Broad Form Commercial General Liability Insurance Arizona - Excel

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Broad Form Commercial General Liability Insurance Arizona - Excel Powered By Docstoc
					                                                              STATEWIDE INSURANCE CORP.
                                                                P.O. Box 30527, Phoenix, Arizona 85046

                                                                       ARIZONA
                                                              Habitational Package Policy
                                                     CERTAIN UNDERWRITERS AT LLOYD'S OF LONDON

Insured:                                                                                      Policy #:
Effective:                                                                                    Agency:

Has this insured had prior insurance coverage?
Is this business a New Venture?
Has this insured been claim free with Statewide for more than one year?
                                                                                                              PREMIUM MODIFIER =                     1.00

Rates effective 2/15/08
                                                           GENERAL LIABILITY CALCULATIONS



Class Description and Code #:                                                                               Please Select Class Description
Occurrence Limit:                                                            Please Select Desired Occurrence Limit
Do you want Double Aggregate?
General Aggregate Requested
Deductible ($500/$1,000)                                                     Please Select Deductible
Additional Insured's Requested ($50 each):


                                                            Aggregate            Deductible                        Final          # of
                          Class Code           Base Rate                                          Modifier
                                                              Factor               Factor                          Rate           Units



                                                                                                                                   GL
                          Number of Swimming Pools                                     Number of Spas
                                                                                                                                Premium
                                                                                                                                   $0




                                                GL RATE TABLE                                                Rates (per Unit)
                                       CLASS                          Code #                     $300,000        $500,000       $1,000,000
                      Apartments                                        60010                     $58.00          $62.50          $84.10
                      Bed & Breakfast Inns                              45192                      $6.75           $7.25          $7.75
                      Condo & Town Home Associations                    62003                     $43.50          $46.87          $63.07
                      Hotels / Motels                                   45190                      $8.02           $8.73          $10.75
                      Rental Dwellings                                  63010                     $118.00         $132.30        $148.50




           /76fab706-1100-4bfd-982c-ba7f1f49c65c.xls/Page 1 - Rating Worksheet                                                             Version 02/08
                                                              ARIZONA
                                                     Habitational Package Policy
                                            CERTAIN UNDERWRITERS AT LLOYD'S OF LONDON

                                                            PROPERTY CALCULATIONS

                                Type of Coverage Desired?
                                Deductible Requested?
                                Protection Class?
                                Building Construction?


                                                      Coverage             Deductible   Protection Class                            Final
                                    Base Rate                                                                  Modifier
                                                       Factor                Factor       Adjustment                                Rate
                                      $0.00



                                                                                            Type of Construction
                                        RATE TABLE                          Frame          Masonry     Non-Combust.             Fire Resistive
                                           Building                          $0.54          $0.50          $0.45                     $0.40
                                    Business Pers. Property                  $0.54          $0.50          $0.45                     $0.40
                                       Business Income                       $0.54          $0.50          $0.45                     $0.40


                                                                                                                 Final
                                     Property Values (ACV)                    Limit of Insurance
                                                                                                               Premium
                                             Building
                                             Contents
                                         Business Income


                                                                      TOTAL PROPERTY PREMIUM                      $0




                                                        OTHER COVERAGES AVAILABLE

     DESCRIPTION                 Limit / Value              Sign Location                            Additional Information                         PREMIUM
         Signs                                                                                     Please select Sign Location                         $0

                                                                                          TOTAL PREMIUM for OTHER COVERAGES                             $0




   TOTAL GL PREMIUM                    $0
                                                                                                                          FINAL COMPUTATIONS

TOTAL PROPERTY PREMIUM                 $0                                                                  General Liability:                           $0
                                                                                                           Property:                                    $0
                                                                                                           Other Coverages:                             $0
   OTHER COVERAGES                     $0                                                                  Add'l Insureds:                              $0
                                                                                                              Sub-Total                                 $0
                                                                                                           Policy Fee                                   $0
  TERRORISM PREMIUM                    $0             Rejected                                             Terrorism:             Rejected              $0
                                                                                                           Taxes / Fees:                               $0.00
    Accept Terrorism?                             Submit Signed Terrorism Form

