| |
|
|
|
|
|
PROPERTY COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Building and Personal Property Coverage Form |
|
|
|
|
|
Building |
______ |
______ |
______ |
______ |
|
Business Personal Property |
______ |
______ |
______ |
______ |
|
Personal Property of Others |
______ |
______ |
______ |
______ |
|
Improvements and Betterments |
______ |
______ |
______ |
______ |
|
Condominium Coverage Form |
|
|
|
|
|
Condo-Unit Owners Coverage |
______ |
______ |
______ |
______ |
|
Commercial Output Policy |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Building and Personal Property Coinsurance |
|
|
|
|
|
Percentages None 80% 90% 100% |
______ |
______ |
______ |
______ |
|
Bldg ____ ____ ____ ____ |
______ |
______ |
______ |
______ |
|
BPP ____ ____ ____ ____ |
______ |
______ |
______ |
______ |
|
PPO ____ ____ ____ ____ |
______ |
______ |
______ |
______ |
|
I & B ____ ____ ____ ____ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Alternatives to Coinsurance |
|
|
|
|
Agreed Value |
______ |
______ |
______ |
______ |
|
Functional Replacement Cost |
______ |
______ |
______ |
______ |
|
Peak Season |
______ |
______ |
______ |
______ |
|
Reporting Form |
______ |
______ |
______ |
______ |
|
Other ________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Optional Property Coverages |
|
|
|
|
Boiler and Machinery |
______ |
______ |
______ |
______ |
|
Legal Liability |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Optional Property Endorsements |
|
|
|
|
|
Additional Debris Removal |
______ |
______ |
______ |
______ |
|
Ordinance or Law |
______ |
______ |
______ |
______ |
|
Outdoor Trees, Shrubs and Plants Enhancement |
______ |
______ |
______ |
______ |
|
Replacement Cost Valuation |
______ |
______ |
______ |
______ |
|
Spoilage |
______ |
______ |
______ |
______ |
|
Utility Services-Direct Damage |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
|
|
|
|
|
|
Other Property Options |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
TIME ELEMENT COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Business Income With Extra Expense Coinsurance Percentage ___ |
______ |
______ |
______ |
______ |
|
Business Income Without Extra Expense Coinsurance Percentage ___ |
______ |
______ |
______ |
______ |
|
Extra Expense |
______ |
______ |
______ |
______ |
|
Leasehold Interest |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Alternatives to Coinsurance |
|
|
|
|
|
Agreed Value |
______ |
______ |
______ |
______ |
|
Maximum Period of Indemnity |
______ |
______ |
______ |
______ |
|
Monthly Limit of Indemnity |
______ |
______ |
______ |
______ |
|
Premium Adjustment |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Optional Time Element Endorsements |
|
|
|
|
|
Business Income from Dependent Properties |
______ |
______ |
______ |
______ |
|
Ordinance or Law Increased Period of Restoration |
______ |
______ |
______ |
______ |
|
Utility Services |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Time Element Coverages |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
PROPERTY AND TIME ELEMENT CAUSES OF LOSS |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Bldg BPP PPO BI EE |
|
|
|
|
|
Basic ____ ____ ____ ___ ____ |
______ |
______ |
______ |
______ |
|
Broad ____ ____ ____ ___ ____ |
______ |
______ |
______ |
______ |
|
Special ____ ____ ____ ___ ____ |
______ |
______ |
______ |
______ |
|
Earthquake ____ ____ ____ ___ ____ |
______ |
______ |
______ |
______ |
|
Flood ____ ____ ____ ___ ____ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Cause of Loss Endorsements |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
| |
|
|
|
|
|
|
INLAND MARINE COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Accounts Receivable |
______ |
______ |
______ |
______ |
|
Bailees Customer |
______ |
______ |
______ |
______ |
|
Builders Risk |
______ |
______ |
______ |
______ |
|
Commercial Articles |
______ |
______ |
______ |
______ |
|
Difference In Conditions – DIC |
______ |
______ |
______ |
______ |
|
Electronic Data Processing |
______ |
______ |
______ |
______ |
|
Fine Arts |
______ |
______ |
______ |
______ |
|
Goods in Transit |
______ |
______ |
______ |
______ |
|
Signs (Neon and Electric) |
______ |
______ |
______ |
______ |
|
Valuable Papers and Records |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Inland Marine Coverages |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
CRIME COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Money, Securities and Other Property |
|
|
|
|
|
Employee Dishonesty Coverage |
______ |
______ |
______ |
______ |
|
Including Customer's Goods |
______ |
______ |
______ |
______ |
|
Computer Fraud Coverage |
______ |
______ |
______ |
______ |
|
Extortion Coverage |
______ |
______ |
______ |
______ |
|
