Tsw Management Services Inc

TSW MANAGEMENT SERVICES INC.

PROPERTY INSURANCE

APPLICATION

Producer:
Effective Date /

Quote required for:

APPLICANT

Insured:
Status:
Operating Since:
Name of Owners
Experience of Owners
Address:
Code postal:
Téléphone bur: / Téléphone fax:
Lienholders:
Current Insurer: / # Policy:
Policy cancelled by insurer / Yes / No / Reason:

LOSSES - 5 years

Date / Type / Description / Amount

TECHNICAL INFORMATION

Location: / # 1
Address:
Code postal:
Lienholder:
Affectation of Bldg / By insured:
Other occupants:
Adjoining risks: / Left: / distance:
Right: / distance:
Back: / distance:
Year of construction: / # Stories: / Basement / Floor Area
Construction: / Walls / Roof / Floor:
Heating:
Alarm Systems: / Theft: / Wired / type: / Central:
Fire: / Wired / type: / Central:
Other protection: / Sprinklers / Smoke detectors: / Extinguishers / Bars on windows:
Hydrant: / Firehall:
Safe: / Marque: / ulc:
Renovations:

TECHNICAL INFORMATION

Location: / # 2
Address:
Code postal:
Lienholder:
Affectation of Bldg / By insured:
Other occupants:
Adjoining risks: / Left: / distance:
Right: / distance:
Back: / distance:
Year of construction: / # Stories: / Basement / Floor Area
Construction: / Walls / Roof / Floor :
Heating:
Alarm Systems: / Theft: / Wired / type: / Central:
Fire: / Wired / type: / Central:
Other protection: / Sprinklers / Smoke detectors: / Extinguishers / Bars on windows:
Hydrant: / Firehall:
Safe: / Marque: / ulc:
Renovations:

SCHEDULE OF INSURANCE

Location / # 1
DESCRIPTION OF PROPERTY / Yes / No / Co-ins / AR / NP / ACV / RC / AMOUNT / DEDUCT. / RATE / PREMIUM
Building / $ / $ / $
Damage to Building following theft / $ / $ / $
Earthquake / $ / $ / $
Flood / $ / $ / $
Sewer Back up / $ / $ / $
Rental income / $ / $ / $
Exterior Signs / $ / $ / $
Glass breakage / $ / $ / $
Office Contents / $ / $ / $
Computers / $ / $ / $
Portable Computers / $ / $ / $
Software / $ / $ / $
Extra expenses – information tech / $ / $ / $
Reconstitution of files / $ / $ / $
Reconstitution of accounts receiv. / $ / $ / $
Valuable Papers / $ / $ / $
$ / $ / $
Machinery / $ / $ / $
$ / $ / $
Stock / $ / $ / $
Stock – periode de pointe / $ / $ / $
Stock – unnamed locations / $ / $ / $
$ / $ / $
Cargo – via insured carrier (incl. Loading and unloading) / $ / $ / $
Cargo – by insured / $ / $ / $
Courrier / mail / $ / $ / $
Extra expenses / $ / $ / $
Loss of Revenue – Gross Profits / $ / $ / $
Loss of Revenue – Net profits / $ / $ / $
Salaries / $ / $ / $
Contractor’s equipment / $ / $ / $
Tools / $ / $
Machinery Breakdown / $ / $ / $
Loss of Revenue - / $ / $ / $
Machinery breakdown / $ / $ / $
Indirect losses- / $ / $ / $
Machinery breakdown / $ / $ / $
Extra expenses / $ / $ / $
Newly acquired / $ / $ / $
Fire fighting expenses / $ / $ / $
By-laws / $ / $ / $
Professional fees / $ / $ / $
Légende: Co-ins: Co-insurance % AR / NP: All Risk or Named Perils
ACV: Actual Cash Value RP: Replacement Cost

SCHEDULE OF INSURANCE

Location / # 2
DESCRIPTION OF PROPERTY / Yes / No / Co-ins / AR / NP / ACV / RC / AMOUNT / DEDUCT. / RATE / PREMIUM
Building / $ / $ / $
Damage to Building following theft / $ / $ / $
Earthquake / $ / $ / $
Flood / $ / $ / $
Sewer Back up / $ / $ / $
Rental income / $ / $ / $
Exterior Signs / $ / $ / $
Glass breakage / $ / $ / $
Office Contents / $ / $ / $
Computers / $ / $ / $
Portable Computers / $ / $ / $
Software / $ / $ / $
Extra expenses – information tech / $ / $ / $
Reconstitution of files / $ / $ / $
Reconstitution of accounts receiv. / $ / $ / $
Valuable Papers / $ / $ / $
$ / $ / $
Machinery / $ / $ / $
$ / $ / $
Stock / $ / $ / $
Stock – periode de pointe / $ / $ / $
Stock – unnamed locations / $ / $ / $
$ / $ / $
Cargo – via insured carrier (incl. Loading and unloading) / $ / $ / $
Cargo – by insured / $ / $ / $
Courrier / mail / $ / $ / $
Extra expenses / $ / $ / $
Loss of Revenue – Gross Profits / $ / $ / $
Loss of Revenue – Net profits / $ / $ / $
Salaries / $ / $ / $
Contractor’s equipment / $ / $ / $
Tools / $ / $
Machinery Breakdown / $ / $ / $
Loss of Revenue - / $ / $ / $
Machinery breakdown / $ / $ / $
Indirect losses- / $ / $ / $
Machinery breakdown / $ / $ / $
Extra expenses / $ / $ / $
Newly acquired / $ / $ / $
Fire fighting expenses / $ / $ / $
By-laws / $ / $ / $
Professional fees / $ / $ / $
Légende: Co-ins: Co-insurance % AR / NP: All Risk or Named Perils
ACV: Actual Cash Value RP: Replacement Cost
CRIME / YES / NO / LIMIT / DEDUCTIBLE / PREMIUM
Dishonesty - form A / $ / $ / $
Theft Inside / Outside / $ / $ / $
Money & Security– Broad Form
(3D conventions II & III) / $ / $ / $
Money Orders & Counterfeit Paper Currency ( IV ) / $ / $ / $
Safe Burglary / $ / $ / $
Night Deposit Box Burglary / $ / $ / $
Damage to promises by Burglary / $ / $ / $
Credit Cards / $ / $ / $
LIABILITY / YES / NO / LIMIT / DEDUCTIBLE / RATE / PREMIUM
CGL / $ / $ / $ / $
incl .products / $ / $ / $ / $
Umbrella / $ / $ / $ / $
Pollution / $ / $ / $ / $
Tenant legal liability / $ / $ / $ / $
Total premium / $
Taxes / $
Engineering / $
Honoraires / $
Grand total / $
Signature of Broker / Date
Signature du Applicant / Date