| Pawnshop Name |
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| Contact Person |
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| Mailing Address |
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| City |
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| County |
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| State |
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| Zip |
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| Location of Pawnshop |
CHECK THIS BOX IF ADDRESS SAME AS ABOVE |
| Address |
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| City |
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| State |
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| Zip |
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| Telephone |
-- |
| Fax |
-- |
| Email Address |
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| Website Address |
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| Current Insurance Carrier |
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| Premium |
|
| Policy Renewal Date |
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| How Did You Find Us |
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| Your Building Construction |
Frame
Brick Veneer
Fire Resistive
Metal Clad
Masonry
Other
|
| Year Building Built |
|
| Updates To Building (Year) |
Heating
Roof
Electrical
Plumbing
|
| Sprinkler System |
Yes No |
Coverages Desired
(Enter The Limit Of insurance Needed) |
| Building |
$
Replacement Cost Actual Cash Value
|
| Furniture & Fixtures |
$
|
| Tenants Improvements |
$
|
| Business Income (Per Month) |
$
How Many Months |
| Items-Other Than Firearms & Jewelry (Both) |
Pawned $
Owned $
|
| Items-Firearms & Jewelry (Both) |
Pawned $
Owned $
|
| The values Indicated For My Owned Merchandise Were based On |
Cost Market Value Other
|
| The values Indicated For My Pawned Merchandise Were based On |
Loan Value Market Value Other
|
| Deductible Desired |
If OTHER, Amount : $
|
| General Liability Desired |
|
| Are Your Firearms Sales Less Than 30% Of your Gross Sales |
Yes No |
| If YES, Would You Like Firearms Product Liability |
Yes No |
| Hired & Non Owned Auto Coverage (not Available IL/OH) ? |
Yes No |
Any Optional Coverages
(Select The Limit Desired) |
| Signs ? |
If YES, Amount : $
|
| Exterior Glass (approx. sq. ft.) ? |
|
| Money & Securities ? |
$5,000/$2,000 $10,000/$2,000 |
| Computer (Hardware) ? |
If YES, Amount : $
|
| Computer (Software) ? |
If YES, Amount : $
|
| Property Off Premises ? |
If YES, Amount : $
|
| Memoing ? |
If YES, Amount : $
|
| Shipments ? |
Yes |
| # Of Shipments Per Year ? |
|
| By Registered Mail |
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| By Merchants Parcel |
|
| By Armored Carrier |
|
Just A Few More Questions |
| All My Safes/Vaults Are Rated TL-30 or Better |
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| I have a Central Station Premises Alarm |
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| My Alarm System Has the following connections |
Door
Window
Motion Detectors
Infrared
Audio
Panic
Battery Backup
Cellular Backup
Radio Transmitter
Other
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| If My Alarm line Is Cut By An Intruder the Central Station Is Notified? |
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| My Alarm Is Connected To My Safes Containing Jewelry & Firearms? |
|
| I Do Not Have A Safe Alarm But Motion Detectors Cover This Area? |
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| My Safe Has |
|
| At close of business, I store |
% Of Firearms (excluding Long Guns) and Jewelry In My Safe At Night |
| Comments |
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