| For Help Call (469) 633-0183 |
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| Fields marked (*) are mandatory. |
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| Broker/Company | |
| Submitted By | |
| Phone Number | |
| Fax Number | |
| E-Mail Address | |
| Effective Date | |
| Select Program(s) you're Interested In |
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| Basic | |
| Comprehensive | |
| Property & Liability | |
| Property only | |
| Liability only | |
| Other | |
| Vesting/Registered Owner Information |
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| Named Insured | |
| Address | |
| City | |
| State | |
| Zip | |
| Contact Person | |
| Phone | |
| Fax | |
| New CIBA Member | |
| Have you been a member of CIBA before? | |
| If Yes, year | |
| current CIBA Member | |
| Approximate number of properties enrolled | |
| Premium Finance Quote Requested | |
| Special Comments | |
| Property Information |
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| Location Address | |
| City | |
| State | |
| Zip | |
| EQ Zone | |
| Portfolio? | |
| Property Type |
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| Commercial/Industrial | |
| Retail space | |
| Office Building | |
| Warehouse | |
| Apartment Building/Complex | |
| Condominium | |
| Rental Dwelling | |
| Mixed Tenancy | |
| Vacant Land | |
| Nature of Rusinpss/Tenant | |
| Description of Operations | |
| Total Square Footage | |
| # of Units | |
| # of Pools | |
| # of Spas | |
| Fenced? | |
| Building RCV | |
| Annual Rents | |
| Year Built * | |
| Retrofitted? * | |
| * Bull dings built in or before 1969 that do not meet the California Uniform Building code of 1976 do not qualify for comprehensive coverage under the |
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| year Construction type | |
| Number of years property owned hy insured | |
| # of Buildings | |
| # of Stories | |
| Sprinklers | |
| Central Station Alarm | |
| Parking | |
| If Other | |
| a. Are driveways, parking & sidewalks In smooth repair? | |
| If No please explain | |
| b. Are stairs, porches, rails, landings and balconies In good repair? | |
| If No please explain | |
| c. Any graffiti on walls or fences? | |
| If Yes please explain | |
| d. any garbage, debris or Inoperable vehicles on premises? | |
| If Yes please explain | |
| e. Does structure have wood shake roof? | |
| f. Has this property or Insured sustained a loss during the past 5 years? | |
| If yes, please attach a Loss History | |
| Current Insurance Coverages |
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| Commercial General Liability |
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| Insurance Company | |
| Limit | |
| Deductible | |
| Premium | |
| Auto Liability |
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| Insurance Company | |
| Limit | |
| Deductible | |
| Premium | |
| Property -All Risk |
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| Insurance Company | |
| Limit | |
| Deductible | |
| Premium | |
| Property- DIC |
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| Insurance Company | |
| Limit | |
| Deductible | |
| Premium | |
| Non-Habitational: Number of tenants | |
| Tenants Operations | |
| Additional Insured Information |
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| Loan #1 |
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| Name | |
| Address | |
| City | |
| State | |
| Zip | |
| Nature of Interest |
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| 1st Mortgagee | |
| 2nd Mortgagee | |
| 3rd Mortgagee | |
| Additional Insured | |
| Loss Payee | |
| 438BFUNS Applies | |
| GL 15-1 | |
| GL 15-2A | |
| GL 15-2B | |
| Loan #2 |
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| Name | |
| Address | |
| City | |
| State | |
| Zip | |
| Nature of Interest |
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| 1st Mortgagee | |
| 2nd Mortgagee | |
| 3rd Mortgagee | |
| Additional Insured | |
| Loss Payee | |
| 438BFUNS Applies | |
| GL 15-1 | |
| GL 15-2A | |
| GL 15-2B | |
| Loan #3 |
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| Name | |
| Address | |
| City | |
| State | |
| Zip | |
| Nature of Interest |
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| 1st Mortgagee | |
| 2nd Mortgagee | |
| 3rd Mortgagee | |
| Additional Insured | |
| Loss Payee | |
| 438BFUNS Applies | |
| GL 15-1 | |
| GL 15-2A | |
| GL 15-2B | |
| Loan #4 |
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| Name | |
| Address | |
| City | |
| State | |
| Zip | |
| Nature of Interest |
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| 1st Mortgagee | |
| 2nd Mortgagee | |
| 3rd Mortgagee | |
| Additional Insured | |
| Loss Payee | |
| 438BFUNS Applies | |
| GL 15-1 | |
| GL 15-2A | |
| GL 15-2B | |