Reinsurance Information - Must be completed for each location with 75+ employees (complete as many sections as needed - please attach additional copies if there are more than 3 locations with 75+ employees) Address: Number of employees at this location: Number of shifts: Hours of operation: Type of construction: Location is: Seismically retrofit: [ ] Frame [ ] Single building [ ] Yes Year: [ ] Joisted Masonry [ ] Multi-building [ ] No [ ] Non-combustible [ ] Urban Building characteristics: [ ] Masonry non-combustible [ ] Suburban Age of building: [ ] Modified fire resistive [ ] Rural Number of floors: [ ] Fire resistive Specific floors occupied: Classifications / Occupations at this location: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Address: Number of employees at this location: Number of shifts: Hours of operation: Type of construction: Location is: Seismically retrofit: [ ] Frame [ ] Single building [ ] Yes Year: [ ] Joisted Masonry [ ] Multi-building [ ] No [ ] Non-combustible [ ] Urban Building characteristics: [ ] Masonry non-combustible [ ] Suburban Age of building: [ ] Modified fire resistive [ ] Rural Number of floors: [ ] Fire resistive Specific floors occupied: Classifications / Occupations at this location: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: By signing this supplemental application, the applicant states that the information provided is accu rate to the best of t heir knowledge. All information provided is subject to verification. The application or policy coverage may be cancelled for misrepre sentation if informa tion provided is not accurate . Signature of Applicant Date Signature of Producer Date
Reinsurance Information - Must be completed for each location with 75+ employees (complete as many sections as needed - please attach additional copies if there are more than 3 locations with 75+ employees) Address: Number of employees at this location: Number of shifts: Hours of operation: Type of construction: Location is: Seismically retrofit: [ ] Frame [ ] Joisted Masonry [ ] Non-combustible [ ] Masonry non-combustible [ ] Modified fire resistive [ ] Fire resistive [ ] Single building [ ] Multi-building [ ] Urban [ ] Suburban [ ] Rural [ ] Yes Year: [ ] No Building characteristics: Age of building: Number of floors: Specific floors occupied: Classifications / Occupations at this location: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Address: Number of employees at this location: Number of shifts: Hours of operation: Type of construction: Location is: Seismically retrofit: [ ] Frame [ ] Joisted Masonry [ ] Non-combustible [ ] Masonry non-combustible [ ] Modified fire resistive [ ] Fire resistive [ ] Single building [ ] Multi-building [ ] Urban [ ] Suburban [ ] Rural [ ] Yes Year: [ ] No Building characteristics: Age of building: Number of floors: Specific floors occupied: Classifications / Occupations at this location: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: Class code: SIC Code: Employee Count: Payroll: By signing this supplemental application, the applicant states that the information provided is accu provided is subject to verification. The application or policy coverage may be cancelled for misrepre rate to the best of t sentation if informa heir knowledge. All information tion provided is not accurate . Signature of Applicant Date Signature of Producer Date