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PAWN SHOP INSURANCE APPLICATION (All Risks, Ltd)

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AXIS 101 1738 (08.18) Page 1 of 9
PAWN SHOP INSURANCE APPLICATION
1. Applicant’s Name:
2. Proposed First Named Insured:
(First Named Insured is responsible for premium payment, cancellation and changes—refer to policy wording.)
3. Other Insureds:
(Relationship to the first Named Insured)
4. Mailing Address:
5. Inspection/Audit Contact Name: Contact Phone:
6. Business Phone: Business Fax:
7. E-mail: Website Address:
8. Principal Business Address:
City: State: Zip:
9. Form of Business: Individual Partnership Corporation
LLC Other:
10. Years in business at this location: Years of Industry Experience:
Proposed Effective Date: From: To:
11. Additional Interests:
Type: Mortgagor (M) Additional Insured (AI) Loss Payee (LP)
Type
Name
Address
City
State
Zip Code
12. Pawn Shop Location Information
Loc
No.
Street Address
City
County
State
Zip Code
13. Loss Information—(Loss Information for the past three years is required. If no insurance—state no
insurance.)
Carrier
Policy No.
Incurred
Losses
Description of Loss
AXIS 101 1738 (08.18) Page 2 of 9
14. Coverage Requested
Limits of Insurance: Property
Loc.
No.
Building
Limit
BPP Limit
(incl. TI)
Pledged
(OTFJ)
Unpledged
(OTFJ)
Pledged
(FJ)
Unpledged
(FJ)
Constr.
PC
Sq.
Footage
(OTFJ=Other than Firearms and Jewelry FJ=Firearms and Jewelry)
Pledged means Items taken in on Pawn as collateral. Unpledged means everything but Pledged.
Equipment Breakdown
Include Exclude
Deductibles
Building:
BPP/OTFJ:
Firearms/Jewelry: $1,000 Min.
Optional Coverage Limits:
Show Windows—Protected
Open: See Coverage Extensions
Closed: $
Show Windows—Unprotected
Open: $
Closed: $
Inventory with Other Dealers (memoing)
$
Property In Transit (Merchant Parcel or Armored Car)
$
Ordinance of Law - Coverage A
Coverage B: $
Coverage C: $
Increased Per Item Jewelry Theft Limit
$ ($10,000 Included)
Bullion Include Exclude
$
General Liability Limits
Per Occurrence
$
Aggregate
$
Fire Damage Legal Liability
$
Medical Payments
$
Firearms Products Liability
Include—Limit $100,000 $300,000
Exclude
Hired and Non-Owned Auto Liability
Include Exclude
Employee Benefits Liability
Include Exclude
AXIS 101 1738 (08.18) Page 3 of 9
Other Coverages
Cyber Insurance with a $50,000
Aggregate Limit
Include Exclude
Request Higher Limit: $
Montana, New Hampshire, New York and North Dakota require minimum limits of $100,000.
For requested limits of $100K or $250K, answer questions below. If they do not apply, indicate “N/A”
1. Has your organization suffered a breach of personal information in the last 12 months? .. Yes No N/A
2. Do you conduct background screens for prospective employees? ..................................... Yes No N/A
3. Do you maintain regularly updated computer security measures, e.g. firewall, secured wireless connectivity, virus
protection?........................................................................................................................... Yes No N/A
4. Are your employee, customer, and other physical records maintained in a secure environment with limited
access?............... ................................................................................................................ Yes No N/A
Employment Practices Liability
Include — Limit $25,000 $50,000
$75,000 $100,000
Exclude
Deductible $2,500 $5,000
Minimum Deductible in California is $5,000
Coverage Extensions:
The following coverages are provided without additional charge at the limit indicated. For higher limits, please indicate
desired limit in space below.
Coverage
Limit
Provided
Desired Limit
Coverage
Limit
Provided
Desired Limit
Accounts Receivable
$25,000
Money Orders & Counterfeit
$ 1,000
Animal Damage
$ 5,000
Newly Acquired –Buildings
$500,000
Automatic Fire Suppression
$ 5,000
Newly Acquired –BPP
$500,000
Business Income
ALS
N/A
Non-Owned Trailer
$ 5,000
BI – Civil Authority
$10,000
Off Premises – Utility
Failure
$25,000
BI - Dependent Prop.
