| Pawnshop Name |
|
| Location # |
of #
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Telephone |
-- |
| Fax |
-- |
| Email Address |
|
| Website Address |
|
| How Did You Find Us |
|
| Policy Number |
NJ10 |
| Mortgagee bank/individual and mailing address |
|
Additional Insured |
| Name |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| Describe any changes in your business in the last 12 months |
|
| Policy Renewal Date |
From
To
|
Property Questions |
| Building Construction |
Frame
Brick Veneer
Fire Resistive
Metal Clad
Masonry
Other
|
| Year Building Built |
|
| Sprinkler System |
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 |
| Do you lease space to others |
Yes No |
| If yes, Occupant |
|
| Square Feet |
|
Property Limits |
| 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 |
Loan value plus interest
Market value
Other
|
| The values Indicated For My Pawned Merchandise Were based On |
Cost
Market value
Other
|
| How is stock inventory kept ? |
Computer printout
Manual |
| Property Deductible Desired |
|
| Gun and Jewelry Deductible |
|
| General Liability Desired |
|
| 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 |
| Gross Sales |
$
|
| Gun Sales |
$ |
| %Pawn |
$ |
| Total Payroll |
$ |
| Interest from Pawn |
$ |
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 |
|
| Signs ? |
If YES, Amount : $
|
| Accounts Receivable |
$
|
| Valuable Papers |
$
|
| Show Windows: |
| Open/Protected |
$ |
| Open/Unprotected |
$ |
| Closed/Protected |
$ |
| Closed/Unprotected |
$ |
| 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
|
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 |
|
| Number of Safes/Vaults |
|
| Describe Each |
|
If UL rated |
Safe #1 |
| Manufacturer |
|
| UL # |
|
| Type (i.e. –TRL-30) |
|
| Timelock |
Yes No |
| Relock |
Yes No |
| Alarm |
Yes No |
Safe #2 |
| Manufacturer |
|
| UL # |
|
| Type (i.e. –TRL-30) |
|
| Timelock |
Yes No |
| Relock |
Yes No |
| Alarm |
Yes No |
Safe #3 |
| Manufacturer |
|
| UL # |
|
| Type (i.e. –TRL-30) |
|
| Timelock |
Yes No |
| Relock |
Yes No |
| Alarm |
Yes No |
Safe #4 |
| Manufacturer |
|
| UL # |
|
| Type (i.e. –TRL-30) |
|
| Timelock |
Yes No |
| Relock |
Yes No |
| Alarm |
Yes No |
Safe/Vaults |
Other than UL rated |
Safe #1 |
| Thickness of walls |
|
| Thickness of Doors |
|
| Construction of walls |
|
| Alarm |
Yes No |
Safe #2 |
| Thickness of walls |
|
| Thickness of Doors |
|
| Construction of walls |
|
| Alarm |
Yes No |
Safe #3 |
| Thickness of walls |
|
| Thickness of Doors |
|
| Construction of walls |
|
| Alarm |
Yes No |
Safe #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 (total must equal 100%) |
| % 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 |
|
Comments |
|
| |
|
