AGENCY CUSTOMER ID:
EFFECTIVE DATE
NAIC CODE
CARRIER
POLICY NUMBER
APPLICANT / FIRST NAMED INSURED
AGENCY
4. RETROACTIVE DATE:
3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:
2. NUMBER OF EMPLOYEES:
$1. DEDUCTIBLE PER CLAIM:
EMPLOYEE BENEFITS LIABILITY
© 1993-2016 ACORD CORPORATION. All rights reserved.ACORD 126 (2016/09)
The ACORD name and logo are registered marks of ACORD
Y / N
4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?
3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?
EXPLAIN ALL "YES" RESPONSES
2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:
1. PROPOSED RETROACTIVE DATE:
CLAIMS MADE (Explain all "Yes" responses)
DATE (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY SECTION
LOC #
CLASSIFICATION DESCRIPTION
CLASS
CODE
PREMIUM
BASIS
TERR
EXPOSUREHAZ #
(T) OTHER
(U) UNIT - PER UNIT
(M) ADMISSIONS - PER 1,000/ADM
(C) TOTAL COST - PER $1,000/COST
(A) AREA - PER 1,000/SQ FT
(P) PAYROLL - PER $1,000/PAY
(S) GROSS SALES - PER $1,000/SALES
RATING AND PREMIUM BASIS
PRODUCTS
PREMIUMRATE
SCHEDULE OF HAZARDS (ACORD 211, Schedule of Hazards, may be attached if more space is required)
IS NOT AVAILABLE.IS2. MEDICAL PAYMENTS COVERAGEIS NOT AVAILABLE.IS1. UM / UIM COVERAGE
APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY:
$
OTHER:
LOCATION
PROJECT
POLICY
LIMIT APPLIES PER:
GENERAL AGGREGATE
PRODUCTS & COMPLETED OPERATIONS AGGREGATE
PERSONAL & ADVERTISING INJURY
EACH OCCURRENCE
DAMAGE TO RENTED PREMISES (each occurrence)
MEDICAL EXPENSE (Any one person)
EMPLOYEE BENEFITS
$
$
$
$
$
$
$
COVERAGES
LIMITS
TOTAL
OTHER
PRODUCTS
PREMISES/OPERATIONS
PREMIUMS
OCCURRENCE
PER
CLAIM
PER
$
$BODILY INJURY
$PROPERTY DAMAGE
DEDUCTIBLES
OCCURRENCECLAIMS MADE
OWNER'S & CONTRACTOR'S PROTECTIVE
COMMERCIAL GENERAL LIABILITY
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)
IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy.
Read all provisions of the policy carefully.
Attach to ACORD 125
PREM / OPSPREM / OPS PRODUCTS
LOC # HAZ #
CLASS
CODE
PREMIUM
BASIS
CLASSIFICATION DESCRIPTION
EXPOSURE
TERR
PREM / OPS
RATE
PRODUCTS PREM / OPS
PREMIUM
PRODUCTS
LOC # HAZ #
CLASS
CODE
PREMIUM
BASIS
EXPOSURE
TERR
PREM / OPS PRODUCTS
RATE
PREM / OPS PRODUCTS
PREMIUM
CLASSIFICATION DESCRIPTION
Page 2 of 4
AGENCY CUSTOMER ID:
CONTRACTORS
TIME STAFF:
# PART-
TIME STAFF:
# FULL-
SUBCONTRACTED:
% OF WORK
CONTRACTORS:
$ PAID TO SUB-
DESCRIBE THE TYPE OF WORK SUBCONTRACTED
6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?
5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?
3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?
2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?
1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?
Y / NEXPLAIN ALL "YES" RESPONSES (For all past or present operations)
PRODUCTS / COMPLETED OPERATIONS
PRINCIPAL COMPONENTSINTENDED USE
LIFE
EXPECTED
MARKET
TIME IN
# OF UNITSANNUAL GROSS SALESPRODUCTS
Y / NEXPLAIN ALL "YES" RESPONSES (For all past or present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC.
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?
4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?
7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?
8. PRODUCTS UNDER LABEL OF OTHERS?
9. VENDORS COVERAGE REQUIRED?
10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
ACORD 126 (2016/09)
AGENCY CUSTOMER ID:
Page 3 of 4
REFERENCE / LOAN #:
EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS
ACORD 45 attached for additional names
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT
ITEM:
CLASS:
ITEM
ITEM DESCRIPTION
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
EMPLOYEE AS LESSOR
LIENHOLDER
MORTGAGEE
LOSS PAYEE
ADDITIONAL INSURED
INTEREST
LARGE EQUIPMENTSMALL TOOLS
EQUIPMENT INSTRUCTION GIVEN (Y/N)
LARGE EQUIPMENTSMALL TOOLS
TYPE OF EQUIPMENT
DO YOU RENT OR LOAN EQUIPMENT TO OTHERS?5.
ANY DEMOLITION EXPOSURE CONTEMPLATED?15.
ANY STRUCTURAL ALTERATIONS CONTEMPLATED?14.
CONTACT
SPORT (Y/N)
EXTENT OF SPONSORSHIP:
OVER 18
13 - 18
12 & UNDER
AGE GROUP
TYPE OF SPORT
CONTACT
SPORT (Y/N)
EXTENT OF SPONSORSHIP:
OVER 18
13 - 18
12 & UNDER
AGE GROUP
TYPE OF SPORT
ARE ATHLETIC TEAMS SPONSORED?13.
ARE SOCIAL EVENTS SPONSORED?12.
LIFE GUARDIN GROUNDABOVE GROUND
DIVING BOARDLIMITED ACCESS
IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply)11.
APPROVED FENCE SLIDE
DESCRIBE OTHER LODGING OPERATIONS
Sq. Ft.
TOTAL APT AREA# APTS
ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES", answer the following):10.
GENERAL INFORMATION
9. RECREATION FACILITIES PROVIDED?
8. IS A FEE CHARGED FOR PARKING?
7. ANY PARKING FACILITIES OWNED/RENTED?
6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?
4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?
3.
DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR
TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)
2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?
1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
Y / NEXPLAIN ALL "YES" RESPONSES (For all past or present operations)
LENDER'S LOSS PAYABLE
ACORD 126 (2016/09)
WORKERS
COMPENSATION
COVERAGE CARRIED (Y/N)
LEASE FROM
WORKERS
COMPENSATION
COVERAGE CARRIED (Y/N)
LEASE TO
DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
17.
16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?
AGENCY CUSTOMER ID:
18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?
19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
GENERAL INFORMATION (continued)
Y / N
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
Page 4 of 4
22. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?
21. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?
20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?
SIGNATURE
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.
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, electronic, electronic impulse, facsimile, magnetic, oral, or
telephonic communication or 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.
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.
ACORD 126 (2016/09)
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