$10,000
Ordinance or Law (A & B)
$10,000
Computer Fraud
$10,000
Outdoor Property
$10,000
Debris Removal
$25,000
Outdoor Signs
$ 2,500
Electronic Data
$15,000
Personal Effects
$ 5,000
Employee Dishonesty
$10,000
Pollution Clean Up
$25,000
Extra Expense
$25,000
Property Mailed – USPS
Express
$25,000
Fine Arts
$ 5,000
Property Off Premises
$10,000
AXIS 101 1738 (08.18) Page 4 of 9
Coverage
Limit
Provided
Desired Limit
Coverage
Limit
Provided
Desired Limit
Fire Dept. Service Charge
$25,000
Reward Payments
$ 5,000
Fire Extinguisher Recharge
$ 2,500
Sewer Back Up
$10,000
Forgery or Alteration
$10,000
Show Windows- Open-
Protected
$10,000
Key Replacement
$ 2,500
Tenant Glass
$ 2,500
Loss Settlement Expense
$ 5,000
Valuable Papers
$25,000
Money & Securities
$10,000
Premises Protection (Check all that Apply)
1. Burglar Alarm: None Local (rings at premises) Police Connected Central Station
2. Exterior Protections—Contacts on all:
All Doors All Windows Floor Ceiling
All Walls Battery Backup Infrared Motion Detectors
Premises Line Security: Cell Backup Other:
3. Maximum Response Time: Monitoring Co.: Install Date: ____
4. Hold-Up Alarm: None Local Police Connected Central Station
Number of Signal Buttons:
5. Safe/Vault: Number of Safes/Vaults:
Describe Each below:
Safe
No.
Prem.
Mfg.
Type (e.g.,
TL15, TL30)
Timelock
Relock
Alarm
1
Yes No
Yes No
Yes No
2
Yes No
Yes No
Yes No
3
Yes No
Yes No
Yes No
4
Yes No
Yes No
Yes No
6. Safe/Vault Alarm: None Local Police Connected Central Station Motion Detectors Only
7. Extent of Protection: Door All Safe Walls Contact
8. Other Security Protections:
Guard on Premises Armed Guard Guard Dogs Bullet Proof Glass
Bars on Windows Roll-down Gate Surveillance Camera with Recorder
Surveillance Camera without Recorder Other:
AXIS 101 1738 (08.18) Page 5 of 9
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” OR “N/A”
UNDERWRITING INFORMATION
General Section
1. Pawned items include (check all that apply):
Jewelry Guns Tools Motorcycles
Automobiles Boats Recreational Vehicles
If Motorcycles, Boats or Recreational Vehicles are checked, what percent of sales belong to these? ............ %
2. Operations (check all that apply and indicate percent of total sales):
Auto Pawn .................................................. % Title Pawn ...................................................... %
Rent to Own ................................................ % Check Cashing ............................................... %
3. Gross Sales: $ Interest from Pawns $
Gun Sales $ Payroll $
4. Management Personnel
Name
Age
Job Description
Years
Employed
Percent of
Ownership
%
%
%
5. Bonding:
Are you bonded? ......................................................................................................................................... Yes No
Are your employees bonded? ...................................................................................................................... Yes No
6. Do you perform criminal background checks on all employees? ................................................................ Yes No
7. List any State and/or National Association Pawnbroker membership number:
8. Business Hours: From: To:
9. Total Employees: Minimum Number of Employees at One Time:
10. All Firearms kept on the premises are (check all that apply):
Cabled Locked Stored in Locked Cases
11. Has your license been revoked or suspended within the past five years? ..................................... Yes No N/A
12. Has any employee or owner ever had any prior convictions for illegal activities? ......................... Yes No N/A
13. Are all employees handling firearms properly trained? .................................................................. Yes No N/A
14. Are firearms test fired on the premises?......................................................................................... Yes No N/A
15. Do you have the proper state and local license to sell firearms? ................................................... Yes No N/A
16. Do you offer warranties on goods sold? ......................................................................................... Yes No N/A
17. Have any of your operations been sold, acquired, or discontinued within the past five years? ..... Yes No N/A
AXIS 101 1738 (08.18) Page 6 of 9
18. Are your parking facilities in common areas free from defects and adequately lighted? ............... Yes No N/A
19. Are any products of others sold or repackaged under your own label? ......................................... Yes No N/A
20. Do you have any other operations, other than Pawn brokering not described above? ................. Yes No N/A
If yes, please describe:
21. Do you have any owned autos (if yes, ineligible for HNOA coverage)? ......................................... Yes No N/A
Property Section
1. Building Information (indicate year of updates)
Prem.
