Fillable PROPERTY SECTION PREMISES INFORMATION DIRECT BILL AGENCY BILL

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PROPERTY SECTION PREMISES INFORMATION DIRECT BILL AGENCY BILL

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DATE (MM/DD/YYYY)
PHONE
AGENCY APPLICANT
(A/C, No, Ext):
(First
FAX
Named
(A/C, No):
Insured)
EFFECTIVE DATE EXPIRATION DATE PAYMENT PLAN AUDIT
FOR
COMPANY
USE ONLY
CODE: SUB CODE:
AGENCY
CUSTOMER ID:
PREMISES #: STREET ADDRESS:
BUILDING #: BLDG DESCRIPTION:
BLKT
INFLATION
SUBJECT OF INSURANCE AMOUNT COINS % VALUATION CAUSES OF LOSS DEDUCTIBLE(S) FORMS AND CONDITIONS TO APPLY
#GUARD %
ADDITIONAL INFORMATION BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810 VALUE REPORTING INFORMATION - Attach ACORD 811
YES NO YES NO
DISTANCE TO
CONSTRUCTION TYPE FIRE DISTRICT/CODE NUMBER PROT CL # STORIES # BASM’TS YR BUILT TOTAL AREA
HYDRANT FIRE STAT
BLDG CODE
TAX CODE ROOF TYPE OTHER OCCUPANCIES
BUILDING IMPROVEMENTS
GRADE
WIND CLASS
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
BURGLAR ALARM INSTALLED AND SERVICED BY EXTENT GRADE # GUARDS/WATCHMEN
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)
% SPRNK FIRE ALARM MANUFACTURER
RANK: NAME AND ADDRESS: REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
INTEREST
LOCATION: BUILDING:
SCHEDULED ITEM NUMBER:
OTHER:
ITEM DESCRIPTION:
DIRECT BILL
AGENCY BILL
FT MI
WIRING, YR: PLUMBING, YR:
ROOFING, YR: HEATING, YR: HEATING BOILER ON PREMISES? YES NO
SEMI-
OTHER: RESISTIVE OTHER IF YES, IS INSURANCE PLACED ELSEWHERE? YES NO
RESISTIVE
CENTRAL STATION
WITH KEYS
CLOCK HOURLY
CENTRAL STATION
LOCAL GONG
LOSS
PAYEE
MORT-
GAGEE
SPOILAGE COVERAGE DESCRIPTION OF PROPERTY COVERED LIMIT DEDUCTIBLE REFRIG MAINT AGREEMENT OPTIONS
$$
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
PREMISES INFORMATION
ADDITIONAL INTERESTS
ATTACH TO APPLICANT INFORMATION SECTIONACORD 140 (2005/01) © ACORD CORPORATION 1985-2005
PROPERTY SECTION
PREMISES #: STREET ADDRESS:
BUILDING #: BLDG DESCRIPTION:
BLKT
INFLATION
SUBJECT OF INSURANCE AMOUNT COINS % VALUATION CAUSES OF LOSS DEDUCTIBLE(S) FORMS AND CONDITIONS TO APPLY
#GUARD %
ADDITIONAL INFORMATION BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810 VALUE REPORTING INFORMATION - Attach ACORD 811
YES NO YES NO
DISTANCE TO
CONSTRUCTION TYPE FIRE DISTRICT/CODE NUMBER PROT CL # STORIES # BASM’TS YR BUILT TOTAL AREA
HYDRANT FIRE STAT
BLDG CODE
TAX CODE ROOF TYPE OTHER OCCUPANCIES
BUILDING IMPROVEMENTS
GRADE
WIND CLASS
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
BURGLAR ALARM INSTALLED AND SERVICED BY EXTENT GRADE # GUARDS/WATCHMEN
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)
% SPRNK FIRE ALARM MANUFACTURER
RANK: NAME AND ADDRESS: REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
INTEREST
LOCATION: BUILDING:
SCHEDULED ITEM NUMBER:
OTHER:
ITEM DESCRIPTION:
FT MI
WIRING, YR: PLUMBING, YR:
ROOFING, YR: HEATING, YR: HEATING BOILER ON PREMISES? YES NO
SEMI-
OTHER: RESISTIVE OTHER IF YES, IS INSURANCE PLACED ELSEWHERE? YES NO
RESISTIVE
CENTRAL STATION
WITH KEYS
CLOCK HOURLY
CENTRAL STATION
LOCAL GONG
LOSS
PAYEE
MORT-
GAGEE
SPOILAGE COVERAGE DESCRIPTION OF PROPERTY COVERED LIMIT DEDUCTIBLE REFRIG MAINT AGREEMENT OPTIONS
$$
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY:
SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, MA, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
ADDITIONAL
PREMISES INFORMATION
ADDITIONAL INTERESTS
REMARKS
ACORD 140 (2005/01)
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PROPERTY SECTION PREMISES INFORMATION DIRECT BILL AGENCY BILL

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Completed 15 December 2021

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