRAM
Avalon Office:Producer Name:
Contact:
Insured(s)
Named Insured (Legal Name):
Additional Named Insureds:
Mailing Address:
Street
City / State / Zip Code
Business Affiliations
Name any associations, groups, etc.,
to which your company belongs
Locations To Be Insured (One application for ALL locations)
1. / Refer to Statement of Values Spreadsheet (“SOV”) for ALL locations.
Number of Locations / For leased locations, who is responsible for maintenance?
Owned / Leased
Warehouse Forms
% of the
Time Used
Attach a copy of standard warehouse receipt.
Describe any agreements used other than your standard warehouse agreement – attach copy of all such agreements.
Updated 08/24/2016 www.avalonrisk.com Form WA104 | Page 3
Named Insured:Building Information (Provide information ONLY for Main Location below – List ALL other locations on “SOV”)
1. / Identify and describe other tenants’ operations:
2. / Is the building located in a Flood Zone? / Yes / No
If “Yes”, how is this exposure controlled?
3. / Is there basement storage? / Yes / No
If “Yes”, describe the storage and any protection in place to address rising water.
4. / Are the customers’ goods on racks or pallets? / Racks / Pallets
5. / Building Age (year built):
Building System Updates (provide year): / Wiring / Roof / Plumbing / Heating
Construction of the walls:
Construction of the roof:
6. / Does this location have sprinklers? / Yes / No
If “Yes”, complete the following: / Wet / Dry
Manufacturer’s Name:
Is there a secondary water source? / Yes / No
If “Yes”, please describe:
Sprinkler Contractor’s Name:
Sprinkler Contractor’s Phone Number:
7. / Do you have any other private fire protection? / Yes / No
If “Yes”, please describe.
8. / Do you have a theft/burglar alarm system? / Yes / No
If “Yes”, what type? / Police / Local / Central Station
9. / Do you have watchmen? / Yes / No
If “Yes”, what are their hours?
Refrigerated Storage
a. / Are you providing refrigerated storage? / Yes / No
b. / If “Yes”, please answer the following:
c. / Description of storage:
d. / Amount of square feet used for storage:
e. / % of total revenues for this storage:
Updated 08/24/2016 www.avalonrisk.com Form WA104 | Page 3
Named Insured:Types of Commodities Being Stored (Combine storage for ALL locations – should total 100%)
Canned Foods / % / Auto Parts / %
Other Food / % / Electronics / %
Furniture / % / Tobacco Products / %
Industrial Chemicals / % / Temperature Controlled / %
Red Label Items / % / Frozen Foods / %
Rubber Goods / % / Other – please list
Clothing / % / %
Paper Products / % / %
Liquor / Spirits / % / %
Beer / Wine / % / %
Tires / % / %
Appliances / % / %
Warehouse Inventory Practices
a. / How often is a physical inventory taken?
b. / How often is the inventory reconciled with the customer?
Warehouse Staffing
a. / Total number of warehouse employees:
b. / Are any employees bonded? / Yes / No
Gross Receipts
Time Period / Storage / Handling / Transit
a. / 20
b. / 20
c. / Current
d. / Next 12 months
Losses
Give details on losses totaling $25,000 and
over which have occurred in the past 5 years
Limits
Limit Desired: / $ / Deductible Desired: / $
Effective Date:
Updated 08/24/2016 www.avalonrisk.com Form WA104 | Page 3