Business Owners Supplement Business Owners Supplement PDF Download Business Owners Supplement Specified Professions Professional Liability Product BUSINESS OWNERS SUPPLEMENTAL PACKAGE ADDENDUM If you DO NOT currently carry general liability and/or property insurance with United States Liability Insurance Group and would like a quotation, please complete the following questions:Applicant Name:* Prefix First Last Suffix Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Has the applicant had any general liability claims paid, reserved or pending in the last five years?*YesNoIf “Yes,” please provide details:2. Additional insured(s) to be included on general liability:*Name:Relationship to ApplicantAddress: Please use the + button to the right to add additional Insured(s)3. Personal property limit, including computer hardware (at 80% coinsurance/replacement cost):*4. Building Characteristics: (a) Are functioning burglar alarms present?*YesNo(b) Is the electrical system connected to circuit breakers?*YesNo(c) Are functioning smoke detectors and fire alarms present?*YesNo(d) Is aluminum wiring present in the building?*YesNo5. Has the applicant had any property claims paid, reserved or pending in the last five years?*YesNoIf “Yes,” please provide details:This supplemental application is subject to the same provisions concerning representations made in the general application originally submitted to obtain professional liability insurance.Signature:*(Principal, Partner or Officer)Title:*Date:* Date Format: MM slash DD slash YYYY This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws. This iframe contains the logic required to handle Ajax powered Gravity Forms.