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JEWELRY DEALERS PROPOSAL (Kinsale Insurance)

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Copyright, American Association of Insurance Services, Inc., 2005
AAIS
IM 1211 01 05
Page 1 of 14
JEWELRY DEALERS PROPOSAL
[ ] Special Perils [ ] Named Peril
You need to complete and sign this proposal.
EACH ANSWER GIVEN IN THIS PROPOSAL WILL
BECOME A WARRANTY IF A POLICY IS ISSUED
All parts of the proposal must be completed. If the answer to a question is
"none", then enter "none" in the appropriate blank. A quotation cannot be given
nor can a policy be issued if the proposal is incomplete. If more than one location
is to be covered, A SEPARATE PROPOSAL MUST BE COMPLETED FOR
EACH LOCATION.
PART 1 -- GENERAL INFORMATION
A. The name of your company or corporation is: ________________________
_____________________________________________________________
Is your business incorporated? [ ] yes [ ] no
B. List the principals of your firm or officers of your corporation.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
C. Your described premises is located at: ______________________________
(street address) (floor)
_____________________________________________________________
(city) (county) (state) (zip code)
Your telephone number: _________________________
D. How long have you been doing business at this location? ______________
How long at a previous location? __________________________________
AAIS
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Page 2 of 14
Copyright, American Association of Insurance Services, Inc., 2005
PART 2 -- NATURE OF BUSINESS
The nature of your business, based on annual sales is:
____% Retail ____% Manufacturing
____% Wholesale ____% Pawnbroking
____% Other ___________________________
(describe)
PART 3 -- EMPLOYEES
A. What is the least number of employees, officers, or owners customarily
present during business hours?_______________
B. What is the least number of employees, officers, or owners customarily
present when you open or when you close your
premises?_______________
PART 4 -- PREVIOUS EXPERIENCE
Show the following information for the past five years on property covered by this
type of policy, whether insured or not.
Year ______ Year ______ Year ______
Prior Carrier
Premium $____________ $____________ $____________
Date of Loss
Loss Incurred $____________ $____________ $____________
Loss Collected $____________ $____________ $____________
Cause of Loss
Deductible Amount $____________ $____________ $____________
Year ______ Year ______
Prior Carrier
Premium $____________ $____________
Date of Loss
Loss Incurred $____________ $____________
Loss Collected $____________ $____________
Cause of Loss
Deductible Amount $____________ $____________
AAIS
IM 1211 01 05
Page 3 of 14
Copyright, American Association of Insurance Services, Inc., 2005
PART 5 -- PRIOR CANCELLATION, REFUSAL OR
NON-RENEWAL
To your knowledge has any company ever canceled, refused to issue, or refused
to renew a policy for you? (An answer to this question is not required by
Missouri applicants.) [ ] yes [ ] no
If yes, give details. _________________________________________________
________________________________________________________________
_
PART 6 -- RECORDS
A. Do you keep a detailed record that shows the
nature and value of your stock for sale? [ ] yes [ ] no
B. Do you take a physical inventory at least once
a year? [ ] yes [ ] no
C. Do you keep all purchase invoices, sales
receipts, and related documents? [ ] yes [ ] no
If any answers are no, please explain.
__________________________________
________________________________________________________________
_
PART 7 -- JEWELERS SECURITY ALLIANCE
Are you a member of the Jewelers Security Alliance? [ ] yes [ ] no
PART 8 -- LIMIT OF COVERAGE DESIRED AT
YOUR DESCRIBED PREMISES
Limit
A. Stock for Sale (including property of others): $_______________
B. Peak Season: limit applicable
for the period _________ through _________ $_______________
AAIS
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Page 4 of 14
Copyright, American Association of Insurance Services, Inc., 2005
C. Crime:
1. Burglary of money from a locked safe or vault: $_______________
2. Robbery of money and securities: $_______________
D. Personal Property:
1. Patterns, molds, models, and dies: $_______________
2. Your interest in tenant's improvements
and betterments: $_______________
3. Machinery, tools, and their parts: $_______________
4. Furniture, fixtures, office equipment, and
supplies: $_______________
E. Damage to or Theft of Safes: $_______________
PART 9 -- LIMIT OF COVERAGE AWAY FROM
YOUR DESCRIBED PREMISES
A. For property in transit by:
1. first class registered mail: $_______________
2. common or contract carrier: $_______________
3. armored car messenger service: $_______________
4. private paid delivery service: $_______________
B. For property in the safe or vault of a bank, trust,
or safe deposit company: $_______________
C. For property on the premises of another jewelry dealer.
(This does not include property that is left with a
dealer for temporary safekeeping while you or your
employee or sales representative, are traveling.): $_______________
D. For property in the custody of a sales representative,
including property that is left with a dealer for temporary
safekeeping while away from your premises: $_______________
E. For property in your custody or the custody of a
principal, officer, or employee, while away from your
premises: $_______________
F. For property that is otherwise away from your
premises not described above: $_______________
AAIS
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Copyright, American Association of Insurance Services, Inc., 2005
PART 10 – (Check the box that applies)
What deductible amount do you want?
