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Municipal Entity Underwriting Application

Premium

Total Insured Values

Excess Limit

Annual Aggregate Limit

Retained Limit

 Deductible   SIR

 Deductible   SIR

Current Carrier

Unique Extensions or Exclusions

Statement of Values or current appraisal must be attached including construction, occupancy, protection, year built, square footage, number of stories and building last updated for each location.

1.      If your entity desires an SIR program, does your entity have a preferred Third Party Administrator (TPA)?

If yes, complete the Third Party Administrator Information section.

 Yes

 No

2.

Provide Total Values for the following:

a.

Total Real Property

b.

Total Contents

c.

Business Interruption

d.

Contingent Business Interruption

1.

Extra Expense

2.

Loss of Rents

e.              Accounts Receivable

f.             Valuable Papers & Records

g.

        Fine Arts

h.

        EDP Equipment

i.

        EDP Media

j.

        Auto Physical Damage

k.

        Contractor’s Equipment

l.

         Inland Marine

Total Insured Values

3.

Total Number of Locations

4.

Does the total value of vehicles stored/garaged at any one location exceed $500,000?

                  If yes, describe the site(s) and estimate the maximum site value.  

 Yes

 No

5.

Are any buildings vacant?

If yes complete supplemental questionnaire.

 Yes

 No

Construction/Occupancy Protection Information

1.

Percentage of total values (Building & Contents) with following protections and actual number of locations.

Sprinklered

Locations

4 of 3410/23/2007

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