To receive an accurate quote, your application should be as complete as possible. CLA Insurance coverage is contingent upon membership in the Coin Laundry Association. Coverage is not available in all areas. Fax completed applications to (847) 427-2633. Contact information: (800) 346-8424. PO Box 518, Wylie, TX 75098-0518. www.coinlaundryinsurance.com   Want an express quote? Call us at (800) 346-8424 for assistance.
How did you hear about the CLA Insurance program? *
 Word of Mouth
 Through membership with CLA
 Via a postcard mailer
 At a seminar
 Internet Search
 Other

Contact Information

Begin Application:
Name of the entity as it should appear on policy:
 
Name of Laundromat or DBA name:
 
Contact Person: *
 
Mailing Address:
 
City:
 
State:
 
Zip Code:
 
Phone Number: *
 
Business Phone: *
 
Fax:
 
Email Address: *
 
Desired Effective Date: *
 
How many years have you been in the laundry business?
 
What's the name of your current or prior insurance company?
 
Federal Employee ID Number (FEIN):
 

Detailed Information

Has any carrier declined, cancelled or nonrenewed your insurance within the past three years? Please explain if you were declined, cancelled or nonrenewed.
 No
 Yes
List losses, date of claim and amount paid from your present carrier for the last three (3) years. This is required for each location to be bound. If none, put "none".
 
 
 
 
 
 
 
To meet your water heating needs in your laundry, which do you use:
 Water Heater
 Boiler

Property

All policies are Special Form Policies. This type of policy includes coverage for all risks of direct physical loss including theft and theft damage. This excludes, but is not limited to, building enforcement, earth movements, government action, nuclear hazard, power failure, war and military action, flood and pollutants, or contaminants. Refer to the policy for a complete listing of exclusions.
Laundry's Street Address:
 
Laundry's City:
 
Laundry's State:
 
Laundry's Zipcode:
 
Building construction:
 Frame (wood walls & roof)
 Noncombustible (all metal)
 Fire resistant (all concrete)
 Joisted masonry (masonry walls, wood trusses)
 Masonry noncombustible (all masonry, no wood)
 Other
Do you own or rent the building?
 Own
 Rent
Are you in a high hazard flood zone?
 Yes
 No

Building Insurance

Complete this section whether you Own or Rent. CLA Insurance does not insure buildings with dwellings. If you wish to insure the building, provide the replacement value of building, including attached exterior signs. The following information regarding age of building, square footage of building, and date and extent of building renovations, is required whether you’re the owner or tenant.
Year Built:
 
Laundromat's Total Square Footage:
 
Building's Total Square Footage:
 
Number of floors in the building.
 
Building Value(if insuring) $
 
List other tenants in the building if applicable:
 
 
 
 
 
 
 
List date and extent of electrical renovations completed (even if you rent):
 
 
 
 
 
 
 
List date and extent of HVAC renovation completed (even if you rent):
 
 
 
 
 
 
 
List date and extent of plumbing renovations completed (even if you rent):
 
 
 
 
 
 
 
List date and extent of roof renovations completed (even if you rent):
 
 
 
 
 
 
 

Services

Do you have a self-service laundry?
 Yes
 No
Do you have wash, dry, fold service? If Yes, list your annual receipts $ for your wash, dry and fold service:
 No
 Yes
Do you have a self-service car wash? If yes, how many wash bays do you have?
 No
 Yes
Is there drycleaning on the premises? If “yes”, list your annual receipts $ for drycleaning on premises:
 No
 Yes
Is there drycleaning drop-off? If “yes”, list your annual receipts $ for drycleaning drop-off:
 No
 Yes
Do you have employees? If “yes”, how many employees do you have?
 No
 Yes
Please list any other services offered on the premises. If none, put none.
 
 
 
 
 
 
 
Are you open 24 hours?
 Yes
 No
If not 24 hours, list the times you open and close:
 
How many hours per day is your store attended? 0-24, Enter zero (0) if none.
 
If you rent, what is the Value of Leasehold Improvements?
 
 
 
 
 
 
 
What’s the total Content Value for your business personal property? Must be replacement cost – new.
 
 
 
 
 
 
 
List the total Annual Gross Receipts for this store. If insuring a brand-new store, provide an estimate of the first year’s revenue.
 
Do you have a burglar alarm?
 Yes
 No
Do you have a fire alarm?
 Yes
 No
Do you have a security service central station that monitors your alarms?
 Yes
 No
Are there building sprinklers?
 Yes
 No

Policy Information

List all mortgagees, loss payees ( equipment lenders and finance) and additional insureds with complete address:
 
 
 
 
 
 
 
Please select your desired property deductible.
 $1,000
 $2,500
 $5,000

General Liability Underwriting

Do you have machines operated at facilities away from the store (e.g. apartments)?
 Yes
 No
Do you perform pickup and delivery service?
 Yes
 No
Do you have a Commercial Auto policy? (Only answer if you you replied "Yes" to the previous question)
 
Do your employees drive their own vehicles? (Only answer if you provide pickup/drop off services)
 
Do you use independent contractors for wash/dry/fold or dry cleaning on a regular basis?
 Yes
 No
Standard General Liability default values are $1,000,000 per occurrence and $2,000,000 aggregate. However, these can be increased upon request. Please let us know any amounts you need to have increased.
 
 
 
 
 
 
 

Agreement

Agreement No coverage is in effect until premium and signed application have been received along with verification of your CLA membership. All the answers to the above questions are subject to the terms and conditions of the policy chosen. I hereby apply to the Company for a policy of insurance as set forth in this application on the basis of the statements contained herein. I agree that such policy shall be null and void if such information is false, misleading or would materially affect acceptance of the risk by the Company. Upon written request by the applicant, additional information as to the nature and scope of the report, if one is made, will be provided.
By typing my name in the box, I hereby affirm that this is the same as if I were signing my name. * If you have completed your application and checked it for errors, we recommend that you print a copy for your records. We will email you a copy of this application to the email address you supplied on the first page. We will contact you shortly via email with a quote. *