Union Life & Casualty

Application

Pawnshop Name
Location #	of #
Type Of Entity	Corporation Individual Partnership Other
Other Insured(s)
Contact Person
Mailing Address
City
County
State
Zip
Location of Pawnshop	CHECK THIS BOX IF ADDRESS SAME AS ABOVE
Address
City
State
Zip
Telephone	--
Fax	--
Email Address
Email of Agent
Pawnshop Website Address
How Did You Find Us
Year In Business
If less than 3 explain experience
Effective date desired	(mm-dd-yy)
Prior Insurance Carrier and Loss History(Whether covered by Insurance or not) for the past three years:
This Year
Carrier
Policy Number
Premium
Coverage
#Losses
Amount
Description of Losses
Last Year
Carrier
Policy Number
Premium
Coverage
#Losses
Amount
Description of Losses
Two Year Ago
Carrier
Policy Number
Premium
Coverage
#Losses
Amount
Description of Losses
Missouri Applications do not answer this question:
Has insurance of this type been cancelled,refused, or nonrenewed by any company during the past three years?	Yes No
If yes Name of Company
Date
Reason
Mortgagee holder
Address
City
State
Coverages Desired (Enter The Limit Of insurance Needed)
Building	$ Replacement Cost Actual Cash Value
Business Income (Per Month)	$ How Many Months
Furniture & Fixtures	$
Tenants Improvements	$
Items-Other Than Firearms & Jewelry (Both)	Pawned $ Owned $
Items-Firearms & Jewelry (Both)	Pawned $ Owned $
Property Deductible Desired	If OTHER, Amount : $
Block Deductible
General Liability Limits
Fire Damage Legal Liability
Medical Payments	$ 5000
Would You Like Firearms Product Liability	Yes No
Firearms Product Liability
Hired & Non Owned Auto Coverage (not Available IL/OH)	Yes No
Any Optional Coverages (Select The Limit Desired)
Business Computer (Hardware) ?	If YES, Amount : $
Business Computer (Software) ?	If YES, Amount : $
Business Computer In-transit	Amount : $
Money & Securities ?	$5,000/$2,000 $10,000/$2,000
Interior Glass - RC - Total Sq Footage
Exterior Glass - RC Total sq footage
Show Windows:
Open/Protected	$
Open/Unprotected	$
Closed/Protected	$
Closed/Unprotected	$
Signs ?	If YES, Amount : $
Accounts Receivable	$
Valuable Papers	$
Shipments ?	Yes
# Of Shipments Per Year ?
By Registered Mail	$
By Merchants Parcel	$
By Armored Carrier	$
Memoing ?	If YES, Amount : $
Property Off Premises ?	If YES, Amount : $
Mechanical Breakdown only applies if we insure building	$
Ordinance or Law	$
Garagekeepers Legal Liability (Supplemental Information Required)	$
Peak season coverage	$ From To
Underwriting Information
General Section
Nature of Business:
Pawnbroking	%
Other	%
Describe Other
Describe items taken in pawn
Check any operation which apply	Auto Pawn Title Pawn Check Cashing Rent to own
List Key Management Personal:
Name,Age,% Ownership,Length of employment,Job Description
Are you Bonded	Yes No
Are your employees Bonded	Yes No
Describe employee hiring procedure
Gross Sales	$
Gun Sales	$
Total Payroll	$
Interest from Pawn	$
List State and/or National Pawnbroker Associations Memberships
Business Hours	FromTo
Minimum number of employees/owners of the premises at any time
Total Employees
Has your license been suspended or revoked in the last five years?	Yes No
Has any employee or owner ever had any prior convictions for illegal activities?	Yes No
Where are firearms kept on premises and under whose control?