[ ] $500 [ ] $1,000 [ ] $2,500 [ ] $5,000
[ ] $10,000 [ ] $25,000 [ ] Other $______________
PART 11 -- PROPERTY AWAY FROM YOUR LOCATION
DURING THE PAST 12 MONTHS
A. While in your custody or the custody of members of the firm, officers of the
corporation, or employees other than sales representatives. Within a 50 mile
radius of your premises:
Name No. of Average Amount Maximum Amount
Days Out Carried Carried
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
B. Sales representative. Within a 50 mile radius of your premises:
Name No. of Average Amount Maximum Amount
Days Out Carried Carried
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
_______________ ________ _____________ ______________
C. Name and address of persons carrying over $25,000 in property while away
from your premises must be listed below. Anyone not listed below is limited
to a maximum limit of coverage of $25,000:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
AAIS
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Copyright, American Association of Insurance Services, Inc., 2005
D. The estimated daily average amount of property in the custody of others
such as United States Customs, appraisers, stores, other jewelry dealers,
custom house brokers, repairers, processors, polishers, setters, out on
approval, consignment, or memorandum is: $_______________
E. The total value of the property shipped at your risk during the past 12
months:
1. first class registered mail: $_______________
2. common or contract carrier: $_______________
3. armored car messenger service: $_______________
4. private paid delivery service: $_______________
PART 12 -- SHOW WINDOW AND OUTSIDE SHOWCASE
DISPLAYS ON YOUR PREMISES
NOTE: Property in show windows and outside showcases are considered
protected only when displayed:
-- behind metal bars or a metal grille that is completely across the
show window or showcase;
-- behind swinging plate glass (or its equivalent) that is secondary to
the window pane;
-- behind (UL) listed burglary/bullet resistant glass; or
-- in a showcase that is in a show window.
Outside showcases are those that do not open into the interior of your premises.
A. The amount of coverage desired when premises are:
Open to Business Closed to Business
1. in all windows or Protected Protected
outside showcases: $____________ $____________
Unprotected Unprotected
$____________ $____________
Protected Protected
2. in any one window: $____________ $____________
Unprotected Unprotected
$____________ $____________
3. in any one outside Protected Protected
showcase: $____________ $____________
Unprotected Unprotected
$____________ $____________
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Copyright, American Association of Insurance Services, Inc., 2005
B. How many show windows open to the interior of your premises? __________
C. How many are protected against window smashing? __________
D. How are the show windows protected? ______________________________
E. How many outside showcases do you have? __________
F. Describe the showcases and give their location. ______________________
_____________________________________________________________
G. How are the showcases protected against forcible entry? _______________
PART 13 -- SHOW WINDOW OR SHOWCASE DISPLAY
AWAY FROM YOUR PREMISES
If you desire to cover property that is displayed in showcases or show windows
that are located in building lobbies or anywhere else that is not on your premises,
you must furnish the full particulars of each display on a supplemental page.
PART 14 – PREMISES PROTECTION
A. Are your premises protected by an operating
alarm system while closed to business? [ ] yes [ ] no
1. Is it: [ ] Central Station?
[ ] Local?
[ ] Police Station Connected?
If police station connected, is alarm
monitored at all times? [ ] yes [ ] no
2. What is the extent of protection? __________ (1, 2 or 3)
3. What is the grade? __________ (AA, A, BB, B, CC or C)
4. Name of Protective Company? _________________________________
5. Underwriters Laboratory (UL) Certificate number? __________________
The certificate expires: _____________________
AAIS
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Copyright, American Association of Insurance Services, Inc., 2005
B. Is there a hold-up alarm system? [ ] yes [ ] no
1. How many signal buttons do you have? ____________
2. How many signal buttons are portable? ____________
C. Do you maintain any of the following operating surveillance systems on your
premises while occupied?
