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CHUBB ACCESS PROGRAM
QUOTE SHEET
 



You must be an enrolled agent in Chubb Access Program to Request a Quote. Access agents must include their agency name and producer number prior to submission for a quote to be processed. If this information is not included or is not valid, the quote will not be processed.

Agency Contact Name:  
Producer Number:           Sub-Code:  
Producer Phone#:   Producer FAX#:  
Customer Name:  
DOB:  
Client Phone# (Home):              (Work)#:  
Occupation:  
Job Title:  
Company:  
If Retired List Prior Occupation:  
 
Spouse's Name:  
Spouse's DOB:  
Spouse's Occupation:  
Spouse's Job Title:  
Spouse's Company:  
If Retired List Prior Occupation:  
 
Customer's Mailing Address:  
Present Carrier:  
Expiration Date:  
Non-Renewed/Details:  
Loss History: Claims/Accidents/Violations:  


HOMEOWNERS QUOTE SHEET

Type of Dwelling:             Condo      House      Townhouse      Renters
Risk Location:
Mailing Address (If different than location):
Dwelling Limit/Additions & Alterations:   Contents/Personal Property:  
Liability:   Deductibles:  
Standard or Deluxe Contents:   Occupancy:  
If Secondary - Rented to Others:   Yes        No
Year Built:  

PROTECTION
Within 5 Miles From Fire Department:   Yes        No
Within 1,000 Feet From Hydrant:   Yes        No
Fire Resistive:   Yes        No
Burglar Alarm: Central Station  Yes        No
Fire Alarm: Central Station:   Yes        No
Sprinkler System:   Yes        No
Gated Community:   Yes        No
Guarded:   Yes        No
Distance From Water:   Cross Street:  
Updates to Electrical/PlumbingGuarded:  
  (If Yes, list Year)     

Yes        No
TEXAS HOMEOWNERS ONLY
Rate Level:   Protection Class:  
No of Families: (1-4)  Type of Roof:       
Within City Limits:   Yes        No
Swimming Pool:   Yes        No
Farmers Liability:   Yes        No
Endorsements Requested:   Yes        No


VALUABLE ARTICLE QUOTE SHEET

Jewelry:  Amount       Coverage Type:    Itemized    Blanket
In-vault:  Amount
Fine Arts:  Amount       Coverage Type:    Itemized    Blanket
Furs:  Amount       Coverage Type:    Itemized    Blanket
Camera/Others:  Amount       Coverage Type:    Itemized    Blanket
In-Vault Information: (Please provide bank address)


AUTOMOBILE QUOTE SHEET

AUTOMOBILES
VEH
No		YEARMAKEMODELVIN/SYMBOLUSAGE
1
2
3
4


VEHICLE GARAGE LOCATIONS
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:


COVERAGES
CoverageVEH#1 VEH#2 VEH#3VEH#4
Liability Limit
UM/UIM
PIP
ADD'L PIP
Roadside Coverage
Coll Deductible
Comp Deductible
Alarms Yes     No Yes     No Yes     No Yes     No
Anti-Lock Brakes Yes     No Yes     No Yes     No Yes     No
Full Window Glass Yes     No Yes     No Yes     No Yes     No


DRIVERS
Driver NameDate of BirthLicense#Vehicle #
1 
2 
3 
4 
5 


EXCESS LIABILITY QUOTE SHEET

Excess Liability Limit:   
# OF RESIDENCES:
Residence #1
Residence #2
Residence #3
Residence #4


NUMBER OF VEHICLES:
YEARMAKEMODEL
Corporate Car:    Yes    No
Underlying Automobile Liability Limit:  


NUMBER OF WATERCRAFT:
YEAR MAKE MODELLENGTHHP/SPEED
 
WATERCRAFT #1 #2#3#4
Hull ID  
No of Engines  
Fuel  
Type of Boat  
Inland or Coastal  
Agreed Value  


        

 

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