Coverage Placed with US Plate Glass Insurance Company

G L A S S A P P L I C A T I O N

(Coverage placed with US Plate Glass Insurance Company)

Producer Name:

Agency:

Address: City: ZIP:

Phone: Fax:

APPLICATION

Insured’s Name:

Address of Risk:

Mailing Address (If different):

Occupancy of Risk: Effective Date: Quote Only

Note: Coverage cannot be effective until the risk has been inspected and approved by the company.

Contact Name : Phone No:

The section below pertains to condominium risks. If this is a non habitational risk, please submit a schedule of glass with measurements, if available. If not available, a survey will be performed to determine the glass schedule.

Total number of units in building: Are these Villas or Townhouses? Yes No (Please circle one)

Full (Common area glass and unit glass)

Units up to 1,200 sq. ft. Total number of floors in building:

Units from 1,200 to 3,000 sq. ft. Units with shutters: %

Units from 3,000 to 5,000 sq. ft. Impact Glass:

Units over 5,000 sq. ft. Units: No Yes %

Common Area: No Yes % Please complete application and return. Quote will be faxed to your agency upon receipt from the company.

Best Regards,

Production Underwriter 400 Colonial Center Parkway Suite 100 Lake Mary, FL 32476 www.seacoastunderwriters.com