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 / Name & email of person submitting application
City, State Zip / Mailing Address, 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 MasonryConcrete TiltOther: / (Drop Down)FrameBrick/BlockBrick or Stone VeneerStucco VeneerJoisted MasonryConcrete TiltOther: / (Drop Down)FrameBrick/BlockBrick or Stone VeneerStucco VeneerJoisted MasonryConcrete TiltOther:
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.

8.  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.

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Date Signature of Applicant Signature of Producer EQ 3/13