Forgery or Alterations Coverage |
______ |
______ |
______ |
______ |
|
Lessees of Safe Deposit Boxes Coverage (Securities and Other Property only) |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Money and/or Securities Only |
|
|
|
|
|
Theft, Disappearance and Destruction |
______ |
______ |
______ |
______ |
|
Robbery and Safe Burglary |
______ |
______ |
______ |
______ |
|
Securities Deposited With Others Coverage |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Property other than Money and Securities |
|
|
|
|
|
Premises Burglary |
______ |
______ |
______ |
______ |
|
Premises Theft |
______ |
______ |
______ |
______ |
|
Robbery and Safe Burglary |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Crime Coverages |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
LIABILITY COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Commercial General Liability |
|
|
|
|
|
Occurrence Basis |
______ |
______ |
______ |
______ |
|
Claims- Made Basis |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Optional Liability Coverages |
|
|
|
|
|
Directors and Officers |
______ |
______ |
______ |
______ |
|
Employee Benefits |
______ |
______ |
______ |
______ |
|
Employment- Related Practices |
______ |
______ |
______ |
______ |
|
Liquor |
______ |
______ |
______ |
______ |
|
Owners and Contractors Protective |
______ |
______ |
______ |
______ |
|
Railroad Protective |
______ |
______ |
______ |
______ |
|
Special Events |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Liability Coverages |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
COMMERCIAL AUTO COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Liability |
______ |
______ |
______ |
______ |
|
Physical Damage |
______ |
______ |
______ |
______ |
|
Uninsured Motorists |
______ |
______ |
______ |
______ |
|
Underinsured Motorist |
______ |
______ |
______ |
______ |
|
Hired Cars |
______ |
______ |
______ |
______ |
|
Non-Ownership Auto |
______ |
______ |
______ |
______ |
|
P.I.P./No-Fault |
______ |
______ |
______ |
______ |
|
Garagekeepers |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Auto Coverages |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
WORKERS COMPENSATION COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Workers Compensation and Employers Liability |
______ |
______ |
______ |
______ |
|
Stop Gap or Employers Liability Coverage |
______ |
______ |
______ |
______ |
|
Federal Employers Liability Act |
______ |
______ |
______ |
______ |
|
Longshore and Harbor Workers Coverage |
______ |
______ |
______ |
______ |
|
Voluntary Compensation |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Workers Compensation Endorsements |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
EXCESS LIABILITY COVERAGES |
|
|
|
|
|
|
Recommend |
Accept |
Reject |
Not Applicable |
|
Umbrella Policy |
______ |
______ |
______ |
______ |
|
Excess Liability Policy |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
AVIATION COVERAGES |
|
|
|
|
|
Aircraft Policy |
______ |
______ |
______ |
______ |
|
Passenger Liability |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
SPECIALTY COVERAGES |
|
|
|
|
|
Environmental Impairment Liability Policy |
______ |
______ |
______ |
______ |
|
Fiduciary Liability Insurance |
______ |
______ |
______ |
______ |
|
International/Foreign Operations Insurance |
______ |
______ |
______ |
______ |
|
Rain or Weather Insurance |
______ |
______ |
______ |
______ |
|
Terrorism Insurance |
______ |
______ |
______ |
______ |
|
Underground Storage Tank Liability – UST |
______ |
______ |
______ |
______ |
|
Other ____________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
BONDS |
|
|
|
|
|
Bid Bond |
______ |
______ |
______ |
______ |
|
Contract Bond |
______ |
______ |
______ |
______ |
|
License Bond |
______ |
______ |
______ |
______ |
|
Other _________________________________ |
______ |
______ |
______ |
______ |
| |
|
|
|
|
|
|
Other Options |
|
|
|
|
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
|
______________________________________ |
______ |
______ |
______ |
______ |
Comments
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I certify that I have reviewed my coverage needs in accordance with this checklist with my agent and I have accepted or rejected the recommended coverages as indicated by my initials in the spaces above.
___________________________________ Signature of Client ______________________ Date
_____________________________________________ Title
I certify that I have reviewed the coverages outlined in this checklist with my client and that the initials of the client indicate the acceptance or rejection of the coverages recommended.
___________________________________ Signature of Agent _______________________ Date