Fillable Commercial Package Application (RT Specialty)

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Commercial Package Application (RT Specialty)

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The Commercial Package Application (RT Specialty) form is 3 pages long and contains:

  • 2 signatures
  • 21 check-boxes
  • 163 other fields

Country of origin: US
File type: PDF

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CPS-APPs (11-06) Page 1 of 3
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Commercial Package Application
Applicant’s Name: Agent Name:
Mailing Address: Address:
PROPOSED EFFECTIVE/EXPIRATION DATES: From To
12:01 A.M., Standard Time, at the address of the Applicant
PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
1. Applicant is: Individual Corporation Partnership Joint Venture Other (Specify):
2. Number of years in business:
3. Describe all business operations conducted by applicant:
PROPERTY SECTION
4. Premises information:
Loc. No. Street, City, County, State, Zip Code Interest
Part
Occupied
Prem-
ises
No.
Exposure
Amount
Requested
Coins.
%
ACV/
Repl. Cost
Cause of
Loss
Deductible Special
Conditions
Building $ $
Contents $ $
Business
Interrup-
tion
$ $
Other $ $
Submit Application
CPS-APPs (11-06) Page 2 of 3
Bldg.
No.
Mortgagee or loss payee:
Additional coverages, restrictions and en-
dorsement information:
Other carriers participating on risk:
1. %
2. %
• Construction type:
• Protection class:
• Number of stories:
• Total square foot area:
• Total number of units:
• Sprinklered?....................................... Yes No
• Operable smoke detectors? .............. Yes No
• Year built:
• Building remodeling (include year):
Wiring? .......... Yes No Year:
Heating? ........ Yes No Year:
Plumbing? ..... Yes No Year:
Roof? ............. Yes No Year:
• Burglar alarm type: ....... Local Central Station
• Fire alarm type: ............. Local Central Station
GENERAL LIABILITY SECTION
5. Limits of Liability Requested
Premiums
General Aggregate $ Premises/Operations
$
Products & Completed Operations Aggregate $
Personal & Advertising Injury $ Products/Completed Operations
$
Each Occurrence $
Fire Damage (any one fire) $ Other
$
Medical Expenses (any one person) $
Other Coverages, Restrictions and/or Endorsements $
Deductible $
Total
$
Schedule of Hazards
Loc.
No.
Classifica-
tion
Class.
Code
Premium Bases:
(s) Gross Sales;
(p) Payroll;
(a) Area; (c) Total
Cost; (t) Others
Terr.
Rate Premium
Prem./
Ops.
Products/
Comp.
Ops.
Prem./Ops.
Products/
Comp. Ops.
CPS-APPs (11-06) Page 3 of 3
6. Previous carrier and loss information (last three years): Check if no losses last three years
Year Company Policy No. Premium
Date of
Loss
Losses
Paid/Reserved
Description of
Loss
Any other insurance with this company or being
submitted? (Please list name[s] and/or policy number[s]):
Any policy or coverage declined, canceled or non-
renewed during the prior three years? Why? (Not
applicable in Missouri)
This application does not bind YOU nor US to complete the insurance, but it is agreed that the information contained
herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING:
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 subjects such
person to criminal and civil penalties.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: Date:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: Date:
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Commercial Package Application (RT Specialty)

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Completed 13 December 2020

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