CIU

Commercial Insurance Underwriters, Inc.
A Surplus Lines Agency
www.ciusgf.com
901 E. Saint Louis St. #205
Springfield, MO. 65806-2537

 

INSTALLATION FLOATER APPLICATION  

 

Applicant's Name

Agency Name

Address

Agent

 

Address

Location

 

 

Email

Web Site Address

Phone

 

PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

 

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company   Other 

 

Contact Name: Telephone:

 

 

Years in Business:

 

 

       1. Type of Merchandise Installed:

 

       2. Installation Gross Receipts for past 12 months $

 

    Projected next 12 months $

 

       3. Total number of jobs completed in past 12 months:

 

       4. Approximate percentage of annual installations in:

 

     Dwellings: %

 

    Commercial risks: %

 

       5. Maximum number of jobs at risk at one time:

 

6.

 

Lowest Job Value

Highest Job Value

Average Job Value

 Dwellings

$

$

$

Commercial

$

 

$

 

$

 

 

       7. Indicate the approximate percentage for cost of materials and labor on installation jobs as follows:

 

Cost of Materials

Cost of Labor

Dwellings

%

%

Commercial

%

 

%

 

 

       8. Indicate Insurance Coverage desired:

 

    Cost of materials only:  

 

    Point when coverage on material to detach:

 

       9. What is the estimated average time in days to complete a job?

 

                                                                      Dwellings: Commercial:

 

      10. What is the maximum Limit of Liability required:

 

At any one job site

$

 

 

Temporary Storage

$

Located

$

While in transit

$

 

In any casualty

$

 

 

      11. Transportation: Indicate annual values at applicant's risk of installation materials moving from plant, or any warehouse to job site:

 

By applicant's own truck

$

Radius-Miles

 

By common carrier trucks

$

Bill of Lading Terms

 

By railroad

$

 

 

 

By other means of transportation

$ 

 

 

 

    Indicate means used:

 

      12. Amount of deductible requested: $

    Deductible(s) on prior policies: $

 

13. Security measures taken at job site and any temporary storage locations:

        

           

      14. Loss Record for past three years:

 

Date

Amount

Type of Loss

 

$

 

$

 

$

 

      15. Has insurance ever been cancelled or refused by any company or Lloyd’s?

 

    If so, when and for what reason?

 

    PROPOSED POLICY TERM:    FROM:        TO:

 

 

This application does not constitute a binder and insurance shall only become effective as of the date advised by the company.

 

The Proposer agrees that the statements contained in this proposal are true and that, if insurance is affected, material misrepresentation or concealment of any information voids this insurance.

 

 

 

Applicant's Signature:___________________________________________ Date:________________

 

 

Agent's Signature:___________________________________________ Date:________________

 

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!

TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:

2.  Hit this Submit button.