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  A Service of Supple-Merrill & Driscoll, Inc.




 Jewelers Block Application Instructions

  1. Please complete and submit this online application for a free, no-obligation quote.

  2. Please be sure to provide all required information in order to receive a quotation. 


  Program Information

This is a secure application.  Strong cryptography is implemented via the Secure Sockets Layer protocol.  Our Privacy Policy.

  Paper Application (Optional)


( indicates required information)

Applicant Information

Name of Company / Organization:

Full Name of Contact:
Street Address:
City, State: ,
Zip/Postal Code:


We will never rent, sell, or share your email address.

Applicant Type:


Client Information
Description of Business/Operations:


Insurance History

Any insurance declined or cancelled in the past 5 years?

Yes  No

Not Applicable in MO

Any prior insurance coverage?

Yes  No

Any loss in the past 5 years?

Yes  No


Operational Data
Annual Sales:

Number of Employees:
Minimum Number of Employees on premises during business hours:
Business Hours:


Estimated daily average value of property in custody of jewelry dealers, including appraisers and repairers, or out on consignment or memorandum, during the past 12 months:


Industry Associations

Are you a member of any Jewelry Associations?

Yes  No

Please Explain



Do you handle pawned property?

Yes  No

If Yes,

What percentage of sales is related to jewelry?

Amount loaned and unpaid plus accrued interest at legal rate on pledged property?


Shipments & Transporting Items
Total value of property shipped during the last 12 months:
Number of shipments the past 12 months:
Maximum value of any one shipment:


At least 1 owner must be scheduled.


First Name

Last Name


Years of Experience






Location Details
Year Built:
Construction Type:
Type of Location:
Number of Floors in Building:
Floor Location of Applicant:
Flood Zone:


Premises Alarm

Is the premises alarm system UL certified?

Yes  No

If Yes,

Central Station Alarm Monitoring Company:

Provide the UL Certificate number for the premises:


Manufacturer's Name:
Vault fire/burglary rating?
Safe fire/burglary rating?
Is safe located within a vault? Yes  No
Safe/vault alarm company name?
Safe/vault alarm UL Certificate Number?
Outside of business hours, percentage of property left outside of safe/vaults?


Additional Security Details
Do you have an armed uniformed guard? Yes  No
Controlled Entry? Yes  No
Closed Circuit TV with DVR/VCR? Yes  No
Double Door Security Vestibule? Yes  No
Bullet Proof Package Receptacle? Yes  No
Number of entrances open to the general public?
Number of entrances not open to the general public?


Inside Showcases

Are there any inside showcases?

Yes  No

If Yes,

Number of inside showcases?
How are the interior showcase tops secured?
Are all inside showcases equipped with key locks? Yes  No
Are all inside showcases kept locked during business hours except when the contents therein are actually being removed or replaced? Yes  No


Show Window Display / Outside Showcase Display
Number of show windows?

Type of Glass?


Regular Plate Glass

Minimum 8mm Glass

Check All That Apply


Do you maintain a detailed record of inventory?

Yes  No

How often is inventory taken?

Last inventory date?


Inventory Exposure
Value of inventory when last taken?
Maximum value of all inventory during the past 12 months?
Estimated average daily amount of other people's property in your custody or control during the last 12 months?


Allocation of Stock at Last Inventory
The total stock allocation for all categories must equal 100%.
Loose diamonds (non-industrial) %
Pearls, natural and cultured (mounted and unmounted) %
Other unset precious stones %
Unset semi-precious and imitation stones %
Jeweler mounted with diamonds or other precious stones %
Other jewelry including costume jeweler and gold jeweler %
Watches, watch cases, watch bracelets mounted with diamonds or other precious stones %
Other watches, watch cases, movements, parts %
Clocks (including cases, movements, parts) %
Silverware, pewter, plate and stainless steel %
Jewelers’ findings, unset mountings and material for manufacture %
All other stock

Please Describe


Stock at Your Premises:

Property in Safe Deposit Vault of Any Bank,

Trust or Safe Deposit Company:

Property at Premises of Any Dealer, Processor

or Similar Bailee in the Jewelry Trade:

Goods In Custody Of Others:

Additional Coverages
Patterns, Molds, Models & Dies:

Office Contents, Furniture, Fixtures,

Tools, Machinery, Fittings:

Tenant Improvements & Betterments:


Earthquake coverage above 25,000 is available for frame construction only.


Coverage Term

Annual Policy Period:

Effective Date

Inland Marine
Policy Deductible:
Travel Coverage (Blanket):
Additional Coverages
Money and Securities:
Electronic Data Processing:
Theft Damage to Buildings:








Terms and Conditions

Please carefully review the Terms and Conditions below:

  • Please read all exclusions indicated on quotation.

  • The quotation received is not binding on the Insurer in any way.

  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  Via email, you will receive a free, no-obligation insurance quotation.

  • Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
  • Please note that once coverage is bound, the policy cannot be cancelled.

  • The insurance quotation will be based solely on the coverages and limits selected on this application.

  • Please ask your Supple-Merrill & Driscoll, Inc. representative to explain coverage details, exclusions, limits or other provisions of any insurance policy.

Type your name below, to indicate that you have read and accepted the Terms and Conditions above:





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