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PARTIAL COMPLETE SMNA DATE (MM/DD/YYYY) AGENCY PHONE APPLICANT (A/C, No, Ext): FAX (A/C, No): PROPOSED EFF. DATE PROPOSED EXP. DATE BILLING PLAN PAYMENT PLAN AUDIT FOR COMPANY USE ONLY : E D O C B U S : E D O C AGENCY CUSTOMER ID S S E N I S U B F O N O I T A C I F I S S A L C S R E L K N I R P S N O I T C U R T S N O C G N I D L I U B ADDRESS OR LOCATION SECTION OF BUILDING FIRE CONTENTS RATE % SAFE/VAULT/RECEPTACLE MANUFACTURER LABEL CLASS DOOR TYPE COMBINATION LOCKS THICKNESS DOOR ROUND SQUARE OUTER INNER CHEST CONSTRUCTION S D R O C E R E T A C I L P U D F O N O I T A C O L T P E K S D R O C E R D O I R E P T P E K S D R O C E R E T A C I L P U D % OF RECORDS : DUPLICATED YES NO S D R A U G # : Y B D E C I V R E S D N A D E L L A T S N I M R A L A ALARM TYPE ALARM DESCRIPTION EXTENT OF PROTECTION WATCHPERSONS: GRADE SAFE/VAULT PREMISES #WATCH PERSONS N O I T C E T O R P R E H T O N O I T C E T O R P & S G N I N E P O E L B I S S E C C A CERTIFICATE NUMBER EXPIRATION DATE: LIMITS: CHECK ONE S N O I T A C O L L L A T A Y T R E P O R P D E R E V O C L L A T I S N A R T N I S E S I M E R P R U O Y T A T O N S E S I M E R P R U O Y ENTER THE AMOUNT OF RECEIVABLES OUTSTANDING AS OF THE LAST FISCAL DAY OF EACH OF THE MONTHS IMMEDIATELY PRECEDING THE DATE OF THIS APPLICATION. MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE $ $ $ $ $ $ $ $ $ $ $ $ STATE PERCENTAGE OF TOTAL MONTHLY ACCOUNTS RECEIVABLE CURRENTLY UNCOLLECTABLE ACCOUNTS (Past Three Years) REPRESENTED BY DEFERRED PAYMENT ACCOUNTS. $ $ $ EXPLAIN ALL "YES" RESPONSES. REMARKS AGENCY DIRECT % G N I R U T C A F U N A M % L I A T E R S E Y % E C N A R U S N I % E L A S E L O H W O N (ACORD 125) UL WALL (EXCL. BOLTWORK) HOLD-UP LOCAL GONG RPT/CENT. ST 3 2 1 N O I T A T S L A R T N E C S E S I M E R P CLOCK HRLY SAFE POLICE CONNECT DONʼT SIGNAL (Fences, Floodlights, ETC.) WITH KEYS REPORTING NON-REPORTING (Including Branches) : R A E Y : R A E Y : R A E Y YES NO 2. ARE BILLED AND UNBILLED RECORDS KEPT SEPARATE? YES NO O N S E Y ? N O I T A C O L Y N A T A G N I D O O L F N E E B E R E H T S A H . 3 ? D E S U M E T S Y S G N I T N U O C C A " G N I L L I B E L C Y C " S I 1 LOCATION OF RECORDS / PROTECTION POLICY INFORMATION HISTORY OF RECEIVABLES GENERAL INFORMATION ACCOUNTS RECEIVABLE

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Page 1: (MM/DD/YYYY) AGENCY PHONE APPLICANT FAX PROPOSED …certificate number expiration date: limits: check one your premises not at your premises in transit all covered property at all

PARTIAL

COMPLETE

SMNA

DATE

(MM/DD/YYYY)

AGENCY PHONE APPLICANT(A/C, No, Ext):FAX(A/C, No):

PROPOSED EFF. DATE PROPOSED EXP. DATE BILLING PLAN PAYMENT PLAN AUDIT

FOR COMPANY USE ONLY

:EDOCBUS:EDOCAGENCY CUSTOMER ID

SSENISUB FO NOITACIFISSALCSRELKNIRPSNOITCURTSNOC GNIDLIUB

ADDRESS OR LOCATION SECTION OF BUILDING FIRE CONTENTS RATE

%

SAFE/VAULT/RECEPTACLE MANUFACTURER LABEL CLASS DOOR TYPE COMBINATION LOCKS THICKNESSDOORROUND SQUARE OUTER INNER CHEST

CONSTRUCTION

SDROCER ETACILPUD FO NOITACOLTPEK SDROCER DOIREPTPEK SDROCER ETACILPUD % OFRECORDS :DUPLICATEDYES NO

SDRAUG#:YB DECIVRES DNA DELLATSNI MRALAALARM TYPE ALARM DESCRIPTION EXTENT OF PROTECTION WATCHPERSONS:GRADE

SAFE/VAULT PREMISES#WATCH

PERSONS

NOITCETORP REHTONOITCETORP & SGNINEPO ELBISSECCA

CERTIFICATE NUMBER

EXPIRATION DATE:

