Fillable FORM PROPERTY APP (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank FORM PROPERTY APP (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FORM PROPERTY APP (Risk Placement Services, Inc.)

On average this form takes 25 minutes to complete

The FORM PROPERTY APP (Risk Placement Services, Inc.) form is 1 page long and contains:

  • 2 signatures
  • 15 check-boxes
  • 86 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Comments:
Signed: Insured: Date:
Broker: Date:
Applicant:
FEIN:
Effective Date:
through
Mailing Address:
Airport Name:
Airport ID:
Nature of Business:
Years in Business:
Broker Name:
Phone:
PROPERTY COVERAGE SCHEDULE
Building / Location #1
Location Address:
Building Age Construction Area Protection Class Sprinklered?
Yes No
Building updates if over 25 years old; Year: Wiring / Roofing / Plumbing / Heating
Is there painting or upholstery work done on premises? No Yes - Describe:
Coverage
(Bld, BPP, BI/EE)
Limit
Coins %
Special
Forms
Occupancy
$
%
$
%
$
%
$
%
Building / Location #2
Location Address:
Building Age Construction Area Protection Class Sprinklered?
Yes No
Building updates if over 25 years old, Year: Wiring / Roofing / Plumbing / Heating
Is there painting or upholstery work done on premises? No Yes - Describe:
Coverage
(Bld, BPP, BI/EE)
Limit
Coins %
Special
Forms
Occupancy
$
%
$
%
$
%
$
%
LIABILITY COVERAGE SCHEDULE
L
IABILITY
L
IMITS
(1,000’
S
)
500/1000
1000/1000
1000/2000
PRIOR INSURANCE
Policy Term:
Carrier:
Premium: $
Policy Term:
Carrier:
Premium: $
Policy Term:
Carrier:
Premium: $
click to sign
signature
click to edit
click to sign
signature
click to edit
STATE FRAUD WARNINGS
NOTICE TO 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 or, conceals, for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and subjects such person
to criminal and civil penalties.
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information
to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the Department of Regulatory Authorities.
Notice TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefi1s if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third
degree.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefi1s.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss
or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
NOTICE TO NEW YORK 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
shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive
any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony (365: 15-1-10. 36 8.S. 3613.1)
NOTICE TO 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, 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.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
NOTICE TO UTAH APPLICANTS: Any person who knowingly presents false or fraudulent underwriting information, files or
causes to be fired a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report
or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in
prison.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FORM PROPERTY APP (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document