WAREHOUSEMAN’S LIABILITY INSURANCE PROPOSAL
(Complete a separate Proposal for each location)
1)Name of Proposer:
Names of Partners, or Officers, if applicable:
2)Post Office Address:
3)Location to be insured:
4)Fire Contents Rate with 80% or higher Co-Insurance:
5)E.C. Contents Rate with 80% or higher Co-Insurance:
6)Is location sprinklered ?
(a) Wet or dry system:
(b) Manufacturer’s name and when installed:
(c) How often serviced:
(d) Is system equipped with a Sprinkler Alarm - Describe:
(e) What is Contents S.L. Rate with 80% or higher Co-Insurance:
7)Are Watchmen employed ?
(a) How many:
(b) Do they signal to a Central Station and how often:
(c) Do they “Punch in” at clock stations and how often:
(d) How many clock stations on premises:
(e) How many pull boxes on Central Station Signals:
8)Describe Premises:
(a) Construction:
(b) Year Built:
(c) If recently remodelled, when:
(d) Height, in stories:
(e) Any basements:
(f) Describe any exposure to flood damage in basements:
(g) What is ground floor area:
(h) What is total area of premises available for storage:
(i) What is present condition and state of repair:
9)How long in business:
10)Details of previous insurance:
11)Give details of all previous losses that would be recoverable under this type of insurance:
12)Are there any cold storage facilities:
(a) Area available:
(b) Type of refrigerant:
(c) Size and capacity of compressors:
(d) Manufacturer’s name:
(e) Year installed:
(f) Is Contamination Insurance carried:
(g) With what Company and what limits:
13)Give percentage of goods or commodities stored:
(a) Furniture:
(b) Foods:
(c) Acids:
(d) Explosives:
(e) Wet Commodities:
(f) Goods particularly susceptible to damage by water or moisture:
(g) Non-Explosive and Non-corrosive chemicals:
(h) All other goods (described briefly):
14)Value in storage
(a) Maximum:(b) Average:(c) Minimum:
15)What Burglary or Theft Protection is provided - Describe:
16)Does location constitute more than one fire-division, in accordance with local fire inspection or rating bureau:
(a) How many divisions:
(b) Describe how separated (fire doors, etc.):
17)What limit of Indemnity is required:
18)What deductible is required:
19)What are annual gross receipts (by year) for last five years:
(a)19$
(b)19$
(c)19$
(d)19$
(e)19$
20)What are the estimated gross receipts for the next twelve (12) months:
21)Underwriters may require an inspection of the premises. In this case, does the Proposer agree to pay the fee:
THE PROPOSER AGREES THAT THE STATEMENTS CONTAINED IN THIS PROPOSAL ARE TRUE AND THAT IF INSURANCE IS EFFECTED, MATERIAL
MISREPRESENTATION OR CONCEALMENT OF ANY INFORMATION WILL VOID THE INSURANCE.
SIGNED:......
BY:......
BROKER:......
ADDRESS:......
whllprop.