Fillable Personal Inland Marine Supplemental Application (Colonial General Insurance Agency, Inc)

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Personal Inland Marine Supplemental Application (Colonial General Insurance Agency, Inc)

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P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (
800) 332-9285
Agent’s E-mail Address____________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Applicant’s E-mail Address _________________ Preferred Method of Correspondence
?
E-Mail Fax Regular Mail
Personal Inland Marine Supplemental Application
(for attachment to a Homeowner’s Application)
Applicant
1. Does applicant travel extensively? .............................................................................................................. Yes No
If so, # of weeks per year?
Where, if outside of the United States?
Coverages:
No. Property Amount of Insurance Rate Premium
1. Jewelry
2. Jewelry in Vault
3. Furs
4. Fine Arts
5. Cameras
6. Silverware
7. Musical Instruments
8. Stamps
9. Coins
10. Golfer’s Equipment
11.
12.
13.
14.
Additional Rating Information: Total $
IM-APP-5 (2-03) Page 1 of 3
General Information:
Explain all “Yes” Responses in Remarks
1. Safes?..........................................................................................................................................................
Yes No
Type and location?
2. Will any Property be exhibited?................................................................................................................... Yes No
3. Is any property used professionally/commercially?..................................................................................... Yes No
4. Do you know the appli
cant personally?.......................................................................................................
Yes No
If so, how long?
5. Are any items held for sale? ........................................................................................................................ Yes No
REMARKS:
Prior Carrier for scheduled items:
Schedule of Property:
No.
Provide a detailed description of each item, from whom purchased, etc. If
addition
al space is required, please use a separate sheet. Be sure to attach
all required appraisals/bills. If any item is over $25,000, please attach
certified independent appraiser’s report.
Purchase/
Apprai
sal Date
Amount Of
Insurance
PRIVACY POLICY:
I have received and read a copy of the “National Casualty Company Privacy Statement an
d Procedures”. By submitting
this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies
issued by National Casualty Company and/or other members of the Scottsdale group of insurance companies. I
understand and agree that any information about me that is contained in, or that is obtained in connection with, this
application or any policy issued to me may be used by any company within the Scottsdale group to issue, review, and
renew the insurance for which I am applying.
APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insu
rance 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.
IM-APP-5 (2-03) Page 2 of 3
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insu
rance 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.
PRODUCER’S SIGNATURE
DATE
APPLICANT’S SIGNATURE DATE
AGENT NAME AGENT LICENSE NUMBER
(Applicable to Florida Agents Only)
IM-APP-5 (2-03) Page 3 of 3
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Personal Inland Marine Supplemental Application (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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