BUSINESS OWNERS POLICY - QUOTE FORM


If you are interested in learning more about the coverages included in our BOP you can read more here
or email Adam Steinmetz at Adam@roundtopinsurance.com.

 General Information
* Indicates a required field.
*Insured Name:
DBA:
*Mailing Address:
*City:
*State:   *Zip: -
*Business Address:
*Business City:
*Business State:   *Business Zip: -
*Telephone:
*Description of Business:
*Proposed Effective Dates - From:   To: (12:01 am)
*#Years Experience:
*Business Type:
(Corp, LLC, etc.)
*Email Address:
 Primary Premises Information
*Address:
*City:
*State:   *Zip: -
*Interest:  *Year Built:
*Construction Type:
Coinsurance %:  Protection Class:
*# Stories:  *# Basm'ts:
*Burglar Alarm: Yes    No
*Central Station: Yes    No
*With Keys: Yes    No
*Guards/Watchmen: Yes    No
*Premises Fire Protection:
(Sprinkler, etc)
Fire District Code Number:
*Retail Area:
*Total Area:
*Occupy %:

Amount of Coverage
*Building:
*Business Personal Property:
*Fire Legal Liability:
 Property
Explain All "Yes" Responses

*Any exposure to Flammables, Explosives, Chemicals?: Yes    No  

*Any other insurance with this company or being submitted?: Yes    No  

*Is the applicant a subsidiary of another entity?: Yes    No  

*Any policy or coverage denied, cancelled or nonrenewed during the prior three (3) years?: Yes    No  

*During the last five years, has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime?: Yes    No  

*Any Uncorrected Fire Code Violations?: Yes    No  

*Any bankruptcies, tax or credit liens against the applicant in the past five (5) years?: Yes    No  
 Liability
Explain All "Yes" Responses

*Was tail coverage purchased under any previous policy?: Yes    No  

*Any operations sold, acquired, or discontinued in the last five (5) years?: Yes    No  

*Any any structural alterations contemplated?: Yes    No  

*Has the applicant been active in or is currently active in joint ventures?: Yes    No  

*Any Demolition exposure contemplated?: Yes    No  

*Does the business promotional literature make any representations about the safety or security of the premises?: Yes    No  

*Do/Have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?: Yes    No  

*Is there a formal, written safety and security policy in effect?: Yes    No  

*Have any crimes occurred or been attempted on your premises within the last three (3) years?: Yes    No  
 Additional Premises
Address:
City:
State:   Zip: -
Interest:  Year Built:
Construction Type:
Coinsurance %:  Protection Class:
# Stories:  # Basm'ts:
Burglar Alarm: Yes    No
Central Station: Yes    No
With Keys: Yes    No
Guards/Watchmen: Yes    No
Premises Fire Protection:
(Sprinkler, etc)
Fire District Code Number:
Retail Area:
Total Area:
Occupy %:

Amount of Coverage
Building:
Business Personal Property:
Fire Legal Liability:
Address:
City:
State:   Zip: -
Interest:  Year Built:
Construction Type:
Coinsurance %:  Protection Class:
# Stories:  # Basm'ts:
Burglar Alarm: Yes    No
Central Station: Yes    No
With Keys: Yes    No
Guards/Watchmen: Yes    No
Premises Fire Protection:
(Sprinkler, etc)
Fire District Code Number:
Retail Area:
Total Area:
Occupy %:

Amount of Coverage
Building:
Business Personal Property:
Fire Legal Liability:
 Loss Information
*Have you had any losses in the last 5 years? Yes    No    - If yes, list all losses below.
*Do you have any knowledge of an occurrence that could result in a claim? Yes    No    - If yes, submit risk.

Loss History
Date Carrier Premium Losses

*Have you ever had prior insurance cancelled, declined, or non-renewed?
If yes, explain:
Yes    No  
Please explain any losses listed above:
Name and Address of Additional Insureds:
 Policyholder Disclosure Notice Of Terrorism Insurance Coverage
You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act, as amended: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States-to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2014, the date on which the TRIA Program is scheduled to terminate or the expiry date of the policy whichever occurs first, and shall not cover any losses or events which arise after the earlier of these dates.

YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 85% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED.

THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.

I hereby elect to purchase coverage for acts of terrorism for a prospective premium of  $
I hereby elect to have coverage for acts of terrorism excluded from my policy.
      I understand that I will have no coverage for losses arising from acts of terrorism.
 
 SUBMIT completed and Signed Application for approval & signed/check Terrorism Form
It is hereby agreed and understood that this application for insurance is subject to review by underwriting. Coverage is not bound until submission for insurance isaccepted by First Flight Insurance Group, Inc., all signed forms are in place, AND the total required deposit premium has been paid in full. Binder of Coverage will beconfirmed with a signed Binder or a Policy, as issued by First Flight Insurance Group, Inc. No other entity or agent has the right bind coverage or issue a Certificateof Insurance or Binder for coverages submitted under this application.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES 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 SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (Not applicable in CO, HI, OH, OK, OR, or VT; in DC, LA, ME and VA, insurance benefits may also be denied).
*Applicant Signature:
Date: 12/12/2019