Fillable Form 33: COMMERCIAL INLAND MARINE SECTION (Graham-Rogers Insurance)

Fill Online, Printable, Fillable, Blank Form 33: COMMERCIAL INLAND MARINE SECTION (Graham-Rogers Insurance) Form

Use Fill to complete blank online GRAHAM-ROGERS INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 33: COMMERCIAL INLAND MARINE SECTION (Graham-Rogers Insurance)

On average this form takes 192 minutes to complete

The Form 33: COMMERCIAL INLAND MARINE SECTION (Graham-Rogers Insurance) form is 4 pages long and contains:

  • 0 signatures
  • 22 check-boxes
  • 757 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Graham-Rogers Insurance forms online.

BROWSE GRAHAM-ROGERS INSURANCE 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
 
EFFECTIVE DATE
NAIC CODE
CARRIER
POLICY NUMBER
APPLICANT / FIRST NAMED INSURED
AGENCY
AGENCY CUSTOMER ID:
COMMERCIAL INLAND MARINE SECTION
DATE (MM/DD/YYYY)
Attach to ACORD 125
The ACORD name and logo are registered marks of ACORD
ACORD 152 (2015/06) © 2015 ACORD CORPORATION. All rights reserved.
1
2
3
4
5
6
7
8
9
10
LOC
#
BLD
#
$
COVERAGES / CAUSES OF LOSS
SUMMARY INFORMATION
SCH
#
1
2
3
4
5
6
7
8
9
10
CLASS
CODE
SUBCLASS
CODE
DESCRIPTION
SCH
Y / N
NUM
ITEMS
VALU-
ATION
BLKT
#
MAX ITEM VALUE
$
$
$
$
$
$
$
$
$
% COINS
%
%
%
%
%
%
%
%
%
%
COVERAGES / CAUSES OF LOSS
SCH
#
POL
LVL
Y / N
COV
CODE
% COINS
%
PREMIUM
$
OPT
CODE
DED
TYPE
DED
$
LIMIT
$
LIMIT
APPLIES
TO
LIMIT
APPLIES
TO
DESCRIPTION LIMIT
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
%$$
LOC
#
BLD
#
NUM
MOS
$
$
$
$
$
$
$
$
$
MAXIMUM VALUE
INSIDE
$
$
$
$
$
$
$
$
$
MAXIMUM VALUE
OUTSIDE
TYPE OF SECURITY
EQUIPMENT STORAGE
Page 1 of 4
$
$
$
$
$
$
$
$
%$$
%$$
%$$
%$$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
IS APPLICANT OPERATING EQUIPMENT NOT LISTED HERE?3.
PROPERTY USED UNDERGROUND?4.
ANY WORK DONE AFLOAT?5.
AGENCY CUSTOMER ID:
ITEM DESCRIPTION:
INTEREST
INTEREST IN ITEM NUMBER
LOSS PAYEE
LIENHOLDER
LOCATION: BUILDING:
SCHEDULE NUMBER:
ACORD 45 AttachedADDITIONAL INTEREST
LENDER'S LOSS PAYABLE
REASON FOR INTEREST:
LIEN AMOUNT:
REFERENCE / LOAN #:
PHONE (A/C, No, Ext):
E-MAIL ADDRESS:
INTEREST END DATE:
SEND BILLPOLICY
EVIDENCE:RANK:
NAME AND ADDRESS
CERTIFICATE
ITEM NUMBER:
ACORD 152 (2015/06) Page 2 of 4
ITEM DESCRIPTION:
INTEREST
INTEREST IN ITEM NUMBER
LOSS PAYEE
LIENHOLDER
LOCATION: BUILDING:
SCHEDULE NUMBER:
LENDER'S LOSS PAYABLE
REASON FOR INTEREST:
LIEN AMOUNT:
REFERENCE / LOAN #:
PHONE (A/C, No, Ext):
E-MAIL ADDRESS:
INTEREST END DATE:
SEND BILLPOLICY
EVIDENCE:RANK:
NAME AND ADDRESS
CERTIFICATE
ITEM NUMBER:
ITEM DESCRIPTION:
INTEREST
INTEREST IN ITEM NUMBER
LOSS PAYEE
LIENHOLDER
LOCATION: BUILDING:
SCHEDULE NUMBER:
LENDER'S LOSS PAYABLE
REASON FOR INTEREST:
LIEN AMOUNT:
REFERENCE / LOAN #:
PHONE (A/C, No, Ext):
E-MAIL ADDRESS:
INTEREST END DATE:
SEND BILLPOLICY
EVIDENCE:RANK:
NAME AND ADDRESS
CERTIFICATE
ITEM NUMBER:
REMARKS
Y / N
EXPLAIN ALL "YES" RESPONSES
EQUIPMENT RENTED, LOANED TO OTHERS WITH / WITHOUT OPERATORS?1.
EQUIPMENT RENTED, LOANED FROM OTHERS WITH / WITHOUT OPERATORS?2.
GENERAL INFORMATION - EQUIPMENT
AGENCY CUSTOMER ID:
SCHEDULED ITEMS
DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEAR
SCH #
ITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH #
ACORD 152 (2015/06) Page 3 of 4
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
SCH # DESCRIPTION
CAPACITYMODELMANUFACTURER AMOUNT OF INSURANCE
NEW /
USED
ID # / SERIAL #YEARITEM #
EXCL
BLKT
ITEM VALUE
$
VALU-
ATION
VALUATION
DATE
PURCHASE
DATE
OWN /
LEASE
% COINS
%
$
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in PR
Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the
presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a
felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand
dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus
established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to
any material fact may be violating state law.
Applicable in ME, TN, VA and WA
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 and denial of insurance benefits. *Applies in ME Only.
Applicable in KY, NY, OH and PA
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* (not to exceed five thousand dollars and the stated value of the claim
for each such violation)*. *Applies in NY Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by
an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of
an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in FL and OK
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 (of the third degree)*. *Applies in FL Only.
Applicable in CO
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
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 Agencies.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
ACORD 152 (2015/06)
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
SIGNATURE
Page 4 of 4
AGENCY CUSTOMER ID:
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 33: COMMERCIAL INLAND MARINE SECTION (Graham-Rogers Insurance)

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 8 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document