Private Client Select

Agency Request to Bind Coverage

FAX Info

To: / Please fill in all appropriate shaded areas. Quotes where complete rating information has not been provided are subject to change and premium may be adjusted accordingly.
Please note: Coverage is not bound until you receive a binder confirmation from a Private Client Selectunderwriter.
Fax Number:
Date:
Re:
From:
Company:
Phone Number:

Contact Info

Named Insured as it should appear on the policy:
/ Inspection Contact Name:
Mailing Address: / Phone Number:
City: / Inspection Instructions/Comments:
State: ZIP:
Affidavit attached (required if not SL licensed): Yes No
Broker Responsibility attached (required if SL licensed): Yes No

Billing Information

Billing Address (if different from mailing):
City: State: ZIP:
Billing Type: Agency Bill

Policy/Customer Information

Policy Effective Date(s):
PLEASE NOTE: All policies are assumed to have the same effective date unless otherwise noted.
IMPORTANT: If the requested policy effective date is prior to today’s date, we must receive signed documentation confirming there are no known losses in order to bind coverage.
HOMEOWNERS 1(Use additional forms, as needed.)
Location 1 Address:
Quote#: Deductible: Premium: $
(Excluding taxes & fees)
Mortgagee (Name, Address):
EarthquakeQuote#: Premium: $
Excess FloodQuote#: Premium: $
Square Footage of Home: Roof type (CA only): # of stories (CA only):
Is the residence under construction or renovation: Yes No
If no, please enter you initials to confirm that this has been verified with client:
HOMEOWNERS 2(Use additional forms, as needed.)
Location 1 Address:
Quote#: Deductible: Premium: $
(Excluding taxes & fees)
Mortgagee (Name, Address):
EarthquakeQuote#: Premium: $
Excess FloodQuote#: Premium: $
Square Footage of Home: Roof type (CA only): # of stories (CA only):
Is the residence under construction or renovation: Yes No
If no, please enter you initials to confirm that this has been verified with client:
EXCESS LIABILITY
Quote#:Limit: $UM/UIM: $ Premium:$
(Excluding taxes & fees)
Please include (check all that apply): EPLINot-for-Profit Board Liability Protection (D&O)
PRIVATE COLLECTIONS
Quote#:Premium:$ Schedule Included: Yes No
(Excluding taxes & fees)
EPLI
Quote#: Limit: $ Deductible: Premium: $
(Excluding taxes & fees)
OTHER PRODUCTS REQUESTED (Please check all that apply.)
OtherQuote#: Premium $:
(Excluding taxes & fees)
NOTES AND SPECIAL INSTRUCTIONS

Version 1.0 (eff. 08/11) 1 of 2