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Desired

Policy

Florida HCF

Florida CPIC

Total

Effective Date:

Premium $

Surcharge $

Surcharge $

Premium $

RLI Insurance Company Peoria, Illinois

Agency Name

Address

Home Business Insurance Application

City

LOCATION TWO PROPERTY ADDRESS, SEE PAGE 3 FOR 2nd LOCATION UNDERWRITING QUESTIONS:

Frame Masonry

INCLUDE A DETAILED BUSINESS DESCRIPTION INCLUDING PRODUCTS AND SERVICES YOU SELL UNDER THIS ENTITY.

CORRESPONDING ELIGIBILITY CLASS OF BUSINESS NUMBER PER HBP-117:

APPLICANT INFORMATION - Please answer each question completely. NAMED INSURED (if a partnership, please provide all individual's names):

BUSINESS NAME: MAILING ADDRESS:

LOCATION ONE PROPERTY ADDRESS, if different from mailing address:

PHONE: W E B S I T E A D D R E S S _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E M A I L A D D R E S S _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

FOR TEXAS & NEW JERSEY RESIDENTS ONLY

County Name

ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT

State

RLI Administrator/Brokering Agent Number

Zip

Construction (For Texas Only)

PLEASE CHECK BOX APPLICABLE TO NAMED INSURED:

INDIVIDUAL

PARTNERSHIP/JOINT VENTURE

CORPORATION/ORGANIZATION (Any Other)

DO YOU OPERATE ANY OTHER BUSINESS FROM YOUR RESIDENCE THAT IS NOT INDICATED IN THE DETAILED BUSINESS DESCRIPTION ABOVE?

Yes

No

If yes, what is the entity of this business?

Individual

Partnership/Joint Venture

Corporation/Organization (Any Other)

Please provide a detailed description of this other business:

LIMITS/COVERAGE REQUESTED Property (No Building Coverage)

General Liability Business Liability each occurrence $300,000 $500,000 $1,000,000 (Medical payments of $5,000 each person included) Class limitations and exclusions may apply.

Deductible

Business Personal Property (BPP) on premises and while temporarily off premises. Must equal 100% of replacement cost. Location One BPP Coverage Limit $__________________ (Minimum limit $5,000) Location Two BPP Coverage Limit $__________________ (Minimum limit $5,000)

Standard Deductible is $250 (No other deductible available)

(Total BPP Coverage limits may not exceed the maximum limit of $50,000)

OPTIONAL COVERAGES: Please review the below listing of optional coverages available. Then select coverages which are desired by checking the box and filling in the requested coverage amount.

Optional Coverages:

Requested Optional Coverage Amount:

Electronic Data Processing Equipment, Data & Media: (EDP coverage)

Money & Securities (On/Off Premises):

sublimit.)

$1,000/$1,000

$2,000/$1,000

$3,000/$1,000

$4,000/$1,000

$5,000/$2,000

$7,500/$2,000

(Maximum limit of $25,000. The sublimit for off-premises EDP coverage is $5,000. No other policy limit may be added to this

$10,000/$5,000

$

_________________

Page 1 of 3 Pages

PLEASE COMPLETE AND SIGN THE APPLICATION

HBP 108 (04/09) FL

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