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<br />I' U~INI:::S:S - ~ ~i>rogram: D ,.,¡..:c.,.tU8ISIMce 0 STATe FARM Af\£ AND CASUALTY COMPANY-8Ioo";ington, IL -1'_"'" "'.
<br />IN THE HOME 0 Mi8c8I-- 0 STATE FAIl.. GENERAL INSURANCE COMPANY.8100ming1lDn, IL
<br />APPUCA TIOH ~()ffice 0 STATE FARM LLOYOS-Oel188, Tex..
<br />
<br />J :11.-;--:"';-:"-- 1~I7\oc ,- l-q'j" \0\ I"~ë:?'-~~y()-\
<br />~~~;ørint('."' lr1ïc.h~Ft', \. 'I~N ....,- --..- l~~~'7- (-/(
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<br />.. ^. II 01.... /) !\. ""'" T~_~, -, ..'.' ~H
<br />:¡DIBIA (~:a,:}..I-1.^(,,>'r~-x ~\':::.ÇJl)Q..~A\";';~ f k"' ):(7.~,",' "'~ bUS
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<br />~ Mailing_.... q¡.ID -::5m,nt .Lr<. Oot;JJ!'ì'I~I.!....IMA. ('Ã Cfé;fï!.:2. i~.:"J-.'" i/': ,w,
<br />CL
<br />. L.DcaliOnot-- ~, ('" .-\
<br />Thenemod ¡"""": - : -, ( Nol-' ,------- IQlherSI8I8 FlllTlinou.._, 0 Aut
<br />oøølicenll8:: IÅ ¡ :: ,-"'----"-1' 0
<br />----
<br />~ 0 ~~o 0 Nomad AcId'1lnourod
<br />¡ -.-
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<br />. !I/O'" 0 ~~ 0 Nomad Add'ilnsurod
<br />~ -.......
<br />
<br />J Ronowal bßlI: tJ ')nour8d 0 SFPP . AcoouIIt Number
<br />iii End""'Lblllo: rið:1n1U'Od OSFPP.AcoounINumbor
<br />
<br />1. Desçr\be the applicant's business activities (a) on premises
<br />and (b) 011 premises. What percenlage of business is
<br />conducted off premises? - %
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<br />~A.1. ~ !
<br />
<br />1n"_Ioo% "--- of'" foItDWtn ÞU8In.1 plr80". propony
<br />
<br />M8fCh8ndiM (Alleragot Monll>1y In\I8IItory) S ~-
<br />'Owned/l.8aeec1 BUlin.. Fwn~..... "Equipment S 00:::> cO
<br />~ ProperlY of OIIIell S -.-
<br />Other Bueine.s Supplies + S ~
<br />Total Business Pel'8Ol'lal Property: S ~
<br />
<br />Deductible: Dl$250 0 S!OO 0 $1000 0 Other
<br />
<br />A. ~~: .;:~::~ ~eplac8menl Cost" ('i /11
<br />
<br />"Al\8ch a Commercial ColI Gukle and photo il detached buildings are
<br />used lor buslnesa purpoeu and will be insured under this policy, List
<br />- c:onottuctìon IYP8 01 the detached buildInG.
<br />2. Doe, the applicant's business meet all CLM Basie r¿' No !oj B. Bullnl. Peraonal ProperlY' Form 3, Replacement Cost.
<br />Underwriting Guide and CMP Program Underwriting. 0 IX Unlit oIll18UfIlllCll (from III section) S LP, (')ùO; úÙ
<br />Guide Standards? (If no, eq#8/t1 ", RamørllS) ~ 0 Exdude Theil
<br />3. Has the applicant had any los"s (other than owned C. Loas oIlnc:ome . Actual LoIs Sustained
<br />auto) In \he past three yeant? (1/ ,.,.lIItrllf8. tocaUØn. O..l...t' 0 (no. I_ding 12 coneecutIve months)
<br />MH, iMUf8r 8I"Umoum 01- in FløwlaJ ~ u L Buelnesa LiabIlity ~
<br />4. How long has the applicant ~ Each Ocourrencll $ 3OD.000 Other /,(JOt),; O()(')
<br />owned and operated this business? L"J . yrs. NOTE: The an_I aggregate and ProductalCompIeted OperaUoI18
<br />AMual Gross SalesIRecelpta: ~ aggregate ØmlIS are ttqu811o 2 lima the oocurrenoe limit. Raler to the
<br />III CLM for cltta8if1C8llon8 which require rnanctalOry endorsemenIA or
<br />Square Footage ot business area within the home: exclusions. 0
<br />I Dellll Produ~lel8d Operations
<br />5. Are other business locations OV.. % 0 Dele" PlrsonaIln ury/Advertising Injury
<br />owned or leased by the appHcant? M. Medical Peymenta . Each p.,. n $5000
<br />(lfyn.I/!iI~....ynol"'UI«I) 80
<br />§! . Çi Ust any Optional OOverage. desired:
<br />= 6. Ate the~ other business operallOl18 conducted by O. eo.e..go Limit of 1-
<br />the applicant? (N)'N. fJtP8ìn in 111_) i i ' ' ----to..! ~
<br />7. Do employees use their own vehiCle, tor business .1 O§ =88IY ~ S
<br />purpoees? (1/,." ØlI- * - 0I8III /OyH - Q % B8Ib8tlBeeUly Professional $
<br />~~II8U~ ~ OIII.~ S
<br />Nu/flber of emplOyet8: . - . , ,., --..-." ,...1: -- .......
