ACE Platinum Portfolio Bind/Issuance Request

ACE Platinum Portfolio Bind/Issuance Request

TYPE OF POLICY: Date: ______

Platinum Portfolio ⁭

E&S ⁭

Manuscript ⁭

Other ⁭ ______

NAMED INSURED & ADDRESS

Named Insured: ______

Secondary Insured: ______

Street Address: ______

Mailing Address (if different): ______

City, State & Zip: ______

Phone Number: ______

Occupation(s): ______

POLICY & PRODUCER INFORMATION

Policy Period: ______To:______Quote #: ______

Agency:______Agency Code:______

Policy Cross Reference #(s): ______Agency Contact:______

______Agency Phone:______

Pay Plan: ⁭ Direct ⁭ Agency Billed

⁭ Cash/Check

⁭ EFT Savings Acct #______Bank #______

⁭ EFT Checking Acct #______Bank #______

⁭ AMEX Acct #______Expiration Date:______

Installment Plan: ⁭ One Pay ⁭Two Pay ⁭Four Pay ⁭Ten Pay

⁭ Twelve Pay (Available for EFT and AMEX only)

(All other installment plans available for EFT and AMEX)

Inspection Information: Inspection Waived by Underwriter (Y/N)_____ If N, complete below:

Inspection Contact:______Phone Number:______Special Inspection Instructions:______

PRIMARY HOME INFORMATION

Quote #______Deductible ______Premium ______

Hurricane/Wind (Y/N) ______Deductible ______Premium ______

Rental (Y/N) ______Deductible ______Premium ______

EQ (Y/N) ______Deductible ______Premium ______

Flood (Y/N) ______Deductible ______Premium ______

Mortgage Billed Yes ⁭ No ⁭

Mortgagee/Additional Insured Name: ______

Mortgagee Address: ______

______

Loan Number: ______

AUTOMOBILE INFORMATION

Quote #______Premium ______State:

Driver Name: ______DOB: ______License #______

Loss Payee Information: ______

Additional Insured (name/address): ______

WATERCRAFT

Quote #______Premium ______

Loss Payee Information: ______

Additional Insured (name/address): ______State:

Driver Name: ______DOB: ______License #______

VALUABLES SCHEDULE

Quote#______Premium______

Valuables Description Attached Yes ⁬ No ⁬

Appraisals included for items greater than $75K ______

EXCESS LIABILITY

Quote # ______Premium______

Excess Limit: ______

UM/UIM Limit: ______

Underlying information for Units covered under Umbrella Only

Carrier: ______Policy #: ______

Non-Profit D & O

Limit: ______Premium ______

Underlying Limit ______

EPL

Limit: ______Premium ______

# of Employees ______

UNDERWRITING

Backdate requested ⁭ Reason for backdate:______

No losses since backdate request (Y/N) ______

Agent Signature:______

Bind request subject to final approval. If underwriting pre-approval was not obtained, quotes cannot be bound without final confirmation from your underwriter.

ADDITIONAL COMMENTS & INFORMATION

Please note any changes from original quote.

HOMEOWNERS #2 INFORMATION

Hurricane/Wind (Y/N) ⁭ Deductible ______Premium ______

Rental (Y/N) ⁭ Deductible ______Premium ______

EQ (Y/N) ⁭ Deductible ______Premium ______

Flood ⁬ Deductible ______Premium ______

Mortgage Billed Yes ⁭ No ⁭

Mortgagee/Additional Insured Name: ______

Mortgagee Address: ______

______

Loan Number: ______

HOMEOWNERS #3 INFORMATION

Hurricane/Wind (Y/N) ⁭ Deductible ______Premium ______

Rental (Y/N) ⁭ Deductible ______Premium ______

EQ (Y/N) ⁭ Deductible ______Premium ______

Flood ⁬ Deductible ______Premium ______

Mortgage Billed Yes ⁭ No ⁭

Mortgagee/Additional Insured Name: ______

Mortgagee Address: ______

______

Loan Number: ______

HOMEOWNERS #4 INFORMATION

Hurricane/Wind (Y/N) ⁭ Deductible ______Premium ______

Rental (Y/N) ⁭ Deductible ______Premium ______

EQ (Y/N) ⁭ Deductible ______Premium ______

Flood ⁬ Deductible ______Premium ______

Mortgage Billed Yes ⁭ No ⁭

Mortgagee/Additional Insured Name: ______

Mortgagee Address: ______

______

Loan Number: ______