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COIN DEALERP.O. Box 4389800-287-7127Davidson, NC 28036FAX: 704-895-0230www.aciginsurance.comAntiques & CollectiblesNational AssociationThe Antiques and Collectibles NationalAssociation (ACNA) is the largest and fastestgrowing Antiques & Collectibles tradeassociation in the country. The goal of thisassociation is to provide you with benefitprograms and affordable insurance as shopowner, mall owner, mall dealer, show dealer,estate sale dealer or show promoter. Theassociation was founded in 1991 and has over3000 members in all 50 states.HOW TO JOINComplete the Membership Form.Make your check for 50 payable to ACNAMail to:ACNAPO Box 4389Davidson, NC 28036Or Fax to:704-895-0230Questions? Call us at 1-800-287-7127COIN DEALER MEMBERSHIP FORMBusiness NamePrincipal(s) Name(s)MEMBER BENEFITSInsurance Programs for Dealers:Property and Liability for Shop Owners,Mall Owners, Mall Dealers, ShowDealers, Show Promoters, Estate Sales,Auctioneers, and Coin DealersInsurance Program for CollectorsQuarterly NewsletterCertificate of MembershipMerchant Services:Discounted Rates For Credit/Debit CardProcessing and Check Guaranties - Cardsinclude VISA, MasterCard, Discover,and American ExpressSell on line through GoAntiques.comEducational Seminars and ProgramsUse of the ACNA LogoDiscount on Home Study program throughAsheford Institute of AntiquesHealth program through America’s BusinessBenefit AssociationDiscounts on Products and Services:Office Supplies, Trade Advertising,Shipping, Travel, Dealer Supplies,Security, & More Mailing AddressCity StateZipBusiness PhoneMobile PhoneFax #E-MailWeb AddressHow did you hear about us?CREDIT CARD AUTHORIZATIONVisaMasterCardDiscoverCard #Expiration DateAmount: Dues Insurance Last three digits on back of cardBilling Address for card:Signature
P.O. Box 4389 - Davidson, NC 28036(P) 800-287-7127 (F) 704-895-0230coin@acna.uswww.aciginsurance.comCOIN DEALER APPLICATION FOR (s) Name(s):Business Name:Business Type:Sole ProprietorPartnershipCorporationLLCMailing Address:City:State:Business Phone:Fax #:Years in Business:Zip:Mobile Phone:Email address:Web Address:Inventory Policy Detail:Amount of Inventory Insurance Requested (Dealer Cost):Total Value of all stock in trade at this time (Dealer Cost):Inventory Deductible amount requesting: (Standard Deductible is 2,500) 500 1,000 2,500 5,000 10,000 25,000Maximum Value of any one item: (Dealer Cost) Do you keep inventory records?YesNoWhat type of inventory records do you keep?WrittenComputerReceiptsPhotosOther:Estimate Percentage of Inventory by Category% Coins% Currency/ScriptInventory Location:% Gold Bullion% Other:% Other:(If you have a secondary location, please complete the multiple locations section on page 4)Primary Location Address:Name: Type:* Values (Dealer Cost):*Type Shop, Mall, Home, Storage, etc.Construction:FrameMasonryYear Building was Built:SteelOther:Year Updated:Number of Stories:Level Occupied:Other Occupants:What is the distance to coastal water from your primary inventory location?What is the distance to the nearest: Fire Hydrant:Less than 1 mile1 to 5 milesFire Department:5 to 10 milesOver 10 milesPolice Station:Security Questions:Fire Alarm:YesNoFire Extinguishers:YesNoIf yes, how many:Smoke Detectors:YesSprinklers:YesNoOther Fire Prevention Securities:Central Station Alarm System:YesNo If yes, System Type:UL Rated Certificate:Yes(If you have a Central Station Alarm System, include a copy of your Alarm Certificate with this completed application)Hold-up Buttons:YesNoVideo Cameras:YesNoNumber of Safes:Dedicated Phone Line:Security Guard:NoNoMotion Detectors:Steel Gates:UL/TL Ratings:Stock % in locked safe when open:05/17YesYesYesNoYesBuzzer Entry:NoNoNoYesSafes wired to Central Station Alarm System:NoYesNoStock % in locked safe when closed:Page 1 of 4
Vault:Do you have a Vault?YesNoIf yes, please complete the following:Construction of Vault:Vault rating or class:Vault wired to Central Station Alarm System:YesNoAre the safes stored in the Vault:YesNo(If another location is needed, please complete the Multiple Locations section on page 4)Bank:Bank Name:Address:Total Value at the Bank (Dealer Cost) ( ):Amount of Insurance Desired at the Bank (Dealer Cost) ( ):Transit:Replacement Value taken to shows & buying/selling trips (Dealer Cost) ( ):Insurance desired for stock taken to shows & buying/selling trips (Dealer Cost) ( ):Estimated number of days away during the last 12 months:Anticipated number of days away expected during the next 12 months:Insurance desired on property in transit within a 25 mile radius of premises (Dealer Cost):Is a 25 mile radius sufficient for local transit coverage:YesNoIf no, how many additional miles?General:Approximately how many shows are you doing annually?How many malls booths are you in?Are all rises and falls in elevations and steps on your premises clearly marked?YesIf you have a Shop, do you rent space out to any of the following and if so how many?NoYesNoFood Service: Other Stores: Flea Market: Apartment: Auction: Storage: Other:Have you had a Loss in the past 5 years?DATEAMOUNTYesNoHave you filed for bankruptcy within the last 7 years?DATEAMOUNTYesHave you ever been convicted of a felony?DATENoYesIf yes, please complete the following:DESCRIPTION OF LOSSNoIf yes, please complete the following:DESCRIPTION OF BANKRUPTCYIf yes, please complete the following:DESCRIPTIONHas any company canceled, non-renewed, or refused insurance coverage for your business?YesNoDATECOMPANY AND