Car Insurance Form

PHOTOGRAPHERS BUSINESSOWNERS APPLICATION

1) Name of Applicant:

Business Mailing Address:

City: State: Zip Code: County:

Owners Name: E-Mail Address:

Telephone: Facsimile:

2) Type of Business: Check One:

Individual      Partnership or Joint Venture

Corporation      Limited Liability Corporation

Other: Describe:

3) What is the Federal Employer Identification Number (FEIN)?

4) Year Business started:

5) Description of Business Operation including a description of goods or services provided:

6) Hours of Operation:

7) Number of employees: Total Payroll:

Do you lease employees from others? Yes No

8) Total Gross Sales / Receipts for the past 12 months:

Total Gross Billable Expenses for the past 12 months:

Total Gross Sales / Receipts estimated for the next 12 months:

Total Gross Billable Expenses estimated for the next 12 months:

9) Are there any businesses or business locations owned or operated that will not be specifically insured by this policy? Yes No

If yes, note that coverage will be limited to the business and/or location(s) listed in questions #1-8 above.

10) Effective Date Desired: (Note: Coverage cannot be backdated)

11) Location Address(es) (if different than mailing address above)

City: State: Zip Code: County:

List all occupancies of the building you occupy:

12) Number of years that your business has operated at this location:

13) Are you Owner/Occupant or do you Rent

14) Year Built: Number of Stories: Does building have elevators: Yes No

Square footage of entire building:

Square footage of portion you occupy:

Construction (Check One):

Frame      Joisted Masonry

Noncombustible      Fire Resistive

Other: Describe:

If the building is older than 25 years you MUST also provide the dates that the following were updated:

Wiring Roof Heating Plumbing

List all occupancies situated adjacent to your premises (Ex: Office Building, Restaurant, Warehouse, Apartments, Vacant Lot, Parking Lot, Retail Stores etc.)

Left Side Right Side

Rear

15) Loss Controls:

Is building sprinklered: Yes No

Are smoke detectors present: Yes No

Are fire extinguishers present: Yes No

Is a doorman present: Yes No

Type of Locks: Cylinder Deadbolts

Are barred windows provided? Do they have safety releases? Yes No

Are there at least two exits provided per floor? Yes No

Do you have a Fire Alarm Is it a Central Station Central Local

Include: Certificate Number Expiration date

Do you have a Burglar Alarm Is it a Central Station Central Local

Include: Certificate Number Expiration date

Include any other loss control measures provided:

16) Is the space you occupy currently under renovation: Yes No

17) How far is your premises situated from a shoreline Miles

18) Please list the following for your existing insurance:

Carrier Policy Number

Effective Date Expiration Date

19) Have there been any Property, General Liability or product losses, claims, suits within the last 3 years (even if not covered by insurance)? Yes No

If Yes, provide date of loss, description of loss and total amount of loss: (Attach separate sheet if needed)

20) Has any form of insurance ever been cancelled or non-renewed: Yes No

If yes, explain:

21) General Information:

22) INSURANCE NEEDED:

Business Personal Property

Computer Equipment *

Camera Equipment- Owned*

Camera Equipment- Rented*

General Liability $1,000,000 Include

Non Owned-Hired Auto $1,000,000 Include

Other

Errors & Omissions for ASMP Members ONLY Include

(Please complete Supplemental Errors & Omissions Application)

TRUTH OF STATEMENTS

THE UNDERSIGNED DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL IMMEDIATELY NOTIFY THE INSURANCE COMPANY OF SUCH CHANGES, AND THE COMPANY MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS AND/OR AUTHORIZATION OR AGREEMENT TO BIND INSURANCE.

FRAUD WARNING

NOTICE TO ALL STATES INCLUDING SPECIAL NOTICE TO ARKANSAS, COLORADO, FLORIDA, KENTUCKY, MAINE, MINNESOTA, NEW JERSEY, NEW MEXICO, NEW YORK, OHIO AND PENNSYLVANIA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND MAY BE SUBJECT TO SUBSTANTIAL CIVIL FINES AND CRIMINAL PENALTIES.”

ARE YOU AN ASMP MEMBER? Yes No MEMBER NUMBER:

TITLE:

DATE:

PRINT APPLICANT NAME: