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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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?* Yes No If “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?* Yes No (b) Is the electrical system connected to circuit breakers?* Yes No (c) Are functioning smoke detectors and fire alarms present?* Yes No (d) Is aluminum wiring present in the building?* Yes No 5. Has the applicant had any property claims paid, reserved or pending in the last five years?* Yes No If “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:* 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.
