Insurance Property & Crime Quote

Insurance Property & Crime Quote

Applicant / Insured Information

Date of Birth / Incorporation:   Federal Tax ID / SSN:

Individual    Corporation    LLC    Partnership    Other

Property & Location Details

Occupancy / Use:   Year Built:

Building Replacement Value: $   Contents / Business Personal Property: $

Policy Details & Coverages Requested

Policy Type: Property    Crime (Employee Theft, Forgery, Money & Securities)    Combined Package

Building Limit: $

Contents Limit: $

Business Interruption: $

Money & Securities: $

Employee Theft / Fidelity: $

Requested Policy Period From:   To:

Security, Risk Controls & Underwriting Questions

Alarm System Installed: Yes    No    If yes, monitored by:

On-site Security: Yes    No    Surveillance Cameras: Yes    No

Requested Crime Coverages (check applicable)

Employee Theft / Dishonesty    Forgery or Alteration    Money & Securities    Computer Fraud    Social Engineering / Fraudulent Transfer

Exclusions & Limitations (Representative)

The following exclusions are typical and may apply to any issued policy. This quote request does not modify or waive exclusions. Exclusions commonly include: intentional acts by insured, nuclear hazard, pollution, governmental action, wear and tear, losses arising from dishonest acts discovered after termination unless discovered within a specified discovery period, and losses excluded by endorsement. The insurer may impose sublimits, waiting periods, and conditions precedent to coverage.

Beneficiary / Payee Information (for settlement of loss)

Documentation Checklist

The following documents assist underwriting. Please indicate included materials:

Financial Statements (most recent)

Loss Runs (past 5 years)

Photographs of Property & Security Systems

Articles of Organization / Incorporation

Declaration and Certification

I certify that the information provided in this Insurance Property & Crime Quote request is true, complete and correct to the best of my knowledge. I understand that this request is for insurance underwriting purposes only and does not bind the applicant or insurer. I authorize the insurer and its representatives to make any investigations and inquiries they deem necessary in connection with this request, including obtaining loss history from prior insurers, and to disclose underwriting information to reinsurers and appropriate third parties as permitted by law.

I understand that any material misrepresentation, omission or concealment of fact in this request may result in declination of coverage, rescission of a policy, or denial of claims. I acknowledge that additional terms, conditions, endorsements and exclusions may be applied to any quote or policy issued.

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