New Business License Phoenix Arizona - Excel

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					                                                           STATEWIDE INSURANCE CORP.
                                                             P.O. Box 30527, Phoenix, Arizona 85046

                                                     ARIZONA, NEVADA, NEW MEXICO & UTAH
                                                           Restaurant Package Policy
                                                      CERTAIN UNDERWRITERS AT LLOYD'S

Insured:                                                                                  Policy #:
Effective:                                                                                Agency:
State:                                                                    Please Select Risk State

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 4/1/08
                                                        GENERAL LIABILITY CALCULATIONS


Class Description and Code #:                                                                                  Please Select Class Description
Occurrence Limit:                                                         Please Select Desired Occurrence Limit
Do you want Double Aggregate Limits?
General Aggregate Selected:
Deductible ($500/$1,000):                                                 Please Select Deductible
Additional Insured's Requested ($75 each):


Total Restaurant Sales:                                                          0
Liquor Sales:


                                                         Incr. Limits      Deductible       Double Agg.                       Final
                         Class Code      Base Rate                                                               Modifier
                                                           Factor            Factor           Factor                          Rate




                                                                        FINAL PREMIUM
                                                                              $0



                                                              PROPERTY CALCULATIONS

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


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




                                                                                                                  Final
                                          Property Values (ACV)                  Limit of Insurance
                                                                                                                Premium
                                                   Building
                                                  Contents
                                       Business Income w/o Extra Exp.
                                      Business Income w/Extra Expense

                                                                           TOTAL PROPERTY PREMIUM                  $0




           /0c2bdd98-380c-4e9a-980b-dcb9ee19d239.xls/Page 1 - Rating Worksheet                                                        Version 05/07
                                               ARIZONA, NEVADA, NEW MEXICO & UTAH
                                                     Restaurant Package Policy
                                                CERTAIN UNDERWRITERS AT LLOYD'S

                                                     OTHER COVERAGES AVAILABLE

      DESCRIPTION               REQUESTED?                                 Additional Information                                 PREMIUM
   Property Enhancement                                                                                                              $0
      Glass Coverage                                                                                                                 $0
           Signs                                                                                                                     $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              Risk State?        Rejected                                 Terrorism:            Rejected         $0.00
                                                                                             Taxes / Fees:                     Select Risk State
     Accept Terrorism?                          Submit Signed Terrorism Form                 Filing Fee (NV only):                  $0.00


                                                                                                    Total                     See Note Below


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




     /0c2bdd98-380c-4e9a-980b-dcb9ee19d239.xls/Page 1 - Rating Worksheet                                                  Version 05/07
                                                                                                                         P.O. Box 30527
                                                                                                                  Phoenix, Arizona 85046
                                                                                                          (602) 494-6900 (800) 228-1710
                                                                                                                     Fax (602) 494-6999
                                                                                                              EFFECTIVE October, 2006
                                                 CERTAIN UNDERWRITERS AT LLOYD'S, LONDON
                                            RESTAURANT PACKAGE POLICY APPLICATION

MARKET AREA: ARIZONA, NEVADA, NEW MEXICO, UTAH                                          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?




          /0c2bdd98-380c-4e9a-980b-dcb9ee19d239.xls              Page 3 of 8                                      Version 05/07
                                              CERTAIN UNDERWRITERS AT LLOYD'S, LONDON
                                         RESTAURANT 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:



        /0c2bdd98-380c-4e9a-980b-dcb9ee19d239.xls                    Page 4 of 8                                       Version 05/07
                                                        STATEWIDE INSURANCE CORP.
                                                      P.O. Box 30527, Phoenix, Arizona 85046

                                                  RESTAURANT PROGRAM
                                      MANDATORY SUPPLEMENTAL QUESTIONS FOR ALL RISKS



                                 RESTAURANT OPERATIONS                                         Yes   No
Do they have a UL approved fire suppression system over ALL cooking surfaces?

Do they have a service contract for the above system?

