| Today's date: |
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| Effective Date: (Date you want policy
to start on)
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| Have you been insured by us before? |
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Yes, This is for a renewal of a Policy? (If Yes Policy #
) |
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No, New Client / New Business |
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| Is this application for a Additional Location on existing Policy? |
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Yes this is a additional location. (If Yes Policy #
) |
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No |
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| Quoting Agents Name: |
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| If you have not received a Quote yet please call (800) 678-0062 for a
quote. |
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| Referred to our company by? |
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| Mall Information |
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| Mall Location Information: Provide the following information
for each location on separate submissions: |
| Mall/Location Name: |
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| Mall/Location Street Address: |
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| Mall/Location City, State, Zip: |
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| Leasing Managers Name: |
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| Mall Phone #: |
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| Mall Fax #: |
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| Coverage Information |
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| General Liability Limits Required by mall or that you desire: (Products
and completed Operations included) |
|
1 Million Per Occurrence
/ 3 Million Aggregate (Basic) |
|
1 Million Per
Occurrence / 5 Million Aggregate |
|
2 Million Per
Occurrence / 2 Million Aggregate |
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2 Million Per
Occurrence / 5 Million Aggregate |
| Medical Payments limits Required by mall or that you desire: |
|
None (Included Basic) |
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5,000 Medical
Payments |
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10,000 medical Payments |
| Fire Legal Limits Required by mall or that you desire: |
|
100,000 Fire Legal
(Included Basic) |
|
500,000 Fire Legal |
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1,000,000 Fire Legal |
| |
| Contents coverage available on request please call (800)
678-0062 if you desire contents coverage. |
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| Business Information |
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| Your Business Information: |
|
| Your Business Name: |
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(Corporate if incorporated or Owners Name if Sole Proprietorship) |
| Business DBA Name: |
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Type of Space leased:
Cart
Kiosk
Booth/table
Un-Manned Kiosk
Store
sqft |
| Owners Name (person signing lease at mall / location):
|
Business Partner(s) or person with authority to make changes to policy:
1.
2.
3.
|
| Your Home Mailing Address: |
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| City:
State:
Zip Code:
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| Phone # |
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| Fax # |
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| Other contact # |
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| Type of Products sold: |
Food (anything eaten or ingested or drank)
Non-food |
| Products sold (List all products sold): |
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| Do you manufacture any products sold at this location?:
Yes
No |
If "Yes",
please describe:
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Please describe any services provided by you at this location
(Such as piercing, tattooing, massages, etc.):
|
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| Do you install service or demonstrate any products?
Yes
No |
If "Yes", please
describe:
|
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Will you be required to insure any leased equipment?
Yes
No
If "Yes",
additional premium may be required. |
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Does your merchandise change occasionally or seasonally?
Yes
No
If "Yes", please
notify us prior to changes. |
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| If you will have other locations please complete form again. |
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Please list any states that you will have a location at in the future:
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Have you had any Business Losses ( Theft, Fire, Flood) within
past 3 years?:
Yes
No |
If "Yes", please explain loss:
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| Credit Card Authorization |
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| Card Holders Name: |
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| Credit Card Billing Address: |
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| City:
State:
Zip Code
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| Card Holders Phone #: |
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| Credit Card Number: |
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| Expiration Date: |
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| CVV Code: |
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| Amount Authorized: |
Subject to verification. |
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**ALL PREMIUMS ARE FULLY EARNED, NO REFUNDS**
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Please Call (800) 678-0062 For Quote on your specific
Location(s) & Coverages.
Please be sure that above is complete and accurate.
Failure to provide us with the correct or complete information may result in
policy issuance delays or termination of policy.
There is no coverage until application is processed. |
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