LAWBIP INSURANCE PROGRAM APPLICATION

Applicant Name: Street Address:
City: Postal Code:
Phone No: Fax No:
How Long in Practice: Type of Law Practiced:
Contact:

E-Mail:

Loss Payee Name & Address:

Loss Payee in respect to (ie: Mortgage, Equipment):

Any Clains in last 3 Years:


 Yes No, Explain

 

Please provide the following information on the building you operate from:

Year Built: Number of Stories:
Exterior Wall Construction Frame Brick Concrete
Building Roof Construction Frame Steel Concrete
Is the building occupied for office use only? Yes No    
Does the building have any Manufacturing or Restaurants in it? Yes No    
Are all Elevators and Stairways enclosed? Yes No    
Does the building have a Fire Sprinkler System? Yes No    
Does the building have a Security System? Yes No    
Is your premises protected by a ULC approved Monitored Alarm? Yes No    
Is the building within 300 yards of a Fire Hydrant? Yes No    
Do you own any Laptop Computers? Yes No    

Provide the limits of insurance required:

Date Insurance Required: 19
Coverage Limit
Replacement Value of Building, (if owned)
Replacement Value of Contents, (including computers & software)
Accounts Receivable Limit, (Max $100,000.00)
Valuable Papers Limit, (Max $100,000.00)
Liability Limit, (Max $500,000.00)
Other:

 

Comments:


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