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?* 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.