                                                                                                                Total                            See Note Below


                                                  Premium Not Offered; Please Select GL Deductible
                                                                                                                           Print Worksheet, then
                                                                                                                           Proceed to Page 2 for
                                                                                                                                 Application




     /76fab706-1100-4bfd-982c-ba7f1f49c65c.xls/Page 1 - Rating Worksheet                                                                     Version 02/08
                                                                                                                              P.O. Box 30527
                                                                                                                       Phoenix, Arizona 85046
                                                                                                               (602) 494-6900 (800) 228-1710
                                                                                                                          Fax (602) 494-6999
                                                                                                                  EFFECTIVE February, 2008
                                                       Certain Underwriters at Lloyd's of London
                                          HABITATIONAL PACKAGE POLICY APPLICATION

MARKET AREA: ARIZONA                                                                         RATES ARE SUBJECT TO CHANGE WITHOUT NOTICE
                             Applicant's Name:                                                  Producer's Name:




Address:                                                                  Address:

City,State,Zip:                                                           City,State,Zip:

Phone:                                   Cell Phone:                      Phone:                        Fax:

Location Address (if different from mailing):

Requested Effect. Date (m/dd/yy):        From:                                         To:

Applicant is? (Select One)

Applicant's Business:




                                UNDERWRITING INFORMATION - PROPERTY AND LIABILITY
1. Number of years Applicant has been in business?
2. How many years has applicant been at this location?
3. Has Building been remodeled? If yes, when?
4. Has Wiring, Plumbing, and Heating been updated? If yes, what year?
5. Describe Alarm/Security System.
6. Is any Commercial Cooking which emits grease laden vapors done on premises?


7. Are any alcoholic beverages served on premises? If yes, shows receipts?
8. Are there any gasoline pumps on the premises? If yes, how many?
9. List other occupancies in the building occupied by the insured
10. Expenditures for Advertising?



                                                             GENERAL INFORMATION
1. Are there any buildings owned or occupied by the insured not described on the application?
2. Last year's Gross Recipts?
3. Rental %
4. Installation, Service or Repair %
5. Building Square Footage?
6. Age of Building?
7. Number of Employees
8. Is there any other Insurance on this Property?




           76fab706-1100-4bfd-982c-ba7f1f49c65c.xls                                                                    Version 02/08
                                                      Certain Underwriters at Lloyd's of London
                                       HABITATIONAL PACKAGE POLICY APPLICATION

                                                  PREVIOUS CARRIER INFORMATION
                   Carrier                                Policy Dates              Coverage                          Premium




Has any Carrier Canceled, Declined or Refused any Insurance During the Past 3 years?




                                                           LIABILITY LIMITS REQUESTED
                         Liability Limit Requested:

                  Do you want Double General Aggregate?

                          Deductible Requested:




                                                               PREVIOUS LOSSES
                      Indicate ALL Losses in the Past Three Years that have been Covered by Insurance
   Date of Loss          Amount of Loss                            Cause and Description of Loss




                                                             ADDITIONAL INSUREDS - 1
Name:
Address:                                                                    Additional Insured or Cert Holder Only?
City,State,Zip:
Interest of Additional Insured:


                                                             ADDITIONAL INSUREDS - 2
Name:
Address:                                                                    Additional Insured or Cert Holder Only?
City,State,Zip:
Interest of Additional Insured:


REMARKS:




 NO COVERAGE WILL BE BOUND UNLESS THE APPLICATION IS SIGNED BY BOTH THE PRODUCER AND THE INSURED
                  AND IS ACCOMPANIED BY THE COMPLETED, SIGNED TERRORISM OFFER.


Signature of Producer                                                                           Date:


Signature of Applicant                                                                          Date:




        76fab706-1100-4bfd-982c-ba7f1f49c65c.xls                                                                       Version 02/08

				
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