APPLICANT INFORMATION
LAST FIRST
Risk Details - Please provide the following information for each garage location.
Location
Number
Garage Location
Construction Type
(describe walls/roof)
Year Built
Distance to
nearest FD
(miles)
Distance
Hydrant
(feet)
Total # of
vehicles at
this location
Aggregate
value of all
vehicles at
this location
1
2
3
4
RATING INFORMATION
(While not required, a copy of the prior carrier declaration statement will facilitate speedier Underwriting and policy issuance.)
a. Name of Prior Carrier:
b. Total policy premium of prior carrier:
PLEASE PROVIDE THE NAME AND CONTACT INFORMATION TO BE USED BY US TO
ARRANGE FOR A SECURITY AND FIRE PROTECTION INSPECTION OF THE GARAGE.
Name:
Phone:
Chubb, P.O. Box 1615, Warren, NJ 07061-1615
www.chubb.com/personal
Chubb refers to the insurers of the Chubb Group of Insurance Companies. Actual coverage is subject
to the language of the policies as issued.
Form 01-10-1514 (Ed. 1/08)
1. Are any garage locations of the “museum-type”? If so, please provide details including whether or no the facility is open to the public and has exterior signs
that would draw any attention to the facility.
2. Are there any employees who care for the facilities and the cars?
Is the employee being listed as an operator on this policy?
3. Does anyone other than the insured store any of their car(s) at the garage? If so, please provide details.
4. Is restoration work done at the garage? If so, please provide details.
5. Are any of the vehicles currently at a restoration facility? If yes, where and for how long? Please provide details regarding security and
fire protection.
6. Are any of the vehicles on loan to a museum or temporarily/permanently stored at a location not owned or controlled by the insured?
If yes, describe the circumstances, security and fire protection.
7. Are vehicles owned in the name of an LLC, Trust, or Corporate Name? If yes, please provide details.
CHUBB COLLECTOR CAR
HIGH VALUE SUPPLEMENTAL INFORMATION
(Required when the value of an individual vehicle is $500,000 +, or the value of the entire collection is $1 million +)
collector car high value form:Layout 1 2/4/08 2:48 PM Page 1