No.
Bldg.
Age
Bldg
Area
(sq ft)
Roof
HVAC
Plumbing
Electrical
Sprinklered
Fire Alarm*
Yes No
L P CS
Yes No
L P CS
Yes No
L P CS
* (L=local, P=Police Connected, CS= Central Station)
2. Building Ownership
Prem.
No.
Own or
Lease
List All Other Occupancies
List Adjacent Operations
3. Do you lease space to others in any of the above locations? ..................................................................... Yes No
If yes, which premises?
4. Do you restore, repair, service or refinish any inventory? ........................................................................... Yes No
If yes, what?
5. If ammunition or gunpowder is sold, how is it stored?
6. How do you establish the value of items (i.e., Blue Book, Orion, Other)?
7. How were property values determined for pledged items:
Loan plus Interest Multiplies of Loan (indicate times):
Wholesale Replacement Other:
8. How were property values determined for unpledged (previously pawned items):
Loan plus Interest Multiplies of Loan (indicate times):
Wholesale Replacement Other:
9. How were property values determined for non-pledged items (items purchased from wholesalers or direct from
public):
Wholesale Replacement Other:
10. How is the stock inventory kept? Computer Printout Manual Other:
11. How often are your inventory records updated?
AXIS 101 1738 (08.18) Page 7 of 9
12. Where is data/media and records stored when not in use? Safe/Vault Computer Other:
13. Is key data duplicated and stored elsewhere? ............................................................................................ Yes No
If yes, where:
14. What is the maximum dollar amount of loose gems and diamonds you have on the premise at any
one time? *The standard policy provides a maximum amount up to $50,000* ........................................ $
WARRANTIES AS TO PROPERTY INSURED WHEN PREMISES ARE CLOSED:
While the business is closed, stock consisting of firearms and jewelry will be stored as follows:
Storage
Percent of Jewelry
Percent of Firearms
Safe No. 1
%
%
Safe No. 2
%
%
Safe No. 3
%
%
Safe No. 4
%
%
Not in Safe
%
%
Off Premises
%
%
Cabled (applies to long guns)
N/A
%
Total (must be 100%)
100%
100%
Chart to be completed on Column Basis not on a by Row Basis.
In the event a policy is issued by the company based on this application, this application shall become a part of the policy
and shall constitute a warranty. Included in the policy is an agreement that I/We will maintain the security and safeguards
at my premises as I/We have indicated in this application. In the event, the protection is not maintained and a loss occurs,
coverage may not be provided. I/We have read the above and agree that to the best of my knowledge and belief it
represents a true and complete statement.
FRAUD WARNINGS
NOTICE TO APPLICANT - PLEASE CAREFULLY READ THE FOLLOWING
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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO RESTITUTION FINES OR
CONFINEMENT IN PRISON, OR ANY COMBINATION THEREOF.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA 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.
AXIS 101 1738 (08.18) Page 8 of 9
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 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 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.
NOTICE TO KANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD,
PRESENTS, CAUSES TO BE PRESENTED OR PREPARED WITH KNOWLEDGE OR BELIEF THAT IT WILL BE
PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY
WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC
COMMUNICATION OR 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 MATERIAL 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.
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 BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE
OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO 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.
NOTICE TO MINNESOTA APPLICANTS: A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS
COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.
AXIS 101 1738 (08.18) Page 9 of 9
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 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, OR 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 §3613.1).
NOTICE TO OREGON 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, MAY BE GUILTY OF A
FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.
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, VIRGINIA AND WASHINGTON 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 VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN
APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES
UNDER STATE LAW.
I/WE DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.
Applicant’s Name: __________________________________________ Applicant’s Title: _______________________
Applicant’s Signature: Date:
(Must be signed by an active owner, partner or officer)
Producer’s Signature: Date:
Agent Name: Phone Number:
Agent Address:
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PAWN SHOP INSURANCE APPLICATION (All Risks, Ltd)

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Completed 20 January 2021

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