North Carolina Office:

Fax 336-584-8880 COMMERCIAL

Florida Office: PACKAGE
Fax 727-572-7909
New York Office: APPLICATION
Fax 516-741-2879
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Texas Office:
Fax 336-584-8880
California Office:
1-800-334-5579 ACCT ID:____________
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Fax 714-542-0815 www.GoTAPCO.com

Darul Arqam School

Insured Name (as it should appear on the policy): _________________________________________________________________________________
(Please include any Doing Business As, Trading As, Care of, Trustee, Executor, or Estate of names.)
8 Thomas Street South River, NJ 08882
Mailing Address: _______________________________________________________________________________________________________
8 Thomas Street South River, NJ 08882
Location of Risk: ________________________________________________________________________________________________________
Private School
Type of Risk/Occupancy: _________________________________________________________________________________________________
12/4/2017
Proposed Effective Date: From________________________ 12/4/2018
To __________________________ 15
Years in Business:__________________
PROPERTY SECTION
Exposure Amount Requested Coinsurance % Valuation/ACV/RCV Deductible
Building #1 $ $
Business Personal Property #1 $ 200,000 80% RCV $ 500
Business Income #1 $ $
Building #2 $ $
Business Personal Property #2 $ $
Business Income #2 $ $
Other $ $

PERILS: [✔] Basic [ ] Broad [ ] Special Excluding Theft [ ] Special Including Theft (Central Station Alarm Required)
Central Station Burglar Alarm: [ ] Yes [✔ ] No CRIME: $______________________________________
500
WIND & HAIL DEDUCTIBLE: $______________________________ THEFT SUBLIMIT: $ __________________________________________
joisted masonry 4 56000
Construction: _________________ Protection Class:____________________ Square Footage: _____________________________________
1910 3
Year Built: _________ No. Stories: ___________ Protective Devices: ___________________________________________________________
2017 2017
Building updates (include year): Wiring?_______________Heating?_____________ 2013
Plumbing?______________ 2014
Roof? ________________
alarm
Fire Alarm: [✔] Yes [ ] No If yes, type: _____________________________________________________ Sprinklered: [✔] Yes [ ] No
If restaurant on premises, is there an Ansul system in place? [ ] Yes [✔] No Service agreement in place? [ ] Yes [ ] No
n/a
Mortgagee or Loss Payee - Name/Address/Loan # if applicable: ______________________________________________________________
_______________________________________________________________________________________________________________________

GENERAL LIABILITY SECTION

Applicant is: [ ] Individual [ ] Corporation [ ] Partnership [ ] Joint Venture [✔] Other (Specify)_____________________
LLC

LIMITS OF LIABILITY REQUESTED

General Aggregate $ 2,000,000
Products & Completed Operations Aggregate $ 1,000,000
Personal & Advertising Injury $ 1,000,000
Each Occurrence $ 1,000,000
Damage to Premises Rented to You $ 100,000
Medical Expense (any one person) $ 5,000
Other Coverages, Restrictions, and/or Endorsements $
Deductible $

n/a
Additional Insured (include Name/Address): _______________________________________________________________________________
Interest of Additional Insured:____________________________________________________________________________________________
NONE NONE