LIMITS: CHECK ONE

SNOITACOL LLA TA YTREPORP DEREVOC LLATISNART NISESIMERP RUOY TA TONSESIMERP RUOY

ENTER THE AMOUNT OF RECEIVABLES OUTSTANDING AS OF THE LAST FISCAL DAY OF EACH OF THE MONTHS IMMEDIATELY PRECEDING THE DATE OF THIS APPLICATION.

MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE MO./YR. ACCOUNTS RECEIVABLE

$$$$

$$$$

$$$$

STATE PERCENTAGE OF TOTAL MONTHLY ACCOUNTS RECEIVABLE CURRENTLY UNCOLLECTABLE ACCOUNTS (Past Three Years)REPRESENTED BY DEFERRED PAYMENT ACCOUNTS.

$$$

EXPLAIN ALL "YES" RESPONSES.

REMARKS

AGENCY

DIRECT

%GNIRUTCAFUNAM%LIATERSEY

%ECNARUSNI%ELASELOHWON

(ACORD 125)

UL WALL(EXCL. BOLTWORK)

HOLD-UP LOCAL GONG RPT/CENT. ST

321NOITATS LARTNECSESIMERP CLOCK HRLY

SAFE POLICE CONNECT DONʼT SIGNAL(Fences, Floodlights, ETC.)WITH KEYS

REPORTING NON-REPORTING

(Including Branches)

:RAEY:RAEY:RAEY

YES NO 2. ARE BILLED AND UNBILLED RECORDS KEPT SEPARATE? YES NOONSEY?NOITACOL YNA TA GNIDOOLF NEEB EREHT SAH.3?DESU METSYS GNITNUOCCA "GNILLIB ELCYC" SI1

LOCATION OF RECORDS / PROTECTION

POLICY INFORMATION

HISTORY OF RECEIVABLES

GENERAL INFORMATION

ACCOUNTS RECEIVABLE

Page 2: (MM/DD/YYYY) AGENCY PHONE APPLICANT FAX PROPOSED …certificate number expiration date: limits: check one your premises not at your premises in transit all covered property at all

PARTIAL

COMPLETE

BUILDING CONSTRUCTION SPRINKLERS

ADDRESS OR LOCATION SECTION OF BUILDING FIRE CONTENTS RATE

%RECEPTACLES IN WHICH PROPERTY IS KEPT AT ALL TIMES WHEN PREMISES NOT OPEN FOR BUSINESS

SAFE/VAULT/RECEPTACLE MANUFACTURER LABEL CLASS DOOR TYPE COMBINATION LOCKS THICKNESSDOORROUND SQUARE OUTER INNER CHEST

CONSTRUCTION

SDRAUG#:YB DECIVRES DNA DELLATSNI MRALAALARM TYPE ALARM DESCRIPTION EXTENT OF PROTECTION WATCHPERSONS:GRADE

SAFE/VAULT PREMISES#WATCH

PERSONS

NOITCETORP REHTONOITCETORP & SGNINEPO ELBISSECCA

CERTIFICATE NUMBER

EXPIRATION DATE:

LIMITSYOUR PREMISES AWAY FROM YOUR PREMISES OCCURRENCE DEDUCTIBLE CAN PAPERS BE REPLACED?

# DESCRIPTION OF PAPERS SPECIFIED AMOUNT

$

$

$

$

$

$

$

$

$

YES NO

(ACORD 125)

UL WALL(EXCL. BOLTWORK)SMNA

HOLD-UP LOCAL GONG RPT/CENT. ST

321NOITATS LARTNECSESIMERP CLOCK HRLY

SAFE POLICE CONNECT DONʼT SIGNAL(Fences, Floodlights, ETC.)WITH KEYS

BLANKET AMOUNT

SPECIFIED AMOUNT $ YES NO

SEE ATTACHED LIST

LOCATION

LOCATION OF RECORDS / PROTECTION

POLICY INFORMATION

PAPERS

REMARKS

VALUABLE PAPERS


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