NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
VEHICLE SCHEDULE
VACANT BUILDING SUPPLEMENT
STATE SUPPLEMENT (If applicable)
STATEMENT / SCHEDULE OF VALUES
RESTAURANT / TAVERN SUPPLEMENT
PROFESSIONAL LIABILITY SUPPLEMENT
PREMIUM PAYMENT SUPPLEMENT
LOSS SUMMARY
INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT
INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT
ADDITIONAL INTEREST SCHEDULE
ATTACHMENTS
CONTRACTORS SUPPLEMENT
CONDO ASSN BYLAWS (for D&O Coverage only)
APARTMENT BUILDING SUPPLEMENT
ADDITIONAL PREMISES INFORMATION SCHEDULE
COVERAGES SCHEDULE
DRIVER INFORMATION SCHEDULE
NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
ACORD 125 (2016/03)
$$
METHOD OF PAYMENT
PREMIUM
MINIMUM
$
DEPOSIT POLICY PREMIUMAUDITPAYMENT PLANBILLING PLAN
DIRECT AGENCY
PROPOSED EXP DATEPROPOSED EFF DATE
POLICY INFORMATION
LINES OF BUSINESS
COMMERCIAL GENERAL LIABILITY
$
$
$
$
$$
$
$
$
$
$
$
$
PREMIUMPREMIUMPREMIUM
BUSINESS OWNERS
BUSINESS AUTO
UMBRELLA
BOILER & MACHINERY
GARAGE AND DEALERS
CRIME
COMMERCIAL PROPERTY
INDICATE LINES OF BUSINESS
YACHT
© 1993-2015 ACORD CORPORATION. All rights reserved.Page 1 of 4
The ACORD name and logo are registered marks of ACORD
APPLICANT INFORMATION
UNDERWRITER OFFICEUNDERWRITER
DATE (MM/DD/YYYY)
COMMERCIAL INSURANCE APPLICATION
APPLICANT INFORMATION SECTION
FAX
(A/C, No):
AGENCY
NAME:
CONTACT
(A/C, No, Ext):
PHONE
SUBCODE:CODE:
AGENCY CUSTOMER ID:
ADDRESS:
E-MAIL
STATUS OF
TRANSACTION
RENEWQUOTE ISSUE POLICY
BOUND (Give Date and/or Attach Copy):
CANCEL
CHANGE
DATE TIME
AM
PM
NAIC CODE
CARRIER
POLICY NUMBER
COMPANY POLICY OR PROGRAM NAME PROGRAM CODE
HOTEL / MOTEL SUPPLEMENT
CYBER AND PRIVACY
FIDUCIARY LIABILITY
$
LIQUOR LIABILITY
$
COMMERCIAL INLAND MARINE
$
TRUCKERS
MOTOR CARRIER
$
ACCOUNTS RECEIVABLE / VALUABLE PAPERS
DEALERS SECTION
ELECTRONIC DATA PROCESSING SECTION
GLASS AND SIGN SECTION
INSTALLATION / BUILDERS RISK SECTION
OPEN CARGO SECTION
$
$
$
$
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER
OWNER
SEND BILLPOLICYEVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
%%
DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS
OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK
DESCRIPTION OF PRIMARY OPERATIONS
RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:
INSTALLATION, SERVICE OR REPAIR WORK
NATURE OF BUSINESS
MANUFACTURING
INSTITUTIONAL
DATE BUSINESS
STARTED (MM/DD/YYYY)
CONTRACTOR RESTAURANT
CONDOMINIUMS
APARTMENTS
WHOLESALERETAIL
SERVICE
OFFICE
PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)
CONTACT NAME:
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
CONTACT TYPE:
CONTACT INFORMATION
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
CONTACT NAME:
CONTACT TYPE:
AGENCY CUSTOMER ID:
ACORD 125 (2016/03)
LENDER'S
LOSS PAYABLE
Page 2 of 4
$$$$
EFFECTIVE DATE
YEAR
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
OTHER:PROPERTYAUTOMOBILEGENERAL LIABILITYCATEGORY
PRIOR CARRIER INFORMATION
REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
SAFETY POSITION OSHAMONTHLY MEETINGSSAFETY MANUAL
2. IS A FORMAL SAFETY PROGRAM IN OPERATION?
Y / NEXPLAIN ALL "YES" RESPONSES
SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED
PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
1a.
1b.
4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
POLICY NUMBER POLICY NUMBERLINE OF BUSINESS LINE OF BUSINESS
NAME OF TRUST:
HAS BUSINESS BEEN PLACED IN A TRUST?
11.
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
10.
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
9.
CONDITION CORRECTED (Describe):UNDERWRITING
AGENT NO LONGER REPRESENTS CARRIER
NON-RENEWAL
NON-PAYMENT
ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR
OPERATIONS? (Missouri Applicants - Do not answer this question)
5.
GENERAL INFORMATION
ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?6.
DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD,
BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?
(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable
by a sentence of up to one year of imprisonment).
7.
RESOLUTION RESOLVE DATEEXPLANATIONOCCUR DATE
ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
8.
ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?
(If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure)
12.
AGENCY CUSTOMER ID:
Page 3 of 4ACORD 125 (2016/03)
OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE
OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE
DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use)14.
15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES", describe use)
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a
false statement as to any material fact may be violating state law.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim 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 such person to criminal and civil penalties (not to exceed five thousand dollars and
the stated value of the claim for each such violation)*. *Applies in NY Only.
(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)
(Applicant's Initials):
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS
OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS
OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE
PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO
REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN
WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY
BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON
HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps,
or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss,
shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty
thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance
of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or
benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison. *Applies in MD Only.
SIGNATURE
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
(Attach Loss Summary for Additional Loss Information)Check if none
YEARS TOTAL LOSSES: $
DATE OF
OCCURRENCE
DATE OF CLAIM AMOUNT PAID
SUBRO-
GATION
Y / N
AMOUNT RESERVED
CLAIM
OPEN
Y / N
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS
FOR THE LAST
LINE
TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM
LOSS HISTORY
$$$$
EFFECTIVE DATE
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
$$$$
EFFECTIVE DATE
YEAR
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
OTHER:PROPERTYAUTOMOBILEGENERAL LIABILITYCATEGORY
PRIOR CARRIER INFORMATION (continued)
AGENCY CUSTOMER ID:
ACORD 125 (2016/03) Page 4 of 4
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