Process a COP

Agency Info:

Date *

Date

Enter the Agency Name (DBA) *

Enter the Agency Address *

	Address
Street
City
State
Zip

Contact Name

Enter the Agency Phone Number *

Agency Street Address

Agency City Address

Agency State Address

Agency Zip Address

Enter the Agency Fax Number *

Enter the Agency E-mail *

Producer Customer ID

Client Info:

How many named insured will there be in the policy, therefore showing on the COP. *

Note: All the names will show on the evidence in the named insured area (box)

What is the name of the 1st Named Insured *

What is the name of the 2nd Named Insured *

What is the name of the 3rd Named Insured *

What is the name of the 4th Named Insured *

How many insurer(s) will there be in the policy, therefore showing on the COP. *

Note: All the names will show on the evidence in the named insured area (box)

What is the name of Insurer A *

What is the NAIC No. of Insurer A

What is the name of Insurer B *

What is the NAIC No. of Insurer B *

What is the name of Insurer C *

What is the NAIC No. of Insurer C *

What is the name of Insurer D *

What is the NAIC No. of Insurer D *

What is the name of Insurer E *

What is the NAIC No. of Insurer E *

What is the name of Insurer F *

What is the NAIC of Insurer F *

Coverage Info:

Certificate Number

Revision Number

Location of Premises/Description of Property

Attach Accord 101, Additional remarks schedule if more space is required

What type of Insurance do you need:

Do you need Property Insurance

Property:

X-Property (FID-29)

What Type of Property Insurance do you need

Building's Deductible

Contents Deductible

X-Basic (FID-38)

X-Broad (FID-41)

X-Special (FID-42)

Do you need Earthquake Insurance

X-Earthquake (FID-49)

Earthquake Deductible

Do you need Wind Insurance

X-Wind (FID-52)

Wind Deductible

Do you need Flood Insurance

X-Flood (FID-56)

Flood Deductible

What is the Policy Number on the Property *

What is the type of policy *

What is the effective date of the Policy on the Property *

Date

What is the expiration date of the Policy on the Property *

Date

Covered Property:

Building

What is the limit amount for Building?

X-Building (for mapping FID-33)

Personal Property

What is the limit amount for Personal Property?

X-Personal Property (for mapping FID-34)

Business Income

What is the limit amount for Business Income?

X-Business Income (for mapping FID-35)

Extra Expense

What is the limit amount for Extra Expense?

X-Extra Expense (for mapping FID-43)

Rental Value

What is the limit amount for Rental Value?

X-Rental Value (for mapping FID-46)

Blanket Building

What is the limit amount for Blanket Building?

X-Blanket Building (for mapping FID-47)

Blanket Pers Prop

What is the limit amount for Blanket Pers Prop?

X-Blanket Pers Prop (for mapping FID-54)

Blanket Bldg & PP

What is the limit amount for Blanket Bldg & PP?

X-Blanket Bldg & PP (for mapping FID-58)

Do you need Inland Marine Insurance

Inland Marine:

X-Inland Marine (FID-62)

X-Named Perils (FID-64)

What is the Named Peril on Inland Marine

What is the Policy number on Inland Marine

What is the type of Policy on Inland Marine

What is the effective date of the Policy on Inland Marine *

Date

What is the expiration date of the Policy on Inland Marine *

Date

Limit amount for Inland Marine

Limit amount for Inland Marine 2

Limit amount for Inland Marine 3

Limit amount for Inland Marine 4

Do you need Crime Insurance

Crime:

X-Crime (FID-71)

What is the Type of Policy on Crime

What is the Policy number on Crime

What is the effective date of the Policy on Crime *

Date

What is the expiration date of the Policy on Crime *

Date

Limit amount - Crime

Limit amount - Crime 2

Limit amount - Crime 3

Do you need Boiler & Machinery/Equipment Breakdown

Boiler & Machinery/Equipment:

X-Boiler & Machinery/Equipment Breakdown (FID-66)

What is the name of Boiler & Machinery/Equipment

What is the Policy number on Boiler & Machinery/Equipment

What is the effective date of the Policy on Boiler & Machinery/Equipment *

Date

What is the expiration date of the Policy on Boiler & Machinery/Equipment *

Date

Limit amount for Boiler & Machinery /Equipment

Special Condition:

Special Condition / Other Coverage 1

Attach Accord 101, Additional remarks schedule if more space is required

Special Condition / Other Coverage 2

Attach Accord 101, Additional remarks schedule if more space is required

Special Condition / Other Coverage 3

Attach Accord 101, Additional remarks schedule if more space is required

Special Condition / Other Coverage 4

Attach Accord 101, Additional remarks schedule if more space is required

Certificate Holder:

Enter the Certificate Holder Name *

Enter the Certificate Holder Address *

	Address
Street
City
State
Zip

Certificate Holder Street Address

Certificate Holder City Address

Certificate Holder State Address

Certificate Holder Zip Address

Cancellation:

Should any of the above descrived policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions.

Authorized Representative *

Completed by *

Enter Acc. Manager / Producer

Agency Name *

Enter the agency name, FYI this does not have an affect on automatic routing