pre cut xmas tree lot rou063 201104
8417 Patterson Avenue Richmond, Virginia 23229 Telephone: (804) 741-7999 WATTS: (800) 628-2967 Fax: (804) 741-9401 www.royaloakunderwriters.com
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
PRE-CUT CHRISTMAS TREE LOT LIABILITY APPLICATION Applicant Name and Address:
Telephone Number Policy Term: From
To
LIABILITY COVERAGES General Liability Per Occurrence
LIMITS REQUESTED $
General Aggregate
$
Products
$
Other coverages requested:
Medical Payments Per Person $ Fire Damage Legal Liability
$
UNDERWRITING INFORMATION Location of Christmas Tree Lot ________________________________________________________________ __________________________________________________________________________________________ Days and Hours of Operation
_________________________________________________________________
Are power tools - chain saws, etc. - used? ........................................ Yes No Are trees for sale grown at insured location? .................................... Yes No Do customers cut their own trees? ................................................... Yes No Describe goods for sale other than Christmas trees and decorations ____________________________________ __________________________________________________________________________________________ List names, addresses and relationships of Additional Insureds: __________________________________________________________________________________________ __________________________________________________________________________________________ List names and addresses of requestors of Certificates of Insurance: __________________________________________________________________________________________ __________________________________________________________________________________________ If insured has operated lot in the past, show: THREE YEAR LOSS EXPERIENCE (Loss description, amounts paid and incurred)
Date
________________ ________________ ________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Comments
Applicant Signature
Producer Name & Address
COVERAGES NOT BOUND UNTIL APPROVED BY THE COMPANY Reset Form rou063-201104
Submit by E-mail Page 1 of 1
Print Form
SAVE
Royal Oak Underwriters, Inc.
ROYAL OAK UNDERWRITERS, INC. Excess and Surplus Lines Insurance Wholesalers
PRE-CUT CHRISTMAS TREE LOT LIABILITY APPLICATION Applicant Name and Address:
Telephone Number Policy Term: From
To
LIABILITY COVERAGES General Liability Per Occurrence
LIMITS REQUESTED $
General Aggregate
$
Products
$
Other coverages requested:
Medical Payments Per Person $ Fire Damage Legal Liability
$
UNDERWRITING INFORMATION Location of Christmas Tree Lot ________________________________________________________________ __________________________________________________________________________________________ Days and Hours of Operation
_________________________________________________________________
Are power tools - chain saws, etc. - used? ........................................ Yes No Are trees for sale grown at insured location? .................................... Yes No Do customers cut their own trees? ................................................... Yes No Describe goods for sale other than Christmas trees and decorations ____________________________________ __________________________________________________________________________________________ List names, addresses and relationships of Additional Insureds: __________________________________________________________________________________________ __________________________________________________________________________________________ List names and addresses of requestors of Certificates of Insurance: __________________________________________________________________________________________ __________________________________________________________________________________________ If insured has operated lot in the past, show: THREE YEAR LOSS EXPERIENCE (Loss description, amounts paid and incurred)
Date
________________ ________________ ________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Comments
Applicant Signature
Producer Name & Address
COVERAGES NOT BOUND UNTIL APPROVED BY THE COMPANY Reset Form rou063-201104
Submit by E-mail Page 1 of 1
Print Form
SAVE
Royal Oak Underwriters, Inc.
