| Location # |
of #
|
| Pawnshop Name |
|
| Contact Person |
|
| Address |
|
| City |
|
| Country |
|
| State |
|
| Zip |
|
| Telephone * |
-- |
| Fax |
-- |
| Email Address |
|
| Pawnshop Website Address |
|
| How Did You Find Us |
|
| Year In Business |
|
| Effective date desired |
(mm-dd-yy) |
| Population of City where store is located |
|
| 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: |
| Gross Sales |
$
|
| Gun Sales |
$
|
| Total Payroll |
$
|
| Interest from Pawn |
$ |
| Business Hours |
FromTo |
| Minimum number of employees/owners of the premises at any time |
|
| Total Employees |
|
| Are parking facilities in common areas free from defects any adequately lighted |
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 |
| 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? |
|
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 |
|
| |
|