DESCRIPTIONHow would you like your quote and policy sent to you?EmailIf yes, please complete the following:MailHow did you hear about us?I agree the answers given on this application are true and accurate and that this application does NOT constitute a binder. All questions must be answeredbefore the application will be accepted. Coverage will begin after the application is received and approved by the Underwriter. It is understood that all policies aresubject to a 25% minimum earned premium at inception and there are no flat cancellations. Any person who, with the intent to defraud or knowing that he or sheis facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud andsubject to fines and/or imprisonment. I agree that any intentional concealment of misrepresentation of a material fact concerning this insurance or the subjectthereof may void any policy issued. I further understand and agree that the issuance of coverage is based on this application and that this application becomes apart of this policy.Date:05/17Signature:Page 2 of 4
(SUPPLEMENTAL) COIN DEALER APPLICATION FOR INSURANCEOPTIONAL INVENTORY COVERAGE:Would you like shipping coverage added onto the policy?(If Yes, please complete the following question)YesNoOn average, how many packages per week are you shipping?Please check which shipping coverage limit(s) you would like added onto the policy? 3,000 Limit per Package through United Parcel Service 5,000 Limit per Package through United Parcel Service 15,000 Limit per Package through Federal Express 25,000 Limit per Package through Federal Express 50,000 Limit per Package through Federal Express 75,000 Limit per Package through Federal Express 3,000 Limit per Package through Federal Express Ground 5,000 Limit per Package through Federal Express Ground 25,000 Limit per Package through United States Postal Service Registered Mail 50,000 Limit per Package through United States Postal Service Registered Mail 75,000 Limit per Package through United States Postal Service Registered Mail 100,000 Limit per Package through United States Postal Service Registered Mail 15,000 Limit per Package through United States Postal Service Express Mail 25,000 Limit per Package through United States Postal Service Express Mail 50,000 Limit per Package through United States Postal Service Express MailOPTIONAL LIABILITY COVERAGE:Would you like the General Aggregate Limit of Liability increased to 2,000,000?Would you like the Each Occurrence Limit of Liability increased to 2,000,000?YesNoYesWould you like to add liability for a Warehouse, Storage, or Office location?NoYesNoIf Yes, How Many? Describe:Do you need to add liability for an Apartment, Store, Office, or Other space rented to others by you?YesNoIf Yes, How Many? Describe:Would you like to add an additional Insured onto the policy? (i.e., landlord)YesNoName:Address:Would you like to add a Waiver of Subrogation in favor of an Additional Insured?YesNoWould you like to add Hired/Non-Owned Auto Liability Coverage onto the policy?YesNo05/17Page 3 of 4
OPTIONAL BUILDING COVERAGE (One app for each Building) Please attach picture.(Available in Most States)1. Address of PropertyCity County St Zip2. Amount of Insurance Desired Deductible Desired ( 1000 Min.)3. Building is occupied as:4. Construction:Frame (wood)5. Within City Limits:YesMasonry with wood joistNoMasonry with steel joist6. Monitored Alarm System:YesNoSteelOther7. Sprinklered:YesNo8. Year Built: Age of Wiring: Age of Roof: Age of Plumbing: Age of Heating:ALL UPDATES MUST BE WITHIN THE PAST 20 YEARS9. Square Footage: 10. Number of Stories:11. How close is the nearest fire department? Nearest fire hydrant?12. If Coastal, what is the distance to water from this building?Less than 1500 ft.1500 ft. to 1 mile1 to 5 milesWithin 1000 ft5 to 10 milesover 1000 ft.Over 10 miles13. Mortgagee: Name:Address:City, State, Zip:Attention: Loan#:Multiple Locations:(Complete only if you have a Second Location)Secondary Location Address:Name: Type:* Values (Dealer Cost):*Type Shop, Mall, Home, Storage, etc.Construction:FrameMasonrySteelOther:Year Building was Built:Year Updated:Number of Stories:Level Occupied:Other Occupants:What is the distance to water from your primary inventory location?Less than 1 mile1 to 5 milesWhat is the distance to the nearest: Fire Hydrant:Fire Department:5 to 10 milesOver 10 milesPolice Station:Security Questions:Fire Alarm:YesNoFire Extinguishers:YesNoIf yes, how many:Smoke Detectors:YesSprinklers:YesNoOther Fire Prevention Securities:Central Station Alarm System:YesNo If yes, System Type:UL Rated Certificate:Yes(If you have a Central Station Alarm System, include a copy of your Alarm Certificate with this completed application)Hold-up Buttons:YesNoVideo Cameras:YesNoNumber of Safes:Dedicated Phone Line:Security Guard:YesYesNoNoSteel Gates:UL Ratings:Stock % in locked safe when open:Motion Detectors:YesNoYesNoNoNoBuzzer Entry:YesNoSafes wired to Central Station Alarm System:YesNoStock % in locked safe when closed:Vault:Do you have a Vault?YesNoIf yes, please complete the following:Construction of Vault:Vault wired to Central Station Alarm System:05/17YesVault rating or class:NoAre the safes stored in the Vault:YesNoPage 4 of 4
COIN DEALER P.O. Box 4389 800-287-7127 Davidson, NC 28036 FAX: 704-895-0230 www.aciginsurance.com Antiques & Collectibles National Association Make your check for 50 payable to The Antiques and Collectibles National Association (ACNA) is the largest and fastest growing Antiques & Collectibles trade .
