Complete a Separate Application for Each Premises
Please Attach a Copy of Your Warehouse and/or Logistics Contract
I. IneligibleOperations
Are You Seeking Insurance for Any of the Following Operations? Yes No If Yes, Please Stop Now and Contact Your Marine Underwriter.
Household Goods Storage Private Warehouses Self Storage Facilities Field Warehouses
Is This a Cold Storage Operation? Yes No If Yes, Please Stop Now and Contact Your Marine Underwriter.
II. General Information
Effective Date:Expiration Date:
Named Insured:Website Address:
Mailing Address:Number of Years in Business:
Inspection Contact: Telephone:
Description of Business: Number of employees:
Expiring Carrier Premium
Has Any of The Named Insured’s Policies or Coverage’sBeen Declined, Cancelled, or Non-Renewed in the Last 3-Years?
Yes No
If the answer is “Yes”, please explain:
Have You Ever Filed for Bankruptcy? Yes No
III. Operation
Customer Type
PublicContract Major Customers:
Facility Type
General Dry Commodity Bonded Storage Agricultural Products Storage
ActivityAnnual Revenue
Warehousing$
Processing, Transloading, Consolidation, Packing, and Other Logistics Services$
Describe processing operation:
Domestic Transportation (complete a separate application for Motor Truck Cargo insurance)$
International Transportation (complete a separate application for Ocean Cargo insurance)$
Do you outsource any transportation operations? Yes No If yes, please complete supplemental application
Do you outsource any non-transportation operations? Yes No
Please describe Name of company
Extent of liability by the party performing outsourcing Full Released Amount:
Premises Address:
County: City: State: Zip:
Construction Type: Protection Class: Year Built:
IV. Premises Information
Premises Address: County:
City: State: Zip:
Building Owned Leased % Space Utilized Neighboring Occupancies
Year Built: Year Roof Updated: Year Plumbing Updated:
Square Footage: Public Protection Class: Number of Stories (above grade): Basement:
Construction Type
Frame (ISO Grade 1) Joisted Masonry (ISO Grade 2) Non-Combustible (ISO Grade 3)
Masonry Non Combustible (ISO Grade 4) Modified Fire Resistive (ISO Grade 5) Fire Resistive (ISO Grade 6)
Heavy Timber Joisted Masonry (ISO Grade 7) Superior Noncombustible (ISO Grade 8)
Superior Masonry Noncombustible (ISO Grade 9)
V. Your Customers’ Property
Contract TypeRevenue
Direct Damage(not limited to negligence per UCC)$
Declared Value(negligence basis per UCC)$
Released (negligence basis per UCC)$
Monetary limitation based on weight or space Total Area Available for Storage
Multiple of monthly charge Other
Commodity / Percentage / Commodity / PercentageAppliances / % / Office Machinery, Equipment, and Supplies / %
Building or Nursery Products / % / Paper Products / %
Automobiles or Mobile Equipment / % / Perishable Goods / %
Food, non-perishable or non-refrigerated / % / Pharmaceuticals / %
Clothing and Footwear / % / Plastics / %
Consumer Electronics / % / Refrigerated Goods / %
Furniture / % / Tobacco / %
Gifts or Novelties / % / Other (describe): / %
Home Furnishings Except Furniture / % / Other (describe): / %
Medical, Hospital, and Surgical Supplies / % / Other (describe): / %
Main Commodities of your Customers:Percentage (by area or volume) of commodities stored
High Hazard Commodities: Percentage (by area or volume) of commodities stored
Commodity / Percentage / Commodity / Percentage / Commodity / PercentageAerosols / % / Idle Wooden or Plastic Pallets / % / Shingles / %
Acids / % / Laptops, Mobile Phones, and PDAs / % / Skis / %
Ammunition, Explosives and Firearms / % / Lighters / % / Stuffed Toys / %
Antiques, Artwork, or Collectibles / % / Live Animals and Trees / % / Textiles / %
Baled Cotton / % / Matches / % / Tires / %
Batteries / % / Mattresses / % / Rubber / %
Bulk Commodities / % / Nail Polish / % / Tobacco Products / %
Candles / % / Paints, Alcohol-based / % / Vinyl Coated Products / %
Carpet, Rolls or Tiles / % / Paper, Rolled / % / Wax and Wax Coated Products / %
Diapers / % / Photographic Film / % / Wine, Liquor and Sprits / %
Fertilizers / % / Plastic Bottles / % / Wire, spooled / %
Fiberglass Insulation / % / Polyurethane / % / Wood Products / %
Flammable or Combustible Liquids / % / Powders / % / Other / %
Hanging Garments / % / PVA Resins / % / Other / %
Household Goods/Personal Effects / % / Radioactive, Restricted, Hazardous, or Controlled Items / % / Other / %
VI. Limits of Insurance
CoverageLimitDeductible
Premises$ $
Off-premises$ $
Domestic Transit$ $
International Transit$$
Additional CoveragesStandard LimitYour Limit
Accounts Receivable: $5,000$
Equipment, Tools and Computers $50,000$
Uncollectible Storage or Freight Charges$25,000$
Debris Removal: First $50,000 25% of the loss$
Pollutant Cleanup$25,000$
Change in Temperature $50,000$
Tenant Improvements and Betterments$25,000$
Valuable Papers, Data and Software$10,000$
Newly Acquired Warehouses$500,000$
Unexplained Disappearance/Shortage of Inventory$50,000$
Optional Limits of Insurance
CoverageLimitDeductible
Flood$ $
Earthquake$ $
Business Income and Extra Expense$ Number of Days
Employee Dishonesty$$
