Process a COP Smart PDF

Producer & Agency Info:

Full Name of Agency/Organization*

Enter exactly as it appears on the agency license

Person completing form (LSI)*

The completed PDF form will be emailed to the email address associated with this person

Person completing form (HRC)*

The completed PDF form will be emailed to the email address associated with this person

Person completing form (Rouland)*

The completed PDF form will be emailed to the email address associated with this person

Person completing form(Searchlight)*

The completed PDF form will be emailed to the email address associated with this person

Person completing form (LA Metro)*

The completed PDF form will be emailed to the email address associated with this person

Agency/Organization DOI License Number*

DOI issued license # of Agency/Organization

Today's Date*

Date

Full Name of Individual Producer (LSI)*

Must be Name of licensed producer/Acc. Manager

Full Name of Individual Producer (HRC)*

Must be Name of licensed producer/Acc. Manager

Full Name of Individual Producer (Rouland)*

Must be Name of licensed producer/Acc. Manager

Full Name of Individual Producer (Searchlight)*

Must be Name of licensed producer/Acc. Manager

Full Name of Individual Producer (LA Metro)*

Must be Name of licensed producer/Acc. Manager

Full Name of Individual Producer*

DOI issued license # of producer/Acc. Manager

Individual DOI License Number*

DOI issued license # of producer/Acc. Manager

Enter the Agency Name (DBA)*

Enter the Agency Address*

Rows	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:

YesNo

Property:

BasicBroadSpecialN/A

Building's Deductible

Contents Deductible

YesNo

Earthquake Deductible

YesNo

Wind Deductible

YesNo

Flood Deductible

Policy Number on the Property*

What is the type of policy*

Effective date of the Policy*

Date

Expiration date of the Policy*

Date

Covered Property:

Building

What is the limit amount for Building?

X-Building (for mapping FID-33)

Personal Property

Limit amount for Personal Property

X-Personal Property (for mapping FID-34)

Business Income

Limit amount for Business Income

X-Business Income (for mapping FID-35)

Extra Expense

Limit amount for Extra Expense

X-Extra Expense (for mapping FID-43)

Rental Value

Limit amount for Rental Value

X-Rental Value (for mapping FID-46)

Blanket Building

Limit amount for Blanket Building

X-Blanket Building (for mapping FID-47)

Blanket Pers Prop

Limit amount for Blanket Pers Prop

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

Blanket Bldg & PP

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)

Named Peril on Inland Marine

Policy number on Inland Marine

Type of Policy on Inland Marine

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

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*

Rows	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*