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26) Do you know of any incidents not currently reported to insurance that may result in a claim Yes No
against you? If yes, please attach an explanation.
27) During the past five years, has any insurer ever canceled or non-renewed similar insurance Yes No
to any applicant or has your insurance been canceled for nonpayment of premium by any
insurance or finance company? If yes, please attach an explanation.
28) Claim Details (duplicate this page for all claims):
a. What was the date of the incident?
b. What line(s) of your coverage(s) was this claim reported on? Check all that apply:
Property in Transit Property in Storage Catastrophe
Other Installation Floater Other Commercial Property Commercial General Liability
Commercial Auto – Liability Commercial Auto – Physical Damage Other:
c. Please describe the circumstances leading up to the claim, the factual details of the incident, the value of
materials or property lost or damaged, and steps taken following the incident to mitigate loss and evaluate the
claim. Please note “attached” and include an additional sheet if the details do not fit below:
d. If this claim is closed, did it require trial or arbitration to settle? Yes No
e. If this claim is open, do you anticipate it going to trial or arbitration? Yes No
+ If yes, when?
f. Were any of your procedures or rules changed after this incident? Yes No
g. Was the incident a total loss/full insured value claimed? Yes No
+ If no, what percentage was lost? %
h. Total claimed: $
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
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 benefits 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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