VII.Protection(Please check all that apply)
Fire
Is the property protected by an Automatic Sprinkler (AS) system? Yes No
Type of System: Wet Pipe Dry Pipe Pre-Action Deluge Mixed Other (describe):
What is the maximum height of storage: Feet
Storage ArrangementsSingle/Double Row Racks Multiple Row Racks
Solid Pile Palletized Bin Boxes Shelves Other
AS Testing –Frequency of General Inspections:
AS Testing - 2” Drain Test Results Date of Last Test: Static pressure psi Residual
psi Static After Test psi
UL certified water flow/valve tamper alarm with central station monitoring
UL certified heat and smoke alarm with central station monitoring
Water Supply: PublicGravity Tank Fire Pump Automatic Smoke and Heat Vents
If building is greater than 30 years old, has wiring been physically upgraded by a licensed electrical contractor within the past 20 years, either in its entirety or as necessary for the occupancy? Yes No
Has wiring has been validated by a licensed electrical contractor to be acceptable for the current occupancy via. a certificate of an ongoing Electrical Preventative Maintenance Contract? Yes No
Year Wiring Updated:
All wiring and electrical equipment is in compliance with NFPA 70, National Electrical Code
Theft
UL Certified Central Station Burglar Alarm UL Certified Local Burglar AlarmWindows have tamperproof locks
Exit doors are equipped with double-cylinder, deadbolt locks Separate caged or fenced area for High-value goods
Security Guards patrols Closed-circuit surveillance cameras Site is completely fencedEmployees background checks including a financial/credit report Annual Physical inventory Written policy is in place on handling OS & D goods.
Virus protection software is employed Data is backed up daily offsite
Contamination
Inventory management and control system to ensure goods are segregated to eliminate risk of contamination
Regular inspection and cleaning of the warehouse
Goods that could be involved in cross-contamination should be segregated or effectively separated
Water Damage
Goods are stored a minimum of 4 inches off the floor on pallets, on dunnage or on racks
AS Valves & In-Rack Sprinkler heads are protected from by barrier or guards
Floors designed to promote proper drainage
Contingency Planning
Demand is seasonal and peaks during what period of time?
A written disaster plan Practice drills More than one owned, operated, or leased location is available
Facility can operate with reduced capacity
ARBITRATION STATEMENT:
For Utah Applicants Only:
ANY MATTER IN DISPUTE BETWEEN YOU AND THE COMPANY MAY BE SUBJECT TO ARBITRATION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER RECOGNIZED ARBITRATOR, A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE COMPANY. ANY DECISION REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY. THE ARBITRATION AWARD MAY INCLUDE ATTORNEY'S FEES IF ALLOWED BY STATE LAW AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT OF PROPER JURISDICTION.
FRAUD WARNINGS
ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICY HOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
DISTRICT OF COLUMBIA APPLICANTS: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT."
FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH.
KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
Massachusetts, Nebraska, Oregon OR Vermont Applicants: ANy person who kNowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially fase information or conceals for the purpose of misleading information concerning any fact material thereto, May be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties
NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION."
OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
PUERTO RICO APPLICANTS: Any person who knowingly and with intent to defraud an insurance company presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if extenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
RHODE ISLAND APPLICANTS: “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.”
TENNESSEE applicants: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
WASHINGTON applicants: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits."
WEST VIRGINIA applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
SIGNING THIS FORM DOES NOT BIND THE APPLICANT FIRM OR THE COMPANY TO COMPLETE THE
INSURANCE. APPLICATION MUST BE SIGNED AND DATED BY AN OWNER, PARTNER OR OFFICER OF
THE APPLICANT FIRM.
APPLICANT’S STATEMENT: I, being duly authorized, have read the above application and declare that to the
Best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as
An inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a
Warranty).
Authorized Signature: Title:
Print Name: Date:
Producer’s Signature: Title:
Print Name: Date:
License Identification Number or National Producer Number:
(Florida Producers must Provide License Identification Number)
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New England Insurance Company
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PLEASE SUBMIT THIS PROPOSAL AND APPROPRIATE MATERIALS TO:
Insert name & address
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