Yes
No
[ ] [ ] Camera(s)
[ ] [ ] Closed circuit TV(s) with monitor(s)
[ ] [ ] Video cassette recorder(s)
[ ] [ ] Other ________________________
D. Other protective measures (armed guard on duty during business hours,
watchperson service, etc.) not shown above. Describe. ________________
_____________________________________________________________
PART 15 -- DESCRIPTION OF SAFE OR VAULT
AND PROTECTIVE DEVICES
A. Describe the Safe 1 2 3
1. Manufacturers Name: ____________ ____________ ____________
2. Fire Rating: ____________ ____________ ____________
3. Burglary Rating: ____________ ____________ ____________
4. Lock Combination: [ ] yes [ ] no [ ] yes [ ] no [ ] yes [ ] no
5. Dimensions inner: ____________ ____________ ____________
outer: ____________ ____________ ____________
6. Weight: ____________ ____________ ____________
B. Protective Devices
1. Relocking device? [ ] yes [ ] no [ ] yes [ ] no [ ] yes [ ] no
If yes, give the
UL number: ____________ ____________ ____________
2. Time lock? [ ] yes [ ] no [ ] yes [ ] no [ ] yes [ ] no
Is it UL listed? [ ] yes [ ] no [ ] yes [ ] no [ ] yes [ ] no
3. Early Morning or
Ambush Device? [ ] yes [ ] no [ ] yes [ ] no [ ] yes [ ] no
AAIS
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Copyright, American Association of Insurance Services, Inc., 2005
C. Burglar Alarm
1. Protection Company: _____________ ____________ ____________
2. Type: [ ] Central [ ] Central [ ] Central
Station Station Station
[ ] Local [ ] Local [ ] Local
[ ] Police [ ] Police [ ] Police
Station Station Station
Connected Connected Connected
3. Extent of Protection: [ ] Partial [ ] Partial [ ] Partial
[ ] Complete [ ] Complete [ ] Complete
4. Grade? (AA, A,
BB, B, CC, or C): _____________ ____________ ____________
5. UL Certificate No.: _____________ ____________ ____________
6. Expiration Date: _____________ ____________ ____________
D. Show the percent of the total value of all stock that is kept in each safe when
you are closed to business. The total of the percentage amounts below must
agree with the total percentage amounts of Part 16.
1 _______________% 2 _______________% 3 _______________%
E. Vault Description _____________ _____________
1. Vault Dimensions:
Height _____________ _____________
Width _____________ _____________
Depth _____________ _____________
2. Vault Construction:
a. Concrete Block [ ] yes [ ] no [ ] yes [ ] no
b. Poured Concrete [ ] yes [ ] no [ ] yes [ ] no
c. Modular
(describe UL class and Manufacturer's Name)
_____________ _____________
_____________ _____________
_____________ _____________
d. Other (describe) _____________ _____________
3. Walls, Floor, and Ceiling:
a. Thickness _____________ _____________
b. Construction _____________ _____________
4. Is Vault Wall Part of Common
or Exterior Wall? [ ] yes [ ] no [ ] yes [ ] no
AAIS
IM 1211 01 05
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Copyright, American Association of Insurance Services, Inc., 2005
5. Vault Door:
a. Manufacturer _____________ _____________
b. Rating
(Fire/Burglary) _____________ _____________
c. Thickness _____________ _____________
d. Relocking Device [ ] yes [ ] no [ ] yes [ ] no
e. Time Lock [ ] yes [ ] no [ ] yes [ ] no
6. Vault Alarm:
a. Alarm Company _____________ _____________
b. Describe Monitoring _____________ _____________
c. UL Certificate No. _____________ _____________
and Expiration Date _____________ _____________
d. Extent and Grade _____________ _____________
_____________ _____________
PART 16 -- WARRANTIES FOR PROPERTY ON YOUR
PREMISES AT ALL TIMES WHEN YOU ARE
CLOSED FOR BUSINESS
If no stock reported If any stock included
in Part 17 is to be in Part 17 is
excluded, complete excluded, complete
this column
this column
A. The minimum percentage by value
of property kept in locked safes
or vaults as indicated under:
Part 15, B. 1., B. 2., E. 5. d., and
E. 5. e. will be: _________% __________%
Part 15, C. and E. 6., (complete
safe/vault protection) will be: _________% __________%
Part 15, C. and E. 6., (partial
safe/vault protection) will be: _________% __________%
B. The minimum percentage of value
of property kept in other locked
safes or vaults: _________% __________%
C. The maximum percentage by
value of property out of locked
safes or vaults will be: _________% __________%
AAIS
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Page 11 of 14
Copyright, American Association of Insurance Services, Inc., 2005
D. The minimum percentage by value
of property kept in safe deposit
vaults of a bank, trust, or safe
deposit company described below
will be: __________% __________%
Total (must equal 100%): 100% 100%
Name and address of bank:
_____________________________________________________________
_____________________________________________________________
PART 17 – INVENTORIES OF ALL PROPERTY YOU OWN
WHEREVER LOCATED. THIS INCLUDES STOCK IN
BANK VAULTS, AT OTHER JEWELERS, OR IN THE
CUSTODY OF SALES REPRESENTATIVE.
