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Contents in Storage Application (Risk Placement Services, Inc.)

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  • 230 other fields

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HO4-APP (03-10) Page 1 of 3
Contents in Storage Application
Applicant’s Name _________________________________________ Agent Name _________________________________________
(And all members of household to which this insurance applies)
_________________________________________ Address _________________________________________
Mailing Address _________________________________________ _________________________________________
_________________________________________ Agent Code _________________________________________
Location _________________________________________
PROPOSED EFFECTIVE DATE:
Address (include
_________________________________________ From ________________________ To _________________________
Unit Numbers) 12:01 A.M., Standard Time at the address of the Applicant
CONTENTS IN A MINI-STORAGE
# Complete this section if there are contents located in a mini-storage warehouse. Provide a minimum of 1 exterior photo of warehouse
1 Mini-storage name ____________________________________________________________________________________________________
Address ____________________________________________ City _______________________________ State __________________
Locker Number____________________________________________
2 If more than one locker, show contents values in each locker below:
#1 __________________________________ #2 __________________________________ #3 __________________________________
3 How are premises secured? Security fence/gate Guard on premises Guard dogs
Manager lives on premises Other ______________________________________________
CONTENTS IN OTHER THAN A MINI-STORA
GE
# Complete this section if contents are located in other than a mini-storage facility – Provide a minimum of 1 exterior photo of building
1 Describe storage area _________________________________________________________________________________________________
Address ____________________________________________ City _______________________________ State __________________
2 If more than one locker, show contents values in each locker below:
#1 __________________________________ #2 __________________________________ #3 __________________________________
3 How are premises secured? Security fence/gate Guard on premises Guard dogs
Manager lives on premises Other ______________________________________________
How long have items been in storage? Protection Class: _______________________________________
Why are the items in storage? ________________
Are any of the items being stored in non-wo
rking condition? Yes No, if yes, provide details_________________________________________
How often does the applicant check/visit the storage location?
Does applicant travel extensively? Ye
s No Is the applicant in the military? Yes No
(If yes, provide details”)
Other than the named insured, who has permit able access to the
_________________________________________________________________ storage facility?
_________________________________________________________________
HO4-APP (03-10) Page 2 of 3
GENERAL INFORMATION
# Explain All “Yes” Responses In Remarks Yes No # Explain All “Yes” Responses In Remarks Yes No
1 Any Burglar Alarms? Local Central 6 Any other insurance with this company?
2 Any Safes? (Type and location? - State Below) 7 Did any loss occur during the last 3 years?
3 Is property located within one mile of a coast? 8 Are there any hazardous materials being stored?
4 Is any property used professionally/commercially? 9 Is the storage facility insured?
5 Any coverage declined/canceled/nonrenewed?
(Last 3 yrs.)
10 Has the applicant been convicted of a crime in the last 7
years?
Remarks:
Are any of the items being stored in non-working condition? ________ If Yes, please explain_______________________________________________
Name of Insurance Company writing Homeowners:________________________________________________________________________________
Dwelling Limit:____________________________________________________ Contents Limit: __________________________________________
PLEASE COMPLETE
LIST OF PROPERTY
#
Provide a detailed description of each item. If additional space is required, please use a separate sheet. Purchase
Date
Value of Item
1
HO4-APP (03-10) Page 3 of 3
LIST OF PROPERTY CONTINUED
#
Provide a detailed description of each item. If additional space is required, please use a separate sheet. Purchase
Date
Value of
Item
QUESTIONS TO BE ANSWERED BY PRODUCER:
1. Do you know the applicant personally?.................................................................................................................................................. Yes No
If yes, for how long? ____________________________________________________________________________________________________
2. Do you handle other insurance for applicant?........................................................................................................................................ Yes No
3. Do you recommend applicant? .............................................................................................................................................................. Yes No
FRAUD WARNING: 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 or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
APPLICANT’S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true; and that these statements are offered as an inducement to the Company to issue the policy for which I am applying.
COVERAGE ACKNOWLEDGMENT
(Coverage cannot be bound without signature)
These coverages have been explained to me and I fully understand that for burglary coverage to apply, there must be visible signs of forcible entry and
that I must notify the police at the time of loss. I understand that this is an Actual Cash Value policy and Replacement Cost is NOT available. I also
understand that coverage only applies once the storage locker is securely locked; there is no coverage during transit or loading and unloading.
Signature of applicant: _________________________________________________ Date: ___________
Coverage will become effective, if accepted, upon written notice by Mutual Insurance Services and coverage will not commence earlier than the date
received in the office of Mutual Insurance Services.
Applicant/Producer Statement: I hereby state I have been unable to produce the above requested coverage from standard insurers. I request Mutual
Insurance Services to effect coverage and I will be responsible for payment of premium, fees and taxes. I understand coverage will not be effective until
accepted by Mutual Insurance Services and flat cancellations are not permitted, 3 month term policies are fully earned and a minimum earned premium
of $200.00 for an annual term policy or $100.00 for a 6 month term will apply.
APPLICANT’S SIGNATURE ____________________________________________________ DATE _____________________________________
PRODUCER’S SIGNATURE____________________________________________________ DATE _____________________________________
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Contents in Storage Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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