Section One
1. Name
2. Principal place of business
3. Nature of business  Wholesale  % - Retail  %
4. Peak value of Customers' Property (over all locations) during the preceding twelve months were $ on
5. Locations (all) used for storage of Customers' Property and Highest Values Preceding 12 Months.
 ADDRESS FLOOR BUILDING
OR SECTION		 OPERATED
BY		 HIGHEST VALUES
AMOUNT MONTH
 (1)      
 $

 
 (2)      
 $

 
 (3)      
 $

 
  NOTE: Separate "Description of Storage Enclosure and Location" Rider must be completed for each Storage Enclosure except where storage is at premises NOT operated by Proposer; then it may be ommited unless or until specifically requested by the Company.
6. With respect to storage locations NOT OPERATED BY PROPOSER, specify,
(a) Those at which a separate storage enclosure is maintained for Proposer's exclusive use (this refers to an entire vault or room, not to a stall or other subdivision thereof)
(b) Any which may be in the same building (but under a different street address) with Proposer's principal place of business
7. Name of present carrier of Furriers' Customers Policy (if none state none)
Attaching date of such policy
8. LOSS EXPERIENCE:
(a) Has Proposer, during past five (5) years, suffered any loss, involving Customers' Property?
(b) If so, give full particulars (on separate sheet if necessary) including name of insurer
(c) Has this form of insurance been cancelled or declined by any other company?
     If so, give details

Section Two
1. BASIC POLICY (Custody Form only)                     Monthly Reporting Annual Premium (Non-Reporting)
Limits of Liability
 (a) At Locations where Customers' Property is Stored

Location		 In
Storage Enclosure 		Outside
Storage Enclosure
 (1)  $  $
 (2)  $  $
 (3)  $  $
 (b) At Locations Not Used for Storage:
       Proposer's Premises $   While In Transit $    At Any Other Location $ 
±Note: This Form is available only when limits in 1 (a) above are not less than the aggregate amount of values as set forth in all receipts outstanding as of (the last day of) the peak month during the preceding 12 months (except in the case of a new business) and the aggregate of said limits for all locations used for storage is not more than $100,000, except those which include: Certifications, Certificates or Special Personal Fur Policies or Form B Excess Legal Liability Endorsement.
2. OPTIONAL EXTENSIONS - Check Box, if desired
 (a) Certificates or Special Personal Fur Policies - Form No.
 (b) Excess Legal Liability
                         Limit any one Catastrophe


                         Limit any one garment		 Location
(1)
(2)
(3)
Form A
$
$
$
$
Form B
$ 
$ 
$ 
$ 
 (c) Accrued Charges:

Catastrophe Limit:                            Location 

 unpaid
  prepaid
(1)
(2)
(3)
reporting form
        flat premium basis   
 $
 $
 $

   
    
    

     Signing this Proposal does not bind the Proposer to complete the Insurance, but it is agreed that the information contained herein and in the "Description of Storage Enclosure and Location" Rider(s) attached hereto shall be the basis of the contract should a Policy be issued.  If any of the questions therein have been answered fraudulently, or in such a way as to conceal or misrepresent any material fact or circumstance concerning this Insurance or the subject thereof, the entire Policy shall be void.
     I/We have read the above and the "Description of Storage Enclosure and Location" Rider(s) attached hereto and agree that to the best of my/our knowledge and belief same fully represents the true statement of facts.                                    ***(please initial):
Date:                                                                                                                                                  Title:

 
DESCRIPTION OF STORAGE ENCLOSURE AND LOCATION
(To be attached to Furriers' Customers Proposal)

Description of Storage Location      of                 is as follows:
1.  STORAGE LOCATION GENERALLY:
Construction of Building (i.e. Frame, Brick, Mill, Reinforced Concrete, etc.)
On which floor is storage enclosure located (i.e. basement, first, second, etc.)
2. STORAGE LOCATION AND STORAGE ENCLOSURE
BURGLARY PROTECTION (See Notes 1 and 2 below)
  STORAGE
LOCATION		 STORAGE
ENCLOSURE
(a) Indicate (By Yes or No) whether the following are Protected by An Alarm System Connected With An Outside Central Station    
(1) All Accessible Windows (Except Stationary Show Windows) - - - - - - - - - - - - - - - - - - - - - - - - - -    
(2) All Doors - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(3) All Transoms - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(4) All Skylights - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(5) All Other Openings - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(6) All Ceilings - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(7) All Floors - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(8) All hall, party partition, and building walls (except building walls which are exposed to street or public highway, and except that part of any building walls which is at least two stories above roof of an adjoining building or other structure) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(9) State type, grade and certificate number - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    

(b)
Indicate (By Yes or No) whether the following are Protected by An Alarm System Connected With A Loud Sounding Gong or Siren on Outside of Building and Operated in Conjunction with Watchman Service Described in Section "C" Following		    
(1) All Accessible Windows (Except Stationary Show Windows) - - - - - - - - - - - - - - - - - - - - - - - - - -    
(2) All Doors - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(3) All Transoms - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(4) All Skylights - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(5) All Other Openings - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(6) All Ceilings - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(7) All Floors - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(8) All hall, party partition, and building walls (except building walls which are exposed to street or public highway, and except that part of any building walls which is at least two stories above roof of an adjoining building or other structure) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(9) State type, grade and certificate number - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -    
(c) Watchman Service

STORAGE LOCATION
(1) How many Private Watchmen are maintained, at one time, within the premises - - - - - - - - - - - - - - -  
(2) Are all such Watchmen on duty at all times when premises are not regularly open for business - - -  
(3) If not, when are such Watchmen on duty - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  
(4) Do such Watchmen signal to a Central Station at least hourly - - - - - - - - - - - - - - - - - - - - - - - - - - -  
(5) If not, do such Watchmen register on a Watchmen's Clock, at least hourly - - - - - - - - - - - - - - - - - -  
Note (1) Accessible windows are those windows not more than 18 feet above the ground, or roof of an adjacent building or projection, or from an extension, or from a ledge or fire escape or other structure.  Windows above the first story of the building and which front on a public thoroughfare and which are more than 18 feet above the ground are not considered accessible.
Note (2) A Police Station may be classed as a Central Station provided there is a regular policeman on duty therein at all times.