Firearms are	cabled locked stored in locked cases other safeguards
Describe training provided to any individuals handling firearms
Have any of your operations been sold,acquired or discontinued in the last five years?	Yes No NA
Are parking facilities in common areas free from defects any adequately lighted	Yes No NA
Do you sponsor sporting or social events(e.g. city,softball team)?	Yes No NA
Are products of others sold or re-packaged under you own label?	Yes No NA
Property Section
Year Building Built
Updates To Building (Year)	Heating Roof Electrical Plumbing
Protection Classes
Number of stories
Area(sq.ft.) of building
Sq.ft. open to public
Your Building Construction	Frame Brick Veneer Fire Resistive Metal Clad Masonry Other
Is building Sprinklered?	Yes No
If the property is located in a rural fire protection district or in an area protected by a rural fire department. Have you paid the appropriate dues or subscription payments? Yes No
Fire/Smoke Alarm	None Local Police Central Station
Do you own building?	Yes No
Do you lease space to others?	Yes No Square feet leased
Are there any occupancies(appartments/rented rooms) in the building?	Yes No
If yes what occupancies(appartments/rented rooms)?
Are there any adjacent exposures?	Yes No
If yes list?
Do you restore,repair,service or refinish any inventory	Yes No
If yes describe
If ammunition or gun powder is sold, how is it stored?
How are the values of items established(Blue book,Orion book,Other listing etc) ?
How were property values determined for pleged items?	Loan value plus interest Market value Other
How were property values determined for unpleged(owned) items?	Cost Market value Other
How is stock inventory kept ?	Computer printout Manual
Frequency of inventory updates ?
Where are data/media and records stored when not in use(safe,vault,computer room,ec)?
Is key data duplicated and stored else where?	Yes No Location:
Premises Protection(check all that apply)
Burglar Alarm	None Local(rings at premises) Police Connected Central Station
Extent of Protection - Contacts on	All doors All windows Floor Ceiling All walls Battery Backup Infrared Motion Detectors Audio Monitor Digital Line Radio Transmitter Direct Wire Line Multiplex Line Dedicated Circuit Connector
Premises Line Security	Cellular Backup Other
Maximum Response Time
Monitoring Company
Install Date
Hold up alarm	None Local Police Connected Central Station # of signal buttons
Maximum Response Time
Monitoring Company
Install Date
Safes/Vaults
Number of Safes/Vaults
Underwriter's Laboratory-Rated Safes:
UL Rated Safe#1 of 4:
Manufacturer
UL #
Type (i.e. -TRL-30)
Timelock	Yes No
Relock	Yes No
Alarm	Yes No
UL Rated Safe#2 of 4:
Manufacturer
UL #
Type (i.e. -TRL-30)
Timelock	Yes No
Relock	Yes No
Alarm	Yes No
UL Rated Safe#3of 4:
Manufacturer
UL #
Type (i.e. -TRL-30)
Timelock	Yes No
Relock	Yes No
Alarm	Yes No
UL Rated Safe#3of 4:
Manufacturer
UL #
Type (i.e. -TRL-30)
Timelock	Yes No
Relock	Yes No
Alarm	Yes No
Safe/Vault other than Underwrites Laboratory Rated
Non UL Rated Safe/Vault #1
Thickness of walls
Thickness of Doors
Construction of walls
Alarm	Yes No
Non UL Rated Safe/Vault #2
Thickness of walls
Thickness of Doors
Construction of walls
Alarm	Yes No
Non UL Rated Safe/Vault #3
Thickness of walls
Thickness of Doors
Construction of walls
Alarm	Yes No
Non UL Rated Safe/Vault #4
Thickness of walls
Thickness of Doors
Construction of walls
Alarm	Yes No
Safe/Vault Alarm	None Local Police Connected Central Station Motion Detectors Only
Extent of Protection	Door Contact Safe Wall Contact Battery Backup Digital Line Radio Transmitter Direct Wire Line Multiplex Line Dedicated Circuit Connector
Maximum Response Time
Monitoring Company
Install Date
Other Security Protection	Guard on Premises Armed Guard Dogs Bullet Proof Glass Bars on Windows Roll Down Gate Surveillance Camera with Recorder Surveillance Camera without Recorder Other
While the business is closed, stock consisting of firearms an jewelry will be stored as follows:
% of Firearms and Jewelry Will be kept in Safe #1
% of Firearms and Jewelry Will be kept in Safe #2
% of Firearms and Jewelry Will be kept in Safe #3
% of Firearms and Jewelry Will be kept on premises not in safe or vault
% of Firearms and Jewelry Will be kept off premises
Describe
% Must equal 100%
Comments