Blanket coverage description (if requesting blanket coverage) - individual items under $2,500 in value:
*Attach another page if necessary. Total Blanket $ _________________________
14. Deductible
q $500 q $1,000 q $2,500 q $5,000 q $10,000
UNDERWRITING AND RATING INFORMATION
15. How many losses has the insured incurred in the past three years? ______________________________________________________________
Total incurred amount? _______________________________________ Details: ___________________________________________________
16. Is the insured a trucking risk or requesting motor truck cargo coverage? q Yes q No
17. Is insured’s covered property or equipment salesperson’s samples? q Yes q No
18. Is insured’s covered property or equipment located on the water? q Yes q No
19. Is insured’s property or equipment routinely sent by mail or parcel post? q Yes q No
20. Does the insured lease, loan or rent covered property or equipment to others? q Yes q No
21. Is any insured property or equipment on this schedule left unlocked and/or unsecured when not in use? q Yes q No
a. If so, is the place of storage protected by a central station alarm system? q Yes q No
22. Are any objects unique or difficult to replace? q Yes q No
23. Do any objects have value beyond their apparent worth due to being rare or collectible? q Yes q No
24. Prior carrier _________________________________ Policy term ______________ to_________________ Premium $ ________________
25. Loss payee _______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Applicant’s Warranty Statement: The undersigned represents to the best of his/her knowledge and belief the particulars and statements
set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The
undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may
render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company
may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application
does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is
understood the Company is relying on the Application in the event the Policy is issued. It is agreed that this Application, including any material
submitted there with, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.
Virginia Notice: You have an option to purchase a separate limit of liability for the extension period. Policy common conditions I. If you
do not elect this option, the limit of liability for the extension period shall be part of an not in addition to the limit specified in the declarations.
Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made
before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was
material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Colorado Fraud Statement: 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.
IMS APP 7/11
page 2 of 3
Description Largest Item Total of Items
1 $ $
2 $ $
3 $ $
4 $ $
5 $ $
