BTIS PUMPKIN PATCH &/OR PRE-CUT CHRISTMAS TREE LOT APPLICATION - CALIFORNIA

Applicant Name
Address
City / State / Zip
Phone / ()- / Fax / ()-
Requested Policy Term / // to //
(Standard term is Nov. 1 to Dec. 31)
BUSINESS OPERATIONS
Location of Lot- Address
City / State / Zip
Are power tools (chain saws, etc.) used? / yes no
Are trees for sale grown at the insured location? / yes no
Do customers cut their own trees? / yes no
Has the applicant operated lot(s) in the past? / yes no
Are goods other than Christmas trees and decorations for sale? / yes no
Has the applicant had any losses in the past three years? / yes no
Please explain any “yes” answers above:
Days and Hours of Operation: / Sunday: Monday: Tuesday: Wednesday:
Thursday: Friday: Saturday:
Forms and conditions applicable: General Liability Declarations (S2000), Commercial General Liability Coverage Form (CG 00 01), Deductible Endorsement - $250 PD only (CG 03 00), Employment Related Practices Exclusion (CG 21 47), Total Pollution Exclusion (CG 21 55), Limitation of Coverage to Designated Premises and Projects (CG 21 44), Assault and Battery Exclusion (S2005), Amendment of Insurance Contract Definition (CG 24 26), Combined Provisions Endorsement (S2002), Nuclear Energy Liability Exclusion Endorsement (IL 00 21), Service of Suit Clause – CA (S1022), 100% Minimum Earned Endorsement (S1003), Exclusion – Mold (CG 21 67), California Changes (CG 32 34), Combined Provisions Endorsement (S2025), California Important Notice About Your Insurance Carrier (S1018)
COVERAGE NOT BOUND UNTIL APPROVED BY THE COMPANY
WARNING: California law requires complete and truthful information by an applicant for insurance. That includes providing any information that would be material to your business organization, even if not specifically asked for on this application. Your failure to provide truthful answers and all material information can result in the insurance company electing to rescind your policy. This means they will not be responsible for any claims which are presented. To avoid such a situation, answer all of the foregoing questions truthfully and completely. I Have Read And Understood All Of The Questions Asked And Have Provided All Information Required.
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APPLICANT SIGNATURE
Additional Insured Endorsement Request(s)
Name of Additional Insured
Address
City / State / Zip

Builders & Tradesmen’s Insurance Services, Inc. (CDI# 0D10271)

6610 Sierra College Boulevard, Rocklin, CA 95677

916-772-9200 phone 916-772-9292 fax

All non-admitted business is placed through LAE Insurance Services, Inc. (CDI# 0E44215)

CA Precut Christmas Tree Lot App. 10-15-08 ed.

Please attach separate sheet if additional endorsements required.

NOTICE-OFFER OF TERRORISM COVERAGE AND DISCLOSURE OF

PREMIUM

You are hereby notified that under the federal Terrorism Risk Insurance Act, as amended (“the Act”), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The term “act of terrorism” means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act oran act that isdangerous to human life, property, or infrastructure; to have resulted in damagewithin the United States, or outside the United States in the case of an air carrier or vessel orthe premises of a United States mission; and to have been committed by an individual orindividuals as part of an effort to coerce the civilian population of the United States or toinfluence the policy or affect the conduct of the United States Government by coercion.

YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FORLOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAYBE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER AFORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAYCONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE. UNDER

THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85%OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHEDDEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE.

THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOESNOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVEREDBY THE FEDERAL GOVERNMENT UNDER THE ACT.

YOU SHOULD ALSO KNOW THAT THE ACT, AS AMENDED, CONTAINS A $100

BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT, AS WELL AS

INSURERS’ LIABILITY FOR LOSSES, RESULTING FROM CERTIFIED ACTS OF

TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAREXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL

INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED.

COVERAGE FOR “INSURED LOSSES” AS DEFINED IN THE ACT IS SUBJECT TO THE

COVERAGE TERMS, CONDITIONS, AMOUNTS AND LIMITS IN THIS POLICY

APPLICABLE TO LOSSES ARISING FROM EVENTS OTHER THAN ACTS OFTERRORISM.

YOU SHOULD KNOW THAT UNDER FEDERAL LAW, YOU ARE NOT REQUIRED TO

PURCHASE COVERAGE FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM.

The Act provides that a separate premium is to be charged for insurance for an “act ofterrorism” covered by the Act.

S101 (01/08)Page 1 of 2

REJECTION OR SELECTION OF TERRORISM INSURANCE COVERAGE

If you choose not to purchase coverage for certified acts of terrorism, you should indicate soin the section below by signing and dating in the space provided.

If you choose to purchase coverage for certified acts of terrorism, you should indicate so inthe section below and remit the quoted premium amount indicated below.

I hereby acknowledge that I have been notified of my right to purchase coveragefor certified acts of terrorism and that I voluntary elect not to purchase suchcoverage. I understand that I will have no coverage for losses arising from acts ofterrorism as defined above.
I hereby elect to purchase coverage for certified acts of terrorism for a premium of $______

Note: If you do not pay the premium as noted above, you will not have Terrorism Coverageunder this policy, as defined in the Act. Failure to sign this form will neither grant norinvalidate coverage.

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Applicant’s Name Insurance Company

______

Authorized Signature Date

______

Print Name Policy Number / Effective Date

S1010 (01/08)Page 2 of 2