COMMERCIAL INSURANCE UNDERWRITERS, INC.
PERSONAL INLAND MARINE APPLICATION
PH: 417.883.3277 / 800.241.9759 - Fax: 417.883.3393
Applicant's Name(s):
Agency Name:
Mailing Address:
Your Name:
City, State, Zip:
Email Address:
Inspection Contact Phone Number: Agency Address:
City, State, Zip:
Agency Phone Number:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

APPLICANT

 

Private Dwelling   Apartment   Condominium   Mobile Home   Other
 

(Describe)

 

How long have you lived at Permanent Address?

Protection Class at Permanent Address:

Occupation of all members of household (describe in detail):

Does applicant travel extensively?

(If yes, provide details under "Remarks.")

Date of Birth:

 

(Please attach medical statement if over 75.)

Number of years at present occupation:

Marital Status:

 

COVERAGES

 

# Property Amount of Ins. Rate Premium  
1 Jewelry  
2 Jewelry in Vault  
3 Furs  
4 Fine Arts  
5 Cameras  
6 Musical Instruments  
7 Silverware  
8 Stamps  
9 Coins  
10 Golfer's Equipment  
11 Contents in Mini-Storage  
12  
13  
14  
     

Total

 $  

 

* If engagement ring, include ring wearers' information:

Name of person:
How stored when not worn:
Occupation:
Date of Birth:
  Additional Rating Information:

GENERAL INFORMATION

# Explain All "Yes" Responses In Remarks Yes/No  
1 Any Burglar Alarms?   Local    Central  
2 Any Safes? (Type and Location? - State Below)  
3 If condominium or apartment, any security in area?  
4 Is property located within one mile of a coast?  
5 Will any property be exhibited?  
6 Is any property used professionally/commercially?  
7 Are articles stored when not worn? Where?  
8 Any other insurance with this company?  
9 Did any loss occur during the last 3 years?  
10 Any coverage declined/canceled/nonrenewed?

(Last 3 yrs.) (Not applicable to Missouri applicants.)

 
  Remarks:

 

Prior carrier for scheduled items:
Name of Insurance Company writing Homeowners:
Dwelling Limit: Content Limit:

 

SCHEDULE OF PROPERTY

#

Provide a detailed description of each item, from whom purchased, etc. If additional space is required, please use a separate sheet. Be sure to attach all required appraisals/bills. If any item of jewelry is over $25,000, please attach certified independent appraiser's report.

Purchase/ Appraisal

Date

Amount of Insurance

 
1  
 
 
 
 
 

 

CONTENTS IN A MINI-STORAGE

# Complete this section if there are contents located in a mini-storage warehouse.
1 Mini-storage name
  Address     City     State
  Locker Number
2 If more than one locker, show contents values in each locker below:
        #1           #2           #3
3 How are premises secured? Security fence/gate Guard on premises Guard dogs
    Manager lives on premises Other

 

QUESTIONS TO BE ANSWERED BY PRODUCER:

1. Do you know the applicant personally? 
  If yes, for how long?
2. Do you handle other insurance for applicant? 
3. Do you recommend applicant? 

 

PRIVACY POLICY: I have received and read a copy of the "Scottsdale Insurance Company Privacy Statement and Procedures". By submitting this application, I am applying for issuance of a policy of insurance and, at its expiration, for appropriate renewal policies issued by Scottsdale Insurance Company and/or other members of the Scottsdale group of insurance companies. I understand and agree that any information about me that is contained in, or that is obtained in connection with, this application or any policy issued to me may be used by any company within the Scottsdale group to issue, review, and renew the insurance for which I am applying.

 

APPLICATION IN THE STATE OF NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

 

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

APPLICANT'S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true; and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)

 

 

APPLICANT'S SIGNATURE____________________________________________ DATE______________

 

PRODUCER'S SIGNATURE____________________________________________ DATE______________

 

AGENT NAME_____________________________________________ AGENT LICENSE NUMBER____________________

(Applicable to Florida Agents Only.)

 

IMPORTANT NOTICE

As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning

character, general reputation, personal characteristics and mode of living. Upon written request, additional information

as to the nature and scope of the report, if one is made, will be provided.

 

 



Before You Submit your Application, Make Sure You Fill in the RED Boxes.  We Also Recommend Printing a Copy!!
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
Select your account executive.