Proposed Effective Date Name of Agent or Broker Company E-mail Website Phone Number Fax Insured Name in the US (if applicable) Insured US Address Street: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Insured Name of Mexico Entity for more than one, please schedule on a separate form Insured Address of Mexico Entity Street: City: State: Postal Code: Value: Building: Contents: Equipment: Flood Coverage: insuring: Buildings Contents Earthquake Coverage: insuring: Buildings Contents Occupancy and brief description of Mexico operation: Construction Type: Number of Stores: Fire Protection Equipment: Extinguisher Fire Hydrant Sprinklers Number of Units: Current Insurer: Yearly Premium Loss History (if available) last 3 years: CGL Liability Limit: Include Products? Burglary Theft Limit: Cash & Securities Limit: EDP Computer Limit: Boiler & Machinery Limit: Glass Coverage Limit: Loss of income Limit: Automobile Fleet Information: Vehicles are registered in USA Mexico Vehicle 1: Year Make Model Value Vehicle 2: Year Make Model Value Vehicle 3: Year Make Model Value Vehicle 4: Year Make Model Value For additional vehicles, email a statement with year, make, model and value of each vehicle to customerservice@g54mexico.com If you have additional buildings, please enter a statement of values or email a list to customerservice@g54mexico.com. Statement of values for additional buildings:
Fax
Street: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:
for more than one, please schedule on a separate form
Street: City: State: Postal Code:
Value:
Automobile Fleet Information: Vehicles are registered in USA Mexico
Year Make Model Value
For additional vehicles, email a statement with year, make, model and value of each vehicle to customerservice@g54mexico.com
If you have additional buildings, please enter a statement of values or email a list to customerservice@g54mexico.com.
Statement of values for additional buildings: