Professional legal forms

Excess flood insurance applica... EXCESS FLOOD INSURANCE APPLICATION NEW POLICY Date: Insured: Mailing Address: City: County:State:First Mortgagee: Loan#: Address: City:Zip:Agency Name: Contact: Address: City: Phone:( ) Email:Property

Crop insurance application for... FORM: PMFBYPF02 Agriculture Insurance Company of India Limited thHead Office:13 Floor, Ambadeep Building, K.G.Marg, New Delhi 110001PRADHAN MANTRI FASAL BIMA YOJNA (PMFBY) Micro Insurance Proposal

Unemployment insurance applica... 1101I01BD0521UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) FILING INSTRUCTIONS Complete this application including any applicable attachment(s). Print or type the information. Use blue or

Unemployment insurance applica... 1101I01BD1114UNEMPLOYMENT INSURANCE APPLICATION (Federal Employee) FILING INSTRUCTIONS Complete this application including any applicable attachment(s). Print or type the information. Use blue or

General liability insurance ap... Page 1 of 4. General Liability. Insurance Application For. Alarm/Electronic Security. Installation & Monitoring. (Submissions email: securitysubs rlicorp.com ).

Veterinarian professional liab... Safehold Special Risk, Inc.Servicing Veterinarians since 1965Veterinarian Professional Liability Program Hanover Insurance Group issuing carrier AM Best Rating: A XIVVeterinarian Professional Liability

Beazley specific projectclient... SPECIFIC PROJECT/CLIENT EXCESS LIMIT OF LIABILITY APPLICATION ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY, ARCHITECTS, ENGINEERS AND CONTRACTORS POLLUTION LIABILITY, TECHNOLOGY BASED SERVICES,

Printable insurance applicatio... MODERN FINANCIAL PLANS Manufactured Home Insurance Application 3070 Bristol Pike 1-124A/B Bensalem PA 19020 Complete and return to us by FAX 215-781-3715 or MAIL 3070 Bristol Pike 1-124A/B Bensalem PA 19020 1-800-523-5686 USE TYPE choose one I Primary I Residence Primary Farm/Ranch Applies to primary use risks when Farm/Ranch operations exceed Hobby Farm definition INSURED INFORMATION - OWNER OCCUPIED Insured Type I Individual I Life Estate I Business Name I Trust-Living I Secondary Rental Renter s personal property liability Trust-Land I In Estate I Trust-Family Other If individual is selected complete Individual First Named Insured information. For all others complete both Individual with Control and Entity that appears on the title or deed. INSURED TYPE - INDIVIDUAL - Including Tenant LAST NAME FIRST NAME MI E-MAIL DATE OF BIRTH SECOND INSURED MANUFACTURED HOME LOCATION ADDRESS Coverage available in these states Delaware Maryland New Jersey New York Pennsylvania and South Carolina Is home located inside incorporated city limits Is home in park/community Yes No PARK COMMUNITY NAME LOT NUMBER CITY STATE STREET ADDRESS ZIP COUNTY MAILING ADDRESS Same as location address If NO provide additional information below. HOME PHONE BUSINESS PHONE BEST TO CONTACT I Home Phone I Business Phone I Email Does the manufactured home or other structure have a woodstove or fireplace If YES Factory Installed Commercially Installed Self-installed MODEL YEAR WIDTH LENGTH SERIAL NUMBER DATE OF PURCHASE PURCHASE PRICE UNDERWRITING QUESTIONS 1. Have you had any losses within the past 5 years I Yes I No 7. Do you own or keep on the premises any non-domestic animal including any exotic or wild animal I Yes I No DESCRIBE ANIMAL If YES provide loss Information caused harm or previously bitten I Yes I No Do you accept the animal liability exclusion If answer to question 1 is yes answer any additional required questions. Any water loss with unrepaired damage I Yes I No Any water related losses greater than 5 000 I Yes I No Two or more water losses from same cause I Yes I No Fire loss of any kind I Yes I No Three or more losses of any kind I Yes I No Any theft or liability loss greater than 2 500 2. Has your policy been cancelled/non-renewed including non-pay in the past five years I Yes I No Was the reason non-pay or because the company/agent had withdrawn from product/state I Yes I No 3. Have you had 3 or more policies cancel for non-pay in the past 5 years regardless of policy type I Yes I No 4. Have you had a lapse of insurance coverage of more than 12 months I Yes I No LAPSE REASON 9. Is the manufactured home or other structure utilized as a commercial risk or is business conducted on premises including a day care I Yes I No Is the business incidental purchase that will be occupied in 60 days I Yes I No utilities I Yes I No If NO will it be fully installed and connected within 60 days 12. Does the manufactured home have additions with heat or plumbing I Yes I No Was the addition approved by a state county or local official 13.

Unemployment insurance applica... 1101I01ABD 1114 UNEMPLOYMENT INSURANCE APPLICATION (ExServicemember and Federal Employee) FILING INSTRUCTIONS Complete this application including any applicable attachment(s). Print or type the information.

Vmia certificate of insurance... ABN ACN Sole Traders or Partnerships The ABN provided cannot be associated with a Trust Companies The ACN must be provided SECTION 2. Vmia.vic.gov.au Victorian Managed Insurance Authority ABN 39 682 497 841 PO Box 18409 Collins Street East Victoria 8003 P 1300 363 424 SECTION 3. Phone Number 1800 633 467 Website www. hiainsurance. com.au Risk Management and Insurance CERTIFICATE OF INSURANCE APPLICATION You can now purchase DBI online using this form From 1 July 2017 Builders can manage and purchase Domestic Building Insurance DBI via the online portal BuildVic. Builders who do not wish to purchase DBI via BuildVic will need to complete this form and submit the application to their nominated DBI distributor for processing. important Your must contact the DBI Distributor immediately if there has been any change to your eligibility details. PROJECT TYPE C01 New Single Dwelling C03 New Multi-Dwelling Construction C05 Swimming pool C06 Refurbishment Non structural C04 Alteration/Additions/ Renovations structural contains structural works Other please specify e.g. landscaping retaining wall Have works already commenced on this project by another builder No Yes describe the scope of work to be covered by this certificate of insurance application e.g. contract to complete dwelling from frame stage to completion Page 1 of 5 office use only COI-APP 0717-6 dbi. I have read and agree to the VMIA s terms and conditions for the provision of DBI a copy of which can be found at www. Card Number CCV Number Name on Card Card Expiry mm/yyyy Signature Date dd/mm/yyyy To the extent permitted by law we may correspond with you by electronic communication unless you instruct us not to do so and vice versa. A copy of the HIAIS Privacy Notice can be located on our website www. hiainsurance. com.au PAYMENT DETAILS FOR CERTIFICATE OF INSURANCE A premium is payable on submission of this application form. Please enter your credit card details in the section below. Credit Card Type Mastercard Visa I authorise the fee / premium of to be deducted from my nominated credit card. Dbi. vmia.vic.gov.au I authorise on my own behalf and on behalf of the Builder and its partners and directors a the VMIA disclosing the Builder s personal information and the directors and partners of the Builder s personal information and any other information provided by the Builder or directors and partners of the Builder including but not limited to any information contained in any application for eligibility for DBI Insurance or application for DBI Insurance or in relation to any claims or recoveries in relation to DBI Insurance including the Builder s and the directors and partners of the Builder s claims and credit history to or obtaining such information from other insurers insurance intermediaries DBI Distributors insurance reference bureaux credit reference agencies VMIA s advisers or report on the building industry or on building works undertaken or to be undertaken by the Builder those involved in the claims handling process including assessors and investigators those involved in any way in connection with building work insured under any DBI insurance the owners of any building work undertaken by the Builder which is insured by the VMIA which may include any successor in title to the owner for whom the work was undertaken family members or agents authorised by me or the Builder eligible for DBI insurance and people making enquiries for details of any DBI Insurance issued in respect of a nominated property for the purpose of assisting the VMIA and them in providing relevant reporting regulation services and products or for the purposes of litigation DBI Insurance policy number date of certificate of insurance address of building site name of Builder whether a claim has been made and the amount of any indemnity remaining under the DBI Insurance policy limits.

Occupational accident insuranc... All Risks, Ltd. 11811 North Tatum Blvd, Ste 4010, Phoenix, AZ 85028 Toll Free: 8004189763 Fax: 6023242306 www.allrisks.comQUESTIONNAIRE Occupational Accident Insurance NOTE:There are six sections

Group term life insurance appl... Group Term Life Insurance Application Please complete and return this form to: Worldwide Assurance for Employees of Public Agencies (WA EPA) 433 Park Ave., Falls Church, VA 22046 (800)3683484 www.waepa.org

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