Kindergarten Registration Form
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1
2CONVENIENCE STORE PROGRAM SUPPLEMENTAL
(Complete in addition to Acord 125)
Acord 125 must include a list of all operations operated and/or leased to others, broken down by square footage
1.
Named Insured: ___________________________________________________________________________________
2.
Location Address: __________________________________________________ Location # ________ (if applicable)
3.
General Information: Number of years in this type of business: _____ Number of years in operation at this location: _____
Hours of operation ________to ________
24 Hours
How many days open a week: _________
Brand name of Gasoline sold: _____________
Total area (square footage) of building: _________
Does the risk have a chain name exposure? (McDonalds, Burger king, Subway, Chester’s etc)
Yes
No
If yes, provide name of establishment: __________________________ Do you operate the operation?
Yes
No
If leased, Are you named as an additional insured on their policy
Yes
No
LPG (Liquid Petroleum Gas) - Coverage $25,000 Occurrence / $50,000 Aggregate – (filing with the RRC)
Any Selling or Swapping of tanks?
Yes
No
Any tanks filled on premises or filled by the applicant off premises?
Yes
No
Are they stored outside the building, encased and protected by barriers to prevent collision?
Yes
No
4.
Financial Information – Annual Figures (estimated for the next 12 months of operations)
Annual Gasoline (Gallons): ___________ Convenience Store Sales: ___________ Deli Sales: ___________
Beer/Wine Sales: ___________
Hard Liquor Sales: ___________
Car Wash Sales: ___________
Restaurant Sales: ___________
Rental Income: ___________
Other: _______________: ___________
Other: _______________: ___________
5.
General Liability Information
a.
Any Auto Repair or Maintenance Operations?
Yes
No If yes, PROHIBITED – See Garage program
b.
If Car Wash Operation exists, provide the following:
Area (Sq Ft) of Car Wash: ________
Attached
Unattached
Fully Automated or
Self-Service
# of Bays: ____________
c.
Area of parking lot: __________ Square feet (estimation acceptable)
d.
Is applicant responsible for Care/Maintenance of lot?
Yes
No
e.
Is parking lot in good repair (smooth driving and walking surface)?
Yes
No
f.
Have there been any health or safety violations?
Yes
No
6 .
Limits of Liability (fire legal 200,000 or 300,000 – must be required by contract – attach copy)
General Aggregate
$500,000
$1,000,000
$2,000,000
Liability Deductibles
Products & Completed/Ops Aggregate
$500,000
$1,000,000
$2,000,000
Bodily Injury (BI)
Personal & Adv. Injury
$500,000
$1,000,000
$0
$250
$500
Each Occurrence
$500,000
$1,000,000
Physical Damage (PD)
Fire Legal
$50,000
$100,000
$200,000
$300,000
$0
$250
$500
Medical Expense (Any one person)
$1,000
$2,500
$5,000
7.
Property Coverage Information
a.
Are there protective barriers/poles surrounding the fuel pumps?
Yes
No
b.
Number of fire Extinguishers ________ Have they been serviced within the past 12 months?
Yes
No
c.
Are there smoke detectors in all common and mechanical equipment areas?
Yes
No
d.
Other Protection(s): (Possible credits)
Sprinkler System – if so what percentage of the building _____%
Fire alarm
if yes,
Central Station or
Local gong
Barriers Protecting Front of Building
Barriers Protecting Entire Building (all sides)
e.
Does Electrical System have aluminum wiring?
Yes
No
f.
Age of roof: ___________(year last replaced)
g.
Type of Roof?
Comp Shingle
Flat Tar & Gravel
Metal
Tile or slate
Wood Shingle
h.
Building - Year originally built: ___________________
Number of Stories:
1
2
3
i.
Updates – If over 25 years old has the building been totally renovated?
Yes
No
j.
Distance to Fire Hydrant: ________ft
Distance to Fire Station: ________ Driving Miles
Cause of Loss:
Basic Form
Special Form (Excl Theft)
Special Form (Theft sub-limit - Excl Tobacco Products)*
$5,000
$10,000
$15,000
_________
Special Form (with Forcible Entry Burglary Coverage Sub-limit)*
$5,000
$7,500
$10,000
_________
Property Enhancement Form (Special Form Only) – See attached highlight sheet – select if desired
VM-CSS-101 (12/06)
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