Business Inventory Insurance

 General Information

* Indicates a required field.
*Insured Name: 
*FEIN Number: 
*Mailing Address:  
*City:  
*State:  
  *Zip: -
*Phone (Business):  
*FAX:  
*Phone (Home):  
*Email Address:  
*Effective Date Requested:  
*Deductible Amount:  

($2,500 or increments of $2,500 to a maximum of $100,000)

 Inventory Information

*Total Replacement Value of all stock in trade at this time:  
*What percentage of your stock is numismatics?:  
%
*What % of inventory is in Currency/Script?:  
%
*What % of inventory is in Autographs/Manuscripts?:  
%
*What % of inventory is in Jewelry?:  
%
*What % of inventory is in Gold Bullion?:  
%
*What % of inventory is in other items?:  
%
*Please describe other items:  

 Premise Information

*Address:  
*City:  
*State:  
  *Zip: -
*Stock Replacement Value ($):  
*Insurance Amount Desired ($):  
*Construction Type:  
*Other Occupants:  
*Location Type:  
*Location:  
 
*Age of Building (years):  
*Number of Stories:  
*Level Occupied:  
*Miles from Fire Department:  
*Fire Alarm:  
Yes    No
*Smoke Detectors:  
Yes    No
*Fire Extinguishers:  
Yes    No
*Sprinklers:  
Yes    No
*Other Fire Prevention Measures:  

 Alarm System Information

*Central Alarm System:  
Yes    No
*Hold-up Buttons:  
Yes    No
*Dedicated Phone Line:  
Yes    No
*Motion Detectors:  
Yes    No
*Video Cameras:  
Yes    No
*Security Guard:  
Yes    No
*Steel Gates:  
Yes    No
*Buzzer Entry:  
Yes    No
*Safes wired to the Central Station:  
Yes    No
*System Type:  
*UL Rated Certificate:  
Yes    No

 Safe and Vault Information

*Number of Safes:  
*UL Ratings:  
*Stock % in locked safe when open:  
*Stock % in locked safe when closed:  
*Construction of vault:  
*Vault rating or class:  
*Vault wired to central station:  
Yes    No
*Are the safes stored in the vault:  
Yes    No

 Bank Information

Bank 1

*Bank Name:  
*Street:  
*City:  
*State:  
  *Zip:
*Replacement Value ($):  
*Insurance Desired ($):  

Bank 2

Bank Name:  
Street:  
City:  
State:  
  Zip:
Replacement Value ($):  
Insurance Desired ($):  

 Transit Information

*Replacement value taken to shows & buying/selling trips:  
*Insurance Desired for stock taken to shows & buying/selling trips:  
*Number of days away during last 12 months:  
*Number of days away expected during next 12 months:  
*Insurance Desired on property in transit within a 25 mile radius of premises:  
*Is a 25 mile radius sufficient for local transit coverage?:  
Yes    No   
If no, how many additional miles:

 Loss Information

Loss 1

Type of Loss within last 5 years: 
Amount of Loss: 
Date of Loss: 
Loss Payee Name: 
Loss Payee Address: 

Loss 2

Type of Loss within last 5 years: 
Amount of Loss: 
Date of Loss: 
Loss Payee Name: 
Loss Payee Address: 

 SUBMIT completed Application for approval

I hereby authorize my alarm company to release any details regarding the qualifications of my alarm system to the North American Collectibles Association for the purposes of obtaining premises insurance. Signing this application and declaration does not bind the applicant or the insurance Company to complete the insurance, but it is agreed that this application and declaration shall constitute a warranty should a policy be issued. I have read the above and agree that to the best of my knowledge and belief it represents a true and complete statement.
*Applicant Signature:  
Date: 
03/27/2023
Effective date requested, if acceptable: