Jewelers Block Application
Policy number:

Account number:

Expiration date:

Part A – General Information

1.	Applicant:

(Include all operating names and subsidiaries that will be covered.)

2.	Described premises:

(floor)	(street address/suite or room number)

(city)	(state)	(ZIP)

(county)

3.	Type of business based on sales:	Retail	%	Repair	%	Wholesale	%	Manufacturing	%

Other	%

4.	The names and titles of principals or officers:

5.	Give names and addresses of other jewelry businesses or locations owned or managed by principals or officers listed in Part A.4.:

Part B – Previous Insurance And Prior Loss Experience

1.	Have you ever been refused any business insurance or had business insurance cancelled for any reason?

(An answer to this question is not required by Missouri applicants.)

Yes No If yes, explain:

2.	Provide loss information, whether insured or not, for the past five years.

Described

Premises

Location

Type of Loss

Jewelers Block

Date of

Loss

Loss

Incurred

Loss

Collected

Policy number:

Expiration date:

Part C – Inventory

1.	Do you take a complete, written, physical inventory of all your stock at least once a year? Yes No

Date last taken:	Exact total: $

2.	Your previous complete, written, physical inventory of all your stock was taken on:

(date must be at least six months prior to Part C.1.); Exact total: $

3.	The maximum value of all your stock during the last 12 months did not exceed: $

4.	Do you maintain detailed records of other people’s property? Yes No The estimated average daily amount of other people’s property in your custody or control during the last 12 months was:

a.	$	on customers’ property; and

b.	$	on memorandum/consignment property.

5.	Do you handle pawned property? Yes No

a.	Do you desire coverage for pawned property? Yes No

If yes, complete Pawned Property Schedule, JB503.

6.	The breakdown of property from your last complete, written, physical inventory is:

a.	Loose diamonds	%

b.	Other loose stones, pearls, mounted jewelry, precious metals, watches, and other jewelry

1)	valued at $300 or more per item at your cost	%

2)	valued at less than $300 per item at your cost	%

c.	Silverware, pewterware, and other giftware	%

d.	All other stock, describe:	%

Total must equal 100%	%

7.	Is any non-jewelry inventory to be excluded from theft coverage? Yes No

If yes, provide Part C.6. item letters:

8.	Is any non-jewelry inventory to be excluded from insurance? Yes No

If yes, provide Part C.6. item letters:

Part D – Exposure Information

1.	Off Described Premises:	Exposure

a.	The total value of property shipped during the last 12 months (exceeding the shippers

limit and deductible) was:

First-Class Registered Mail through the U.S. Postal Service in

excess of any coverage purchased from the U.S. Postal Service	$

2)	Express Mail through the U.S. Postal Service in excess of any

coverage purchased from the U.S. Postal Service	$

3)	Armored car service	$

4)	Specified private, paid delivery service, or other contract or common carrier

a)	$

b)	$

c)	$

5)	Unspecified private, paid delivery service, or other contract or common carrier	$

b.	The estimated daily average value of property in the custody of jewelry dealers, including

appraisers and repairers, or out on consignment or memorandum, during the last

12 months was:	$

Policy number:

Expiration date:

Part E – Security Information

1.	Are all of your display cases and/or show windows equipped with key locks? Yes No

If no, explain:

2.	Number of show windows: How are they protected against forcible entry?

3.	Is your described premises protected by an operating burglar alarm system when closed to business?

Yes No

4.	Name of your premises alarm service company:

Is it a UL listed alarm service company? Yes No

If yes, provide the UL Certificate number(s):	Expires:

5.	Safe(s) (all must be described)

Safe: 1

a.	Manufacturer’s name:

b.	Model name and number:

c.	Fire/burglary rating:

d.	Is safe located within a vault?	Yes No

e.	Safe alarm

1)	Alarm company name:

2)	UL Certificate number:

3)	Expires:

f.	During the term of the policy, the

minimum proportion by value of

property covered on premises that

will be kept in this locked safe at all

times when closed to business is:	%	Safe: 2

Yes No

%

Safe: 3

a.	Manufacturer’s name:

b.	Model name and number:

c.	Fire/burglary rating:

d.	Is safe located within a vault?	Yes No

e.	Safe alarm

1)	Alarm company name:

2)	UL Certificate number:

3)	Expires:

f.	During the term of the policy, the

minimum proportion by value of

property covered on premises that

will be kept in this locked safe at all

times when closed to business is:	%	Safe: 4

Yes No

%

6.	Do you have a vault? Yes No If yes, complete Application Supplement, Part E.6., JB508.

Policy number:

Expiration date:

Part F

Kentucky, North Carolina: All statements or descriptions are deemed representations and not warranties. A misrepresentation, unless material or fraudulent, will not prevent a recovery under the Jewelers Block policy. The signing of this application does not bind the company to issue a policy, and I am not bound to accept one. However, should a policy be issued, I represent that the statements made in this application and any application supplements are true, and acknowledge that the acceptance and pricing of the policy is based on these statements. A copy of this application and any application supplements will be attached to and made part of the policy. If these statements are not true, this policy shall be void, and there shall be no coverage.

Alaska, Louisiana, New Hampshire, New York: The signing of this application does not bind the company to issue a policy, and I am not bound to accept one. However, should a policy be issued, I represent that the statements made in this application and any application supplements are true, and acknowledge that the acceptance and pricing of the policy is based on these statements. A copy of this application and any application supplements will be attached to and made part of the policy. If I have made any false statements or misrepresentations on the application, coverage for a claim may be denied.

All Other States: The signing of this application does not bind the company to issue a policy, and I am not bound to accept one. However, should a policy be issued, I warrant that the statements made in this application and any application supplements are true, and acknowledge that the acceptance and pricing of the policy is based on these statements. A copy of this application and any application supplements will be attached to and made part of the policy. If these statements are not true, this policy shall be void, and there shall be no coverage.

Fraud Warning – Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

Fraud Warning – Louisiana, Maine, Ohio, Tennessee, Virginia, West Virginia: Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, is guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits.

Fraud Warning – New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Fraud Warning – New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Fraud Warning – Oklahoma: Any person who knowingly and with intent to injure, defraud, or deceive an insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information, is guilty of a felony.

Fraud Warning – Oregon: Any person who knowingly conceals or provides materially false, incomplete, or misleading information on an application or concerning a claim to an insurance company for the purpose and intent of defrauding the company, may be guilty of insurance fraud in violation of state law. Penalties may include imprisonment, fines, or denial of insurance benefits.

Fraud Warning – All Other States: A fraudulent act, which is a crime, is committed when a person knowingly and with intent to defraud or mislead; (1) files an insurance application containing any false information, or

(2) conceals information concerning any material fact.

Signature of Applicant
Title
Date

Jewelers Block

Requested Coverage Limits

1.	On The Described Premises Location #

Address

Limit of insurance – The limit of insurance shown is the most we will pay for any one loss.

Limit of

Insurance	Deductible

a.	Stock (Including customers’ and memorandum/consignment

property and samples)	$	$

1)	Peak season additional stock limit of insurance:

a)	From	Through	$	$

b)	From	Through	$	$

c)	From	Through	$	$

b.	Show window(s)

1)	Closed to business	$	$

2)	Open to business	$	$

c.	Patterns, molds, models, and dies	$	$

d.	Your interest in tenant’s improvements	$	$

e.	Furniture; fixtures; safes; modular vaults; machinery, tools and

their parts	$	$

f.	Money and securities safe burglary/robbery	$	$

1)	Peak season additional money and securities limit of insurance:

a)	From	Through	$	$

b)	From	Through	$	$

c)	From	Through	$	$

2.	Off All Described Premises

Limit of insurance – The limit of insurance shown is the most we will pay for any one loss.

Limit of

Insurance	Deductible

a.	In transit by:

1)	First-Class Registered Mail through the U.S. Postal Service in

excess of any coverage purchased from the U.S. Postal Service	$	50,000	$	Zero

2)	Express Mail through the U.S. Postal Service in excess of any

coverage purchased from the U.S. Postal Service	$	25,000	$	Zero

3)	Armored car service	$	$

4)	Specified private, paid delivery service or other contract or

common carrier

a)	$	$

b)	$	$

c)	$	$

5)	Unspecified private, paid delivery service or other contract or

common carrier	$	$

b.	In the custody of jewelry dealers not included in 2.d. This does not

include property covered while entrusted to another jewelry dealer for

safekeeping by someone covered in 2.d.	$	$

c.	In the safe or vault of a bank, trust or safe-deposit company	$	$

d.	Property in the custody of you, your employee, a commissioned

salesperson, or a person you hire for a short time when traveling off

the described premises:

1)	The most we will pay for any one loss involving an individual is

the limit listed below or	$	25,000	$

a)	You, your employees, or a person you hire for a short time

who carry property valued at more than $25,000:

Name, City, State, ZIP

$	$

$	$

b)	Individuals carrying a jewelry line (commissioned salespeople)

valued at more than $25,000:

Name, City, State, ZIP

$	$

$	$

2)	The most we will pay for any one loss involving two or more

individuals traveling together is the lesser of the sum of their

limits or	$	$

e.	Otherwise away from any described premises and not included in

2.a., b., c. or d.	$	$

Underwriting Questionnaire
Policy number:

Location number:

General Information

1.	Proposed effective date:	(No coverage is bound unless authorized by the company.)

2.	Doing business as:	Sole-Proprietor Partnership Corporation Joint Venture

Limited Liability Company Other

3.	What type of payment plan do you want for this insurance policy?

Full Three Pay Four Pay Eight Pay

4.	Applicant’s phone number: ( )	Contact person:

Web address:	E-mail address:

5.	Mailing name, if different than the applicant:

6.	Mailing address, if different than the described premises:

7.	How long have you been in business at this address?	If less than two years,	provide previous

address:

8.	Do you share your premises with others? Yes No If yes, provide name and nature of their business:

9.	Your usual business hours are:

10.	Loss payee (jewelry stock):

Address:

Rating Information

1.	Building construction:

Fire resistive

Masonry/noncombustible

Noncombustible

Joisted masonry

Frame

2.	Protection class:

Protected

Partially protected

Unprotected

3.	Number of floors:

4.	Number of floors occupied by the applicant:

5.	Year of construction:

6.	Building square footage:

7.	Square feet occupied by the applicant:

8.	Completely sprinklered? Yes No

9.	Premises smoke detectors? Yes No

10.	Dates if premises remodeled:

a.	Electrical

b.	Plumbing

c.	Heating

11.	Annual sales: $

12.	Type of location:

Enclosed mall

Strip mall

Downtown (not mall)

Free-standing (not downtown)

Dwelling

Other

13.	Describe adjacent occupancies:

14.	Have you ever had a jewelers block policy?

Yes No

If yes, provide the following:

Year	Company	Premium

General Security Information

1.	Do you maintain any of the following operating surveillance systems on your described premises while open to business? Cameras: Yes No CCTV with monitors: Yes No CCTV with VCR: Yes No

2.	Are all of your display cases or show windows kept key locked during business hours, except when stock is being removed or replaced? Yes No

3.	Do you have an armed uniformed guard? Yes No If yes, when?

4.	What is the total value of merchandise displayed in show windows while open to business? $

5.	Do you have a fire alarm system? Yes No Is it monitored? Yes No

If yes, where?

6.	Do you have double-cylinder dead bolt locks on all exterior exits? Yes No

7.	Who, other than an employee or officer of the company, has the ability to deactivate your alarm system?

8.	Are you called when there is an alarm at your business? Yes No If no, explain why:

9.	What is the least number of employees, officers or owners customarily on your described premises at any time during business hours or when opening or closing for business?

10.	Other security information:

Alarm System Information

11.	Does your described premises have a holdup alarm system? Yes No If yes, describe the type of system:

12.	Does your described premises have motion detection? Yes No If yes, does the motion detection cover the following areas?

a.	Safe/vault area: Yes No

b.	Alarm control panel area: Yes No

c.	Areas where inventory is kept out of safe while closed to business: Yes No

13.	Where is the alarm system monitored?

14.	Are opening and closing signals monitored? Yes No

15.	What is the method of alarm transmission (indicate all methods)?

Derived channel Digital communicator Multiplex Two-way radiowave

One-way radiowave Cellular Other

16.	Is there: No line security Standard line security Encrypted line security

17.	If your safe/vault alarm protection is different than numbers 13-16 above, provide details:

18.	Indicate how each safe/vault is alarmed (no protection, partial protection, complete protection):

19.	Is there an annual maintenance contract for the alarm system? Yes No If no, explain:

1

JB001 Ed 07-05	© 2005 Jewelers Mutual Insurance Company

2

UQJB 07-05	© 2001 Jewelers Mutual Insurance Company

LIMITSJB Ed 07-05	© 2005 Jewelers Mutual Insurance Company

UQJB 07-05	© 2005 Jewelers Mutual Insurance Company

sue diehl

2005-06-07

krowe

Jewelers Mutual Insurance Co.