APPLICATION PROFESSIONAL PHOTOGRAPHERS INSURANCE PACKAGE POLICY
11-1-2001
GENERAL INFORMATION
NAME___________________________________________________________________________
BUSINESS NAME__________________________________________________________________
ADDRESS________________________________________________________________________
CITY____________________STATE_________________________ZIP______________________
PHONE( )_____________________FAX____________________________
DATE BUSINESS ESTABLISHED______________________________________________________
WHERE DID INSURED LEARN TRADE?_________________________________________________
NUMBER OF YEARS IN THIS TRADE__________________________________________________
SPECIALTY OF WORK______________________________________________________________
ANY OUT OF STATE OR OUT OF COUNTRY WORK?_______________________________________
IF SO, GIVE DETAILS____________________________________________________________
DESCRIPTION OF STUDIO / ADVISE CONSTRUCTION DETAILS:
AGE OF BUILDING_____________________ FLOOR MATERIAL___________________________
ROOF MATERIAL_______________________ OUTSIDE WALL MATERIAL____________________
INSIDE WALL MATERIAL________________ HOW HEATED_______________________________
SPRINKLERED_________________________ ADJACENT OCCUPANCIES_____________________
DO YOU HAVE A DARKROOM______________ BURGLARY PROTECTION______________________
TYPE OF NEIGHBORHOOD___________________________________________________________
DESCRIPTION OF BUSINESS:
ANNUAL PAYROLL______________________ ANNUAL SALES_____________________________
NUMBER OF EMPLOYEES_________________ SQUARE FOOTAGE OF SPACE__________________
INSURANCE REQUIREMENTS
TOTAL VALUE OF EQUIPMENT TO INSURE:
CAMERA $_________________ DARKROOM $_________________________
STUDIO $_________________ VIDEO $_________________________
AUDIO $_________________ FURNITURE & FIXTURES $_________________________
BUILDINGS $_________________ PERSONAL PROPERTY $_________________________
STOCK OF PHOTOGRAPH SUPPLIES $_______________________________________________
A SCHEDULE LISTING, WITH MANUFACTURES MODEL NUMBER, SERIAL #'S AND CURRENT
VALUES MUST ACCOMPANY THIS APPLICATION FOR ITEMS IN THE ABOVE SECTION.
AMOUNT OF LIABILITY INSURANCE YOU DESIRE?
( ) $100,000 OCC/AGG. ( ) $250,000 OCC/AGG. ( ) $300,000 OCC/AGG.
( ) $500,000 OCC/AGG. ( ) $1,000,000 OCC/AGG.
PREVIOUS CARRIER________________________ RATE__________PREMIUM__________________
IF NONE---ADVISE WHY COVERAGE NOW WANTED.________________________________________
LOSS EXPERIENCE PAST FIVE YEARS__________________________________________________
_________________________________________________________________________________
I ACKNOWLEDGE AND WARRANT THAT THE INFORMATION GIVEN IN THIS APPLICATION
EVEN IF NOT IN MY HANDWRITING, IS TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
SPECIAL NOTICE: AS PART OF OUR UNDERWRITING PROCEDURE, A ROUTINE INQUIRY
AND/OR A CONSUMER CREDIT REPORT MAY BE MADE WHICH WILL PROVIDE APPLICABLE
INFORMATION CONCERNING CHARACTER, GENERAL REPUTATION, PERSONAL
CHARACTERISTICS, AND MODE OF LIVING. UPON WRITTEN REQUEST, ADDITIONAL
INFORMATION AS TO THE NATURE AND SCOPE OF THE REPORT, IF ONE IS MADE, WILL
BE PROVIDED.
DATE__________INSURED'S SIGNATURE________________________________________
SOCIAL SECURITY NUMBER __________________________________________________
THIS APPLICATION MUST BE FULLY COMPLETED, SIGNED AND DATED BY THE INSURED
OR IT WILL NOT BE ACCEPTED.
AGENT...................................
AGENCY..................................
ADDRESS.................................
CITY....................................
STATE...................................
ZIP.....................................
PHONE...................................