CONDO ASSN BYLAWS (for D&O Coverage only)
PROGRAM CODECOMPANY POLICY OR PROGRAM NAME
POLICY NUMBER
CARRIER
NAIC CODE
PM
AM
TIMEDATE
CHANGE
CANCEL
BOUND (Give Date and/or Attach Copy):
ISSUE POLICYQUOTE RENEW
STATUS OF
TRANSACTION
E-MAIL
ADDRESS:
AGENCY CUSTOMER ID:
CODE: SUBCODE:
PHONE
(A/C, No, Ext):
CONTACT
NAME:
AGENCY
(A/C, No):
FAX
APPLICANT INFORMATION SECTION
COMMERCIAL INSURANCE APPLICATION
DATE (MM/DD/YYYY)
UNDERWRITER UNDERWRITER OFFICE
APPLICANT INFORMATION
The ACORD name and logo are registered marks of ACORD
Page 1 of 4 © 1993-2009 ACORD CORPORATION. All rights reserved.
YACHT
OPEN CARGO
DEALERS
TRANSPORTATION /
MOTOR TRUCK CARGOVALUABLE PAPERS
ACCOUNTS RECEIVABLE /
INDICATE SECTIONS ATTACHED
PROPERTY
GLASS AND SIGN
CRIME / MISCELLANEOUS CRIME
GARAGE AND DEALERS
BOILER & MACHINERY TRUCKERS / MOTOR CARRIER
UMBRELLABUSINESS AUTO
ELECTRONIC DATA PROC
INSTALLATION / BUILDERS RISK
EQUIPMENT FLOATER
BUSINESS OWNERS
PREMIUM PREMIUM PREMIUM
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
COMMERCIAL GENERAL LIABILITY
SECTIONS ATTACHED
$
POLICY INFORMATION
PROPOSED EFF DATE PROPOSED EXP DATE
AGENCYDIRECT
BILLING PLAN PAYMENT PLAN AUDIT POLICY PREMIUMDEPOSIT
$
MINIMUM
PREMIUM
METHOD OF PAYMENT
$ $
ACORD 125 (2009/08)
FEIN OR SOC SEC #GL CODE SIC
WEBSITE ADDRESS
LLCINDIVIDUAL PARTNERSHIP
CORPORATION JOINT VENTURE NOT FOR PROFIT ORG
NO. OF MEMBERS
SUBCHAPTER "S" CORPORATION
AND MANAGERS:
TRUST
BUSINESS PHONE #:
NAICS
NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)
DRIVER INFORMATION SCHEDULE
COVERAGES SCHEDULE
ADDITIONAL PREMISES
APARTMENT BUILDING SUPPLEMENT
CONTRACTORS SUPPLEMENT
ATTACHMENTS
ADDITIONAL INTEREST
INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT
INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT
LOSS SUMMARY
PREMIUM PAYMENT SUPPLEMENT
PROFESSIONAL LIABILITY SUPPLEMENT
RESTAURANT / TAVERN SUPPLEMENT
STATEMENT / SCHEDULE OF VALUES
STATE SUPPLEMENT (If applicable)
VACANT BUILDING SUPPLEMENT
VEHICLE SCHEDULE
FEIN OR SOC SEC #GL CODE SIC
WEBSITE ADDRESS
LLCINDIVIDUAL PARTNERSHIP
CORPORATION JOINT VENTURE NOT FOR PROFIT ORG
NO. OF MEMBERS
SUBCHAPTER "S" CORPORATION
AND MANAGERS:
TRUST
BUSINESS PHONE #:
NAICS
NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
FEIN OR SOC SEC #GL CODE SIC
WEBSITE ADDRESS
LLCINDIVIDUAL PARTNERSHIP
CORPORATION JOINT VENTURE NOT FOR PROFIT ORG
NO. OF MEMBERS
SUBCHAPTER "S" CORPORATION
AND MANAGERS:
TRUST
BUSINESS PHONE #:
NAICS
NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
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AGENCY CUSTOMER ID:
CONTACT TYPE:
CONTACT NAME:
PRIMARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
CONTACT INFORMATION
CONTACT TYPE:
PRIMARY E-MAIL ADDRESS:
SECONDARY E-MAIL ADDRESS:
CONTACT NAME:
PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)
Page 2 of 4
OFFICE
SERVICE
RETAIL WHOLESALE
APARTMENTS
CONDOMINIUMS
RESTAURANTCONTRACTOR
STARTED (MM/DD/YYYY)
DATE BUSINESS
INSTITUTIONAL
MANUFACTURING
NATURE OF BUSINESS
INSTALLATION, SERVICE OR REPAIR WORK
RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:
DESCRIPTION OF PRIMARY OPERATIONS
OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK
DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS
% %
TENANT
OWNER
OUTSIDE
INSIDE
# FULL TIME EMPL
# PART TIME EMPL
STREET
CITY:
COUNTY:
STATE:
ZIP:
DESCRIPTION OF OPERATIONS:
LOC #
BLD #
SQ FT
OCCUPIED AREA:
CITY LIMITS INTEREST ANNUAL REVENUES:
OPEN TO PUBLIC AREA:
SQ FT
TOTAL BUILDING AREA:
ANY AREA LEASED TO OTHERS? Y / N
SQ FT
$
ACORD 125 (2009/08)
PRIMARY
PHONE #
SECONDARY
PHONE #
PRIMARY
PHONE #
SECONDARY
PHONE #
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests
TENANT
OWNER
OUTSIDE
INSIDE
# FULL TIME EMPL
# PART TIME EMPL
STREET
CITY:
COUNTY:
STATE:
ZIP:
DESCRIPTION OF OPERATIONS:
LOC #
BLD #
SQ FT
OCCUPIED AREA:
CITY LIMITS INTEREST ANNUAL REVENUES:
OPEN TO PUBLIC AREA:
SQ FT
TOTAL BUILDING AREA:
ANY AREA LEASED TO OTHERS? Y / N
SQ FT
$
TENANT
OWNER
OUTSIDE
INSIDE
# FULL TIME EMPL
# PART TIME EMPL
STREET
CITY:
COUNTY:
STATE:
ZIP:
DESCRIPTION OF OPERATIONS:
LOC #
BLD #
SQ FT
OCCUPIED AREA:
CITY LIMITS INTEREST ANNUAL REVENUES:
OPEN TO PUBLIC AREA:
SQ FT
TOTAL BUILDING AREA:
ANY AREA LEASED TO OTHERS? Y / N
SQ FT
$
TENANT
