Craftsman

Application

What type of payment plan do you want for this insurance policy?	Full	Three pay

Four pay	Eight pay

Effective:

General Information

1.	Applicant:

(Include all operating names and subsidiaries that will be covered.)

2.	Described premises:

(floor)	(street address/suite or room number)

(city)	(county)	(state)	(ZIP)

Address(es) of other premises you operate from:

3.	Mailing address:

(street address/PO Box)	(city)	(state)	(ZIP)

4.	Doing business as: Individual Partnership Corporation Other

5.	Contact person:	Phone: ( )

6.	Type of business based on sales (must total 100%): Retail	%	Wholesale	%	Repair	%

Custom design/manufacturing for jewelry trade	%	Other	%

7.	How long have you been in business at this described premises?	If less than two

years, give address of previous location:

8.	Have you ever been refused any business insurance or had business insurance cancelled for any reason?

Yes No If yes, explain:

(An answer to this question is not required by Missouri applicants.)

9.	Current insurance information:

(insurer)	(type of policy)	(expiration date)

10.	Provide all loss information for the past five years, whether insured or not:

Underwriting Information

1.	Building construction:

Fire resistive

Masonry/noncombustible

Noncombustible

Joisted masonry

Frame

2.	Protection class:

Protected (1-8)

Partially protected (9)

Unprotected (10)

3.	Number of floors:

4.	Year of construction:

5.	Square feet occupied by applicant:

6.	Completely sprinklered? Yes No

7.	Premises smoke detectors? Yes No

8.	Dates if premises remodeled:

a.	Electrical

b.	Plumbing

c.	Heating

9.	Type of location:

Enclosed mall

Strip mall

Downtown (not mall)

Free-standing (not downtown)

Dwelling

Industrial park

Other

Underwriting Information (Cont.)

10.	Annual sales: $

11.	Describe adjacent occupancies:

12.	Do you share your premises? Yes No

If yes, give name and nature of business:

13.	How long do you keep all purchase invoices, sales receipts and related documents?

14.	Do you take a complete, written, physical inventory of all your jewelry stock at least once a year?

Yes No Describe the type of inventory/records control procedures you have:

15.	Your most recent, complete, written physical inventory of all your jewelry stock was taken on:

Exact total was: $	(rounded to the nearest $10).

16.	Do you maintain detailed records of jewelry property of others in your custody or control? Yes No

Describe the system you use:

17.	The maximum value of jewelry stock during the last 12 months did not exceed:

a.	Owned $	b.	Customers’ $	c.	Memorandum/consignment $

Security Information

1.	Is there a premises alarm system? Yes No If yes, who owns or leases it?

a.	Where is it monitored? Central station Police station Local Other

b.	Is it: Digital communicator Direct wire Multiplex Radio Other

2.	Is the premises alarm system UL certified? Yes No

If yes, provide UL #	, Exp. date

If no, answer the following questions:

a.	Do all exterior doors and openings have contacts? Yes No

b.	Is all exterior glass alarmed? Yes No

c.	Do you have interior motion detection equipment? Yes No

If yes, does it cover:	Safe/vault area? Yes No	Alarm control panel? Yes No

Areas where jewelry property is left out of safe? Yes No

d.	Do you have a holdup alarm system? Yes No

e.	Do you have a local bell/enclosed sounder? Yes No

3.	Other premises theft protection:

4.	Description of safe/vault (including size/weight):

Is there a relock device? Yes No

If the premises is shared, is there a separate locked box within host jeweler’s safe? Yes No

a.	Does the safe door have a contact? Yes No

b.	Other safe protection:

5.	During the term of the policy, the minimum proportion by value of all your stock and personal property of others that will be kept in locked safe(s)/vault(s) when closed to business:	%.

6.	Do you have jewelry display cases? Yes No

a.	If yes, are they equipped with key locks? Yes No

b.	If yes, are they kept key locked during business hours, except when stock is being removed or replaced?

Yes No

Coverage Information

Property

1.	Deductible ($250 min.): $250 $500 $1,000 $3,000 $5,000 $

Limit of Insurance

2.	Building:	Replacement cost Actual cash value	$

3.	Business personal property: Replacement cost Actual cash value

a.	Furniture & fixtures; tenant’s improvements; business tools & equipment;

patterns, dies, molds, models and forms	$

b.	Stock:	Findings and material for repair or custom design/manufacture,

jewelry for sale and non-jewelry stock for sale	($	)

c.	Jewelry property of others:	($	)

Total of items b. and c.: Actual cash value	$

4.	Loss of Income	Actual Loss Sustained

5.	Personal Property – Off Premises	$	10,000

6.	Optional property coverages:

a.	Employee dishonesty

No. of employees: No. of officers:

$5,000 $10,000 $25,000

Deductible: $

b.	Outdoor sign(s) $

c.	Computer coverage

Hardware	$

Software	$

Deductible	$

d.	Money and securities

$	inside the premises

$	outside the premises

Deductible: $ zero

e.	Accounts receivable: $

f.	Valuable papers and records: $

Deductible: $

g.	Other

7.	Mortgagee (building)

Name:

Address:

Loss Payable (interest:	)

Name:

Address:

Liability

1.	Basic limit of insurance

a.	Each occurrence limit for bodily injury, property damage and products liability:

$300,000 $500,000 $1,000,000

b.	Limit for medical payments ($5,000 automatic per person) $10,000 (optional)

c.	Fire legal liability ($300,000 automatic coverage): Additional amount $

2.	Optional liability coverages:

a.	Appraisal liability

(Completed appraisal liability

questionnaire required.)

$50,000 $100,000

b.	Employee benefits liability

c.	Non-owned and hired auto

d.	Additional insured

Name:

Address:

Landlord

Leased equipment

Other

e.	Other

Fraud Warning – Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Fraud Warning – Louisiana, Maine, Ohio, Tennessee, Virginia, West Virginia: Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, is guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits.

Fraud Warning – New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Fraud Warning – 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 – Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive an insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information, is guilty of a felony.

Fraud Warning – Oregon: Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, may be guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits.

Fraud Warning – All Other States: A fraudulent act, which is a crime, is committed when a person knowingly and with intent to defraud or mislead; (1) files an insurance application containing any false information, or

(2) conceals information concerning any material fact.

Applicant’s Signature	Date

Producer’s Signature	Date

Agency Name and Code

1

CRF001 Ed 04-04	© 2004 Jewelers Mutual Insurance Company

2

4

sue diehl

2005-04-26

krowe

Jewelers Mutual Insurance Co.