PROPOSAL FOR FURRIERS BLOCK POLICY
To Be Effected With

Clark Associates

This proposal must be completed and signed in duplicate.  One signed copy, together with supplementary information, if any, will be attached to the policy.
Quotations cannot be given on incomplete proposals.  If the answer to any question is none, state "NONE" or "NIL".

1. a. Our firm or corporation name is
b. The names of the individual members of our firm or of our corporation are
                                                       
                                                       
Fl. Street Address City County State
c.
Our premises are located at
NOTE: IF MORE THAN ONE PREMISES LISTED ABOVE, ALL QUESTIONS WITH THE EXCEPTION OF 2(B) to 2(F) INCLUSIVE MUST BE SEPARATELY ANSWERED FOR EACH.
d. Give names and addresses of any other premises of the Proposer not included in this proposal.
e. Losses: Give statement covering all losses (insured or uninsured) during the past 5 years which would be covered by this form of policy, with dates, nature of loss and amount, name of insurer, and whether paid in full or otherwise.
f. Within your knowledge has any insurer ever cancelled or refused to issue or to continue any insurance for you? "Yes" or "No"
Give particulars
g.
Bookkeeping: (1) Do you keep a detailed and itemized inventory of your stock?   "Yes" or "No"
(2) Do you maintain a separate listing of all travelers' stock?   "Yes" or "No"
(3) Do you maintain detailed records of the property of others in your custody or control?   "Yes" or "No"
(4) How often do you take a physical stock inventory?    
2. LIMITS OF LIABILITY DESIRED
(A)
At the Insured's premises as described herein:
$ situated at
$ situated at
$ situated at
(B)
$ in transit by contract or common carrier, or Registered Mail;
(C)
$ in the custody of a merchants' parcel delivery service;
(D)
$ at the premises of sales agents, dealers, processors, or similar custodians;
(E)
$ in storage at the premises of custodians other than those specified in (D) above located at;
 
(F)
$ elsewhere and not included in Clauses (A), (B), (C), (D), and (E) above or other wise limited herein.
NOTE: The amounts stated above are merely indications and are not to be considered as either increasing or decreasing the limits of liability for which the policy is issued.
3. INVENTORIES OF ALL PROPERTY WHEREVER LOCATED:
a.
The last merchandise inventory was taken on       and was exactly $
If you can give your exact monthly inventories for the last twelve months attach a slip here showing these inventories with the date of each and questions a., b., and c. of this section need not be answered.
b.
The previous merchandise inventory at least six months prior to a. was taken on    and was exactly $
c.
The maximum amount of our stock during the last twelve months did not exceed $
d.
The estimated average daily amount of the property of others who are dealers in such property or otherwise engaged in the trade (including the Proposer's accrued charges thereon) in our custody was $
4. STOCK ENCLOSURE AND PREMISES PROTECTION:
a. Electrical Burglar Alarm Systems
(1)
STOCK ENCLOSURES A B C
Name of Protective Company
Central Station or Local
Extent of Protection
     (Partial or Complete)
Grade (AAA, B or C)
U. L. Certificate No.
Date of Expiration
Indicate minimum proportion by value of property on premises kept in each stock enclosure at all times when premises are closed.
Total to agree with 5a % % %
(2) PREMISES
Are your premises protected by an operating Mercantile Premises Alarm System?  Yes  No
Central Station?   Yes   No        Local Alarm?   Yes   No      Extent of Protection (1, 2, or 3)
Name of Protective Company
Grade AA, A, B, or C) 
Underwriters Laboratories Certificate No.    Expiration Date
b. Holdup Alarm
Is there a Central Station Holdup Alarm System protecting your premises?  "Yes" or "No"    Number of Signal Buttons
Name of Protecting Company
c. Watchman Service
(1) State number of watchmen employed exclusively by you (or if Proposal is for a Leased Department of a Department Store, then exclusively by Department Store) and maintained on duty within your premises at all times when not regularly open to business
(2) Do such watchmen report or register at least hourly on weekdays, and each two hours on Sundays and Holidays
(a) To an outside Central Station?  "Yes" or "No"      (b) On a Watchman's Clock?  "Yes" or "No" 
5. WARRANTIES AS TO PROPERTY INSURED DURING TERM OF INSURANCE AT ALL TIMES WHEN PREMISES ARE CLOSED:
a. The proportion by value of property ON PREMISES kept in Locked Enclosures protected as indicated under 4a (1) will be %
b. The proportion by value of property ON PREMISES kept in other Locked Enclosures will be
(Show separate percentages where more than such enclosure.)		 %
c. The proportion by value of property ON PREMISES (including windows display) out of enclosures will be %
(TOTAL 100%)
6. TRAVEL AND MESSENGER:
Property outside of the Proposer's premises during the last twelve (12) months in the custody or control of the Proposer, messengers, employees, members of the firm or officers of the corporation was:

NOTE: All carrying of property outside of the Proposer's premises must be reported in this section.

Name

 Number
of Days		 Average
Amount		 Maximum
Amount
$ $
$ $