COMMERCIAL MULTIPLE PERIL APPLICATION

Applicant’s Name (Legal and Operating):	Broker:
Risk Location:	Broker Code:
Principal’s Name: Contact Number:	Branch:
Policy Period: to (12:01 AM)
Applicant Data- Occupancy
Description of Operations (Attach financials, company/ product brochures and other related information)
Business Start Date:	Business Experience: # of Years:
Loss and Policy History
Previous claims in the past 5 years? Yes, No Describe:
Previous Insurer:	Policy #:
Has any insurer cancelled, declined or refused to renew Commercial Insurance in the past 5 years? Yes, No
Supporting Business: Policy #:	Company:

Construction Details
Wall Construction	Reinforced Concrete Brick Veneer	Hollow Concrete Block Metal Clad- Steel Frame	Solid Brick Masonry Wood Frame
Roof Construction	Concrete Joist Heavy Timbers Wood Joist	Steel Deck Open Steel System, Corrugated Metal, Steel Trusses Open Wood, Corrugated Metal
Year Built: If building over 25 years, have updates been carried out Yes, No
Renovation Dates:	Roof:	Heating:	Electrical:	Plumbing:
Hydrant Protected?	Distance to Fire hall: kms miles
Smoke Detectors: Yes, No	Alarm System:	Fire:	Burglary:	Monitored 24 Hr:
Sprinklers: Yes, No	CO2 System: Yes, No If yes: Wet Chemical, Dry Chemical
Total Area of Business (Including Basement): sq. m sq. ft
Area Occupied by Insured: sq. m sq. ft
# of Stories (excluding basement)	Basement: Yes, No
Type of Heating: Primary:	Secondary:
Type of Electrical System: Breakers	Fuses

Coverages
Coverages	All Risk	NP	Ded.	Coins %	Amount of Insurance	Rate	Premium
Property
Building
Equipment
Stock
Contents
Office Floater
Builder’s Risk
Contractors Equip
Computer Rider
Cargo
Other
Extensions of Coverage
Inflation Protection	Flood
Peak Season	Sewer Backup
Earthquake	Replacement Cost
Business Interruption
Actual Losses
Gross Earnings
Profits
Boiler and Machinery
Equipment Breakdown	Option 2
Option 1	Option 3
Crime
Broad Form Money and Securities
Inside and Outside Paymaster Robbery
Money Orders and Counterfeit Currency
Depositors Forgery
Employee Dishonesty	Form A:	Form B:
Liability
Liability (occurrence) Limit: $	Prop/ Ops Aggregate: $
BI & PD Deductible: $	Medical Payment: $
Tenants Legal Liability: $	Premises only: Yes, No
Personal Injury: $	Prod/ Comp Ops: Yes, No
Non Owned Automobile: $	Annual Revenue: $
Other: $
M.R.P: $	Total Premium: $

Notes:

Signed by:	Date:

NOTE: Please attach a photo or EMAIL a photo of the RISK