If you can provide the exact inventory amount for each month of the past 12
months, then show the dates the inventories were taken and the amounts on a
supplemental sheet. In this case, B. and C. need not be answered.
A. The last physical inventory was taken on ___________________________
and was exactly $___________________________.
Pawnbrokers only: The maximum amount loaned and unpaid plus the
accrued legal interest was exactly $___________________________.
B. The previous physical inventory was taken on _______________________
(the inventory in B must be dated at least six months prior to the inventory
in A) and was exactly $____________________________.
Pawnbrokers only: The maximum amount loaned and unpaid plus the
accrued legal interest was exactly $____________________________.
C. The maximum value of your inventory did not exceed $________________
during the past 12 months.
Pawnbrokers only: The maximum amount loaned and unpaid plus the
accrued legal interest during the past 12 months was $________________.
D. You estimate that the average daily value of the property of others that was
in your custody for any reason, whether the property was covered or not,
was $____________________. The percentage of this property that was
unset (non-industrial) diamonds was ____________________%.
Do not include property pledged with pawnbrokers or the property of other
members of the jewelry trade that has been given to you for temporary
safekeeping.
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Copyright, American Association of Insurance Services, Inc., 2005
E. Nature of stock for sale (according to the last physical inventory). Do not
include pledges. Show the percent that each classification is to your total
inventory.
1. Unset diamonds: __________%
2. Jewelry, pearls, other precious
stones and precious metals: __________%
3. Watches, watch bracelets, clocks,
cases, movements, or parts not
made of gold or mounted with
precious stones. __________%
4. Silverware, pewterware, plated ware
or stainless steelware. __________%
5. Jewelers findings, unset mountings
or materials for manufacture. __________%
6. All other stock for sale: __________%
(Describe) ____________________________________
_____________________________________________
_____________________________________________
Total (must equal 100%): 100%
F. Low valued stock for sale (according to the last physical inventory).
Retailers and Pawnbrokers do not answer.
1. The percentage of jewelry per Part 17. E. 2., and 4.
valued at less than $50 per item was: __________%
2. The percentage of watches and clocks per
Part 17. E. 3. valued at less than $50 per item was: __________%
PART 18 – DESCRIBE YOUR PREMISES
A. How many entrances are open to the general public? __________
Not open to general public? ___________
B. Your usual business hours are from: __________ to: __________.
What days? __________________________________________________
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Copyright, American Association of Insurance Services, Inc., 2005
C. Give the names and addresses of any other jewelry stores or locations that
are in the jewelry trade that you own or operate:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
PART 19 – COMPLETED BY APPLICANT
The signing and delivery of this proposal does not bind us to provide the
coverage. The signing and delivery of this proposal does not bind you to
purchase this insurance. Each answer in Parts 1 through 18 will constitute a
warranty should a policy be issued and the pricing of the policy is predicated on
these statements. If these statements are false, this policy will be void and there
shall be no coverage.
If it is necessary to provide additional information, it may be given on a separate,
signed supplemental page. A signed copy of this proposal and the supplemental
page, when applicable, will be part of the policy.
Signature of Proposer
_______________________________________________
Title __________________________________ Date
_____________________
ADDITIONAL UNDERWRITING INFORMATION
A. How many floor and wall showcases do you have? ____________
1. Are they all equipped with key locks? [ ] yes [ ] no
If no, describe type of case and/or lock. __________________________
2. Are the showcases kept locked except when
property is being removed or replaced? [ ] yes [ ] no
3. How are the showcase tops secured? ____________________________
B. Are your premises shared with others? [ ] yes [ ] no
If yes, give the name and state the nature of the business:
_____________________________________________________________
_____________________________________________________________
AAIS
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Page 14 of 14
Copyright, American Association of Insurance Services, Inc., 2005
C. Are you located in an enclosed mall? [ ] yes [ ] no
If not, where are you located? ____________________________________
D. List any optional coverages:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
IM 1211 01 05
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JEWELRY DEALERS PROPOSAL (Kinsale Insurance)

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Completed 31 January 2021

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