OWNER
OUTSIDE
INSIDE
# FULL TIME EMPL
# PART TIME EMPL
STREET
CITY:
COUNTY:
STATE:
ZIP:
DESCRIPTION OF OPERATIONS:
LOC #
BLD #
SQ FT
OCCUPIED AREA:
CITY LIMITS INTEREST ANNUAL REVENUES:
OPEN TO PUBLIC AREA:
SQ FT
TOTAL BUILDING AREA:
ANY AREA LEASED TO OTHERS? Y / N
SQ FT
$
ITEM
BOAT:VEHICLE:
BUILDING:LOCATION:
EMPLOYEE
LIENHOLDER
MORTGAGEE
LOSS PAYEE
ADDITIONAL
INTEREST IN ITEM NUMBER
CERTIFICATE
REFERENCE / LOAN #:
NAME AND ADDRESS RANK:INTEREST
ITEM DESCRIPTION
INSURED
AS LESSOR
EVIDENCE: POLICY SEND BILL
OWNERCO-OWNER AIRCRAFT:AIRPORT:
CLASS:
ITEM:
INTEREST END DATE:
LIEN AMOUNT:
PHONE (A/C, No, Ext): FAX (A/C, No):
REGISTRANT
TRUSTEE
BREACH OF
WARRANTY
LEASEBACK
OWNER
REASON FOR INTEREST: E-MAIL ADDRESS:
CELLBUS
HOME
CELLBUS CELLBUS
HOME
CELLBUS
HOME
HOME
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AGENCY CUSTOMER ID:
12. 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)
8.
ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
OCCURRENCE
DATE
EXPLANATION
UNDERWRITING
RESOLUTION
DATE
RESOLUTION
7.
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).
6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
GENERAL INFORMATION
5.
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)
NON-PAYMENT
NON-RENEWAL
AGENT NO LONGER REPRESENTS CARRIER
CONDITION CORRECTED (Describe):
9.
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
OCCURRENCE
DATE
EXPLANATION
RESOLUTION
DATE
RESOLUTION
10.
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
OCCURRENCE
DATE
EXPLANATION
RESOLUTION
DATE
RESOLUTION
11. HAS BUSINESS BEEN PLACED IN A TRUST?
NAME OF TRUST
LINE OF BUSINESSLINE OF BUSINESS POLICY NUMBERPOLICY NUMBER
ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)4.
1b.
1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
% OWNEDRELATIONSHIP DESCRIPTIONPARENT COMPANY NAME
% OWNEDRELATIONSHIP DESCRIPTIONSUBSIDIARY COMPANY NAME
EXPLAIN ALL "YES" RESPONSES Y / N
IS A FORMAL SAFETY PROGRAM IN OPERATION?2.
SAFETY MANUAL MONTHLY MEETINGS
OSHASAFETY POSITION
ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?3.
DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?13.
Page 3 of 4
REMARKS / PROCESSING INSTRUCTIONS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
ACORD 125 (2009/08)
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AGENCY CUSTOMER ID:
PRIOR CARRIER INFORMATION
CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER:
CARRIER
POLICY NUMBER
PREMIUM
EXPIRATION DATE
YEAR
EFFECTIVE DATE
$ $ $ $
CARRIER
POLICY NUMBER
PREMIUM
EXPIRATION DATE
EFFECTIVE DATE
$ $ $ $
CARRIER
POLICY NUMBER
PREMIUM
EXPIRATION DATE
EFFECTIVE DATE
$ $ $ $
CARRIER
POLICY NUMBER
PREMIUM
EXPIRATION DATE
EFFECTIVE DATE
$ $ $ $
LOSS HISTORY
TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM
LINE
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS
FOR THE LAST YEARS
CLAIM
OPEN
Y / N
AMOUNT RESERVED
SUBRO-
GATION
Y / N
AMOUNT PAIDDATE OF CLAIM
DATE OF
OCCURRENCE
TOTAL LOSSES: $
Check if none (Attach Loss Summary for Additional Loss Information)
Page 4 of 4
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY 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.
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN
CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY 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. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A
MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT
OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
STATE PRODUCER LICENSE NO
PRODUCER'S NAME (Please Print)
APPLICANT'S SIGNATURE DATE
PRODUCER'S SIGNATURE
(Required in Florida)
NATIONAL PRODUCER NUMBER
SIGNATURE
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL
PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, VT or WA; in DC, LA, ME, TN and VA, insurance benefits may also be denied)
IN FLORIDA, 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.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER 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
MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF
DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING
THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.
ACORD 125 (2009/08)
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