Warehouse Legal Liability Application
Named Insured
Address of Named Insured
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Named Insured Website:
Business Description:
Goods to be insured with full details of packaging and protection:
Policy Effective Date:
-
Month
-
Day
Year
Date
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Description of Premises (COPE Information):
Year of Construction:
Type of Construction:
Fire Protection (including sprinklers):
Theft Protection:
Are there any Cold Storage Facilities?
Yes
No
Please provide details regarding the Cold Storage Facilities:
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Estimated Values in Storage:
Average Values:
Maximum Values:
Total Number of Employees:
Annual Gross Receipts (2025/2026):
Storage:
Handling:
Loss History
Please select "No Losses" if the entity has not had any losses in the last 5 years.
No Losses
Description of Losses (5 Year Loss History):
Please Upload 5 Years of Loss History:
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Please attach a copy of the Warehouse contract between the Warehouse owner and customer of the goods:
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Please describe liability of the Insured accepting the goods (contractual, extended, or all risks?):
Current Deductible:
Target Premium:
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Agent Details
Agent Name
First Name
Last Name
Agent Phone Number
Please enter a valid phone number.
Agent Email
example@example.com
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Declaration
I declare that the statements and particulars in this application are true and that no material facts have been misstated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before completion of the contract of insurance. A material fact is one which would influence the acceptance or assessment of the risk.
Signature of Applicant
Printed Name of Applicant
First Name
Last Name
Title/Position of Applicant
Current Date:
Submit
Should be Empty: