COMMERCIAL EARTHQUAKE
APPLICATION /
In CA, DBA: Griffin Insurance Services, CA License #0G66558
800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867. Bellevue, WA 98009 / WWW.GOGUS.COM
Bellevue. Portland. Spokane.
APPLICANT / PRODUCER
Full Name of Applicant / Agency Name / Agent #
Mailing Address / Mailing Address
City, State Zip / City, State, Zip
Inspection Contact Name & Phone Number
/ Phone / Fax
DATES COVERAGE REQUESTED: / to
APPLICANT IS: Individual Corporation Partnership Joint Venture Other
LOCATION INFORMATION, INCLUDING ZIP (If more than 3 locations, use separate sheet) / Description of Operations/Occupancy
Loc. 1:
Loc. 2:
Loc. 3:
BUILDING INFORMATION / Loc. 1 / Loc. 2 / Loc. 3
Construction / (Drop Down)FrameBrick/BlockBrick or Stone VeneerStucco VeneerJoisted Masonry / (Drop Down)FrameBrick/BlockBrick or Stone VeneerStucco VeneerJoisted Masonry / (Drop Down)FrameBrick/BlockBrick or Stone VeneerStucco VeneerJoisted Masonry
Year Built
Number of Stories
Total Square Footage
DEDUCTIBLE / 5% 10% 20%
LIMITS OF COVERAGE / Loc. 1 / Loc. 2 / Loc. 3
Building % Coinsurance / $ / $ / $
Business Personal Property % Coins. / $ / $ / $
Business Income % Coins or Mthly. / $ / $ / $
Loss of Rents % Coins. or Mthly. / $ / $ / $
Other: / $ / $ / $
TOTAL LIMITS / $ / $ / $
Describe how values were determined:
Valuation Basis: Actual Cash Value Replacement Cost
GENERAL INFORMATION
Number of years in business at this location:
Mortgage: No Yes – Mortgagee Name:
Loan #

EARTHQUAKE UNDERWRITING INFORMATION

1. Is the structure permanently mechanically attached to the foundation (i.e. bolted)? No Yes Unknown

2. Is building foundation reinforced or engineered high-strength concrete? No Yes

3. Is any part of the building on stilts, pylons or above ground pilings? No Yes – Please Explain:

______

4.Is there any parking area within or under the building? No Yes – Please Explain:

______

5.Has any company cancelled, declined, or refused to renew similar insurance in the last 3 years? No Yes – Please Explain:

______

6.Is there any part of the insured building within 30 feet of a land slope of greater than 15% incline? No Yes – Please Explain:

______

7.Is the building foundation on firm, natural ground? Yes No – Please Explain:

______

Firm natural ground is land that has not been increased in elevation or backfilled through human means.

Firm natural ground does not include reclaimed tidal flats or building sites with an average slope exceeding 15% grade.

  1. List and describe any built-on additions to the building:

______

9.Has the described location[s] experienced any earthquake or landslide losses? No Yes – Please Explain:

______

COMMENTS
IMPORTANT NOTICE: There will be NO COVERAGE UNLESS AND UNTIL THIS APPLICATION HAS BEEN ACCEPTED BY GRIFFIN UNDERWRITING SERVICES which acceptance cannot occur until the application has been physically delivered to GRIFFIN UNDERWRITING SERVICES P.O. BOX 3867, BELLEVUE, WA 98009. Where GRIFFIN UNDERWRITING SERVICES in its sole and absolute discretion believes it appropriate, the above REQUESTED EFFECTIVE DATE will be the date coverage is effective, but GRIFFIN UNDERWRITING SERVICES. RESERVES THE RIGHT AND DISCRETION TO ESTABLISH A LATER EFFECTIVE DATE, AND UNDER NO CIRCUMSTANCES WILL GRIFFIN UNDERWRITING SERVICES ESTABLISH AN EFFECTIVE DATE PRIOR TO THE LATER OF (1) THE ACTUAL DATE OF SIGNATURE ON THIS APPLICATION OF (2) THE ACTUAL DATE OF MAILING OF THIS APPLICATION TO GRIFFIN UNDERWRITING SERVICES.

______X______

Date Signature of Applicant Signature of Producer

Griffin Underwriting Services EQ 1/06

COMMERCIAL DIC
SUPPLEMENTAL QUESTIONNAIRE /
In CA, DBA: Griffin Insurance Services, CA License #0G66558
800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867 . Bellevue, WA 98009 / WWW.GOGUS.COM
Bellevue. Portland. Spokane.

- Complete in addition to the two page Commercial Earthquake Application -

1.Is this structure near or exposed to flooding from a river, stream, creek, canal, ditch, lake, reservoir, pond or any other body of water? YES or NO

If the answer is yes, please answer the following:

  1. How many horizontal feet is structure away from the water? Ft.
  2. How many vertical feet does structure lie: Above or Below the water? Ft.
  3. What is the name of the body or flow of water?

2.Is the structure situated or built:

a. In the path of a potential landslide, avalanche or mud flow?YES or NO

b. On, on top of, or at the base of a steep slope (20% or more)?YES or NO

c. Upon a Landfill or Reclaimed Tidal Flats?YES or NO

If any answer is “YES”, please explain fully and describe condition: ______

3.Is there any existing damage to the structure such as cracking or settling of walls or foundations?

YES or NO

If any answer is “YES”, please explain fully and describe condition: ______

  1. Please advise if this structure or any nearby structures have suffered damage from any of the following perils in the past (your answer should include any such losses that you are aware of, and must cover at least the past five years):
  2. FloodYES or NO
  3. Surface WaterYES or NO
  4. Landslide or Earth MovementYES or NO

If any answer is “YES”, please fully describe the loss:

Provide specific details of measures taken to prevent similar losses, either by the applicant or public authorities (use separate sheet if necessary):

  1. What the Flood Zone Designation for this location?

If location is in a Flood Zone, please explain and include full description of the flood plain surrounding your property:

Griffin Underwriting Services DICSQ 1/01