<br />8, If there are employees, c;omplet8 the following: :
<br />N.... 01 I!rnployel Job ow. _I Componoation
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<br />9. Doss the applicant sell, rebollle, repackage or
<br />manufaCtUre products under (a) the applicant's
<br />own label or (b) the label of a Iranchisor under
<br />whose neme the applicant does business? 2
<br />(H - øo not bind ~1«l."..,.1IIw~, PfP'Iid8 1M /lime ~
<br />8IIf1 - 01- pIDd J(;f in R_J. ~
<br />
<br />10. Premises Inspected on~by #,i)~):" b-../",
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<br />I unctersl8nd lhat: '1tJ InIuranoe 18 In Iorc8 .. oIlhe en80tiv8 date shown
<br />. "\ 8ÞoIfe.
<br />I 0 in8U18IIO8 18 not In Iorœ. "~by s- ~arm's
<br />~ Underwrillng Oepenmlnt, in8U- wig be in ,- as
<br />J of a mutuel1y eg-4 upon dale.
<br />I ~1on~~ ~ft .::~ :::m:, i=:Wc: ..::
<br />oomplt wI~ -,!'! Farm's N1e8 end .... 8I!C\ 7" ~8d,
<br />=.~ ","'" ~/?JlIl) ~
<br />
<br />535-.'0.1 ..,... ......
<br />.
<br />
<br />D"-
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<br />0 UtI ß1' Fire 0 Halllh 0 None
<br />UNDERWRITING
<br />USlCNLY
<br />Appt- By Dalo
<br />
<br />GFU Code
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<br />D..
<br />
<br />...-
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<br />p,.-
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<br />Slat Claes Code X I" ot..
<br />Number of Real Estate Aganœ, Engineers, ArchiteCls ~ BarberI
<br />'- Beautidana Inçludlnp.owner(s). paM'IB, officere:
<br />Construction Type J-C.:AM l!- Year Bulh 1'17 h
<br />ProtectiOn CIäia . .:) Zone Q1,
<br />If hOme Is not inside city limits, show distance
<br />from city limite
<br />FIre Hydrants within 1000 ft? ~y.. DNa
<br />Distance to primary servicing fire departm~~ mi.
<br />Name of primary servicing ~re Øepa¡tment an'øior .
<br />servicing tire distriot /,,- III I Ii ,1.. ,'- .......:."
<br />Does the area used for business purpoaea have any of the
<br />foHowing protectille devlca8?
<br />0 LoceI burglar &Iemt. Manufactured by
<br />0 Fire or 8/IIOI(e cenll8l 8IaIion alarm. MoNtot8d by
<br />0 Centr8I Slation tlulglar RIIIIm. Monilored by
<br />
<br />",
<br />
<br />Basio PremiUm (from CLM TabI8l1-4)
<br />Premium alter CredltslCharges
<br />0pII0na/Endarae1ll8llt8 Premium
<br />
<br />TOI8I Bu8lneu Policy Premium
<br />Arnounl PItid
<br />Balance Due
<br />
<br />S
<br />$
<br />:~. 00
<br />$ IS-In. 00 C~... ~
<br />-0.- I
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<br />. A9¿;oq~ ~~ 7
<br />
<br />Dati 8nd TIm, 01 AppbtiÓn
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<br />"1:/ I it lâ~
<br />/.'00
<br />Hour Õ 'ij'
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