Jewelers Block Coverage Application

Your Contact Information

So we can follow up with your quote.

1. Firm Information

3. Employees

4. Last 3 Years Loss Experience

List ALL losses (insured and uninsured) in the last 3 years involving covered property — date, nature, amount, carrier. Enter NONE if none.

5. Prior Coverage History

6. Bookkeeping

8. Limits of Insurance Desired

Limit cannot be less than 80% of average inventory values for each location.

9. Optional Additional Coverages at Premises

Limit cannot be less than 100% of actual value for Furniture/Fixtures and Improvements/Betterments.

10. Deductible

Mandatory $500 deductible applies to all loss. Select a higher deductible if desired.

11. Inventory History

12. Show Window & Outside Showcase Display

14. Travel & Messenger

15. Annual Shipment Estimates

Estimated total property to be shipped at your risk during the policy period.

16. Burglary Protection of Premises, Safes & Vaults

17. Other Security Measures

18. Safes & Property Distribution

Safe class/UL label, location, and how stock is distributed when premises are closed.

Current Insurance

Additional Notes