AMPC store
On Line Application
Provide Quote By:
E-mail
Fax
Regular Mail
Phone
General Information
Corporation Name
Trade Name
Mailing Address--Street & Suite Number
City
State
Zip
Contact Person
Phone Number
Fax Number
E-mail Address
Web Site URL
Underwriting Information
Location Address:
Same as Mailing
Different from Mailing:
Organization Type
Annual Sales
Building Occupancy
Corporation
Sole Proprietor
Partnership
LLC
Multiple Occupancy
We are sole tenant
We own the building
Construction Type
Sq. Ft. Occupied
Year Built
Frame
Brick/Block & Pitched Roof
Brick/Block & Flat Roof
Metal Building
High Rise
Required--please select
Sq. Ft.
Type of Business/Description of Operations
Protection--Check All That Apply
Deadbolt Locks
Central Station Alarm
Local Alarm
Grated Doors/Windows
Security Lighting
Sprinkler System
Claim History
. .
(Last 5 Years for Coverages to be Quoted)
Type
Date
Amout
Desctiption
No Claims
Property
Liability
Work Comp
Auto
Other
Property
Liability
Work Comp
Auto
Other
Property
Liability
Work Comp
Auto
Other
Property and Liability Coverages
Quote?
Coverage
Limit Requested
Deductible
General Liability Limit
$1 Million
$2 Million
$3 Million
$5 Million
$10 Million
None
Building Coverage
$1,000
$ 500
$2,500
Contents (Except Computers)
$ 250
$ 500
$1,000
$2,500
Select
Computer Hardware & Media
Same as Above
Heating & A/C Equipment
Included if Selected
Same as Above
Plate Glass--
Linear Feet:
Included if Selected
Same as Above
Optional Coverages
(Flood & Earthquake not available in all states.)
Flood Insurance
Earthquake Insurance
Operation of Building Laws
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Hired & Non-Owned Auto
Employee Benefit Liability
Harassment & Discrimination
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Not Needed
Include
Quote as Option
Additional Interests
(indicate number of each type to be added to the policy)
Landlord/Mortgagee
Lessors of Equipment
Grantor of Franchise
Workers' Compensation
Rating Information
No Employees
Employee Class
No. of Employees
Estimated Annual Payroll
Comments
Store Employees
Owners/Officers
Include?
Yes
No
Other
(Describe in Comments)
Federal ID Number:
Experience Modification:
None
Business Automobile
Vehicles
No Owned Autos
No.
Year
Make & Model
Vehicle ID No.
Primary Use
1.
Personal
Business Pickup/Delivery
Home Pickup/Delivery
Other
2.
Personal
Business Pickup/Delivery
Home Pickup/Delivery
Other
3.
Personal
Business Pickup/Delivery
Home Pickup/Delivery
Other
No.
Cost New
Medical Payments
Comp & Collision
Deductible
1.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
2.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
3.
$1,000
$2,000
$5,000
Yes
None
Comp Only
$100/$250
$250/$250
$250/$500
$500/$500
$500/$1,000
Automobile Underwriting
Explain any yes answers.
Have any drivers had more than 1 accident or ticket in the last three years?
No
Yes
Has any driver ever been convicted of DUI?
No
Yes
Are any vehicles
not
titled in the name of the business.
No
Yes
Do any drivers have less than 5 years driving experience?
No
Yes
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