How often is the fire suppression system cleaned/serviced by the licensed contractor?

Do they have an ABC extinguisher in the dining area and/or near the counter?

Are all extinguishers serviced annually?

Do they have hoods and ducts over all cooking equipment?

Do they have a service contract for the hoods & ducts?

How often are the hoods and ducts cleaned/serviced by the licensed contractor?

Are the hoods and filters cleaned weekly by the staff?

Do they have automatic gas or electric shut offs for cooking equipment?

Do they have entertainment?

     If yes, what type? If it's a band, provide the number of members in the band

Do they have a dance floor and/or is dancing permitted on the premises?

Do they have bouncers or doormen?

Do they have amusement devices such as pool tables, video games, gambling, etc?

     If yes, provide the quantity and description of each device

Do they have any on or off premises catering or banquet exposures?

     If yes, describe the exposure and the percent of total receipts from these operations

Are the emergency exits equipped with panic hardware?

Is the owner active in the daily operations of the business?

Do they have a delivery exposure?




                                       LIQUOR LIABILITY                                        Yes   No
Do they have a liquor license?

Do they provide the employees with liquor training?

    If yes, what type?

Do they notify the management prior to shutting off a patron?

Do they have happy hour or other drink promotions?

Have they ever had any liquor board violations?

    If yes, provide details




                                                          Print Supplemental
                                                         App, then Proceed to
                                                         Page 4 for TRIA Form
                                            POLICYHOLDER DISCLOSURE
                                               OFFER 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.



    Policyholder / Applicant's Signature                          ……….Syndicate on behalf of certain
                                                                      underwriters at Lloyd's


                 Print Name                                                Contract Reference


                    Date                                               Certificate / Policy Number


LMA9011
                                             Nevada Surplus Lines Association
                                                DECLINATION DETAIL

This form is to be used when the policy provides insurance for coverage that cannot be written with admitted insurers.
(Category is not listed on open lines eligible for export.) In pursuant of 685A.215 of NRS, identify three admitted
insurers marketing the class of insurance that declined the risk. Include with this submission form NSLA101.


NAME OF INSURED:


POLICY NUMBER:



                                                             1.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             2.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):



                                                             3.
Admitted Insurer:
Address:
Phone Number:                                                     Underwriter
Reason for Declination (enter code from bottom):


                                               Reason for Declination Codes

                1.   Unacceptable Class of Business                             5.   No Market
                2.   Age of Building                                            6.   No Prior Insurance
                3.   Declined to Quote                                          7.   Excessive Claims
                4.   Doesn't Fit Underwriting Requirement                       8.   Other (Please Explain)




SLA AFFIRMATION:                                I hold a Surplus Lines license and will do the SLA filings.
                                                Please do the SLA filings for me. (Must send this form!)




BROKER/AGENT NAME                                              SIGNATURE                                           DATE
                                     EVIDENCE OF GOOD FAITH EFFORT TO PLACE

                                             The Surplus Line Association of Utah

     This form is to be used to document the efforts made by the suplus lines broker (and/or producing agent) to place
     insurance coverage concerned with an admitted insurer before approaching the suplus lines insurer.

     Policy No.                                               Name of Insured:

     List the admitted insurers contacted.

                NAME OF INSURER                              NAME OF UNDERWRITER                        PHONE NUMBER
1.
     Reason for Declining:



2.
     Reason for Declining:



3.
     Reason for Declining:




     If any additional insureds were contracted, attach an additional list.

     Provide any further explanation about the insured and your effort to place the insurance with an admitted insurer
     which would help support the need to place the policy with a surplus lines insurer. Explain why you consider this
     to be reasonable evidence of a good faith effort to place the coverage with an admitted insurer.
     Attach additional sheets if necessary.




     SLA AFFIRMATION:                             I hold a Surplus Lines license and will do the SLA filings.
                                                  Please do the SLA filings for me. (Must send this form!)




     Signature of Producing Producer                                Signature of Surplus Lines Broker

				
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