4. RETROACTIVE DATE:
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)
EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY
OWNER'S & CONTRACTOR'S PROTECTIVE
CLAIMS MADE OCCURRENCE
DEDUCTIBLES
PROPERTY DAMAGE $
BODILY INJURY $
$
PER
CLAIM
PER
OCCURRENCE
PREMIUMS
PREMISES/OPERATIONS
PRODUCTS
OTHER
TOTAL
LIMITS
COVERAGES
$
$
$
$
$
$
$
EMPLOYEE BENEFITS
MEDICAL EXPENSE (Any one person)
DAMAGE TO RENTED PREMISES (each occurrence)
PERSONAL & ADVERTISING INJURY
PRODUCTS & COMPLETED OPERATIONS AGGREGATE
GENERAL AGGREGATE
LIMIT APPLIES PER:
POLICY
PROJECT
LOCATION
OTHER:
$
SCHEDULE OF HAZARDS
RATE
PREM/OPS PRODUCTS
PREMIUM
PREM/OPS PRODUCTS
RATING AND PREMIUM BASIS
(S) GROSS SALES - PER $1,000/SALES
(P) PAYROLL - PER $1,000/PAY
(A) AREA - PER 1,000/SQ FT
(C) TOTAL COST - PER $1,000/COST
(M) ADMISSIONS - PER 1,000/ADM
(U) UNIT - PER UNIT
(T) OTHER
#
HAZ
EXPOSURE
TERR
BASIS
PREMIUM
CODE
CLASS
CLASSIFICATION
#
LOC
COMMERCIAL GENERAL LIABILITY SECTION
DATE (MM/DD/YYYY)
CLAIMS MADE (Explain all "Yes" responses)
1. PROPOSED RETROACTIVE DATE:
2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:
EXPLAIN ALL "YES" RESPONSES
3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?
4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?
Y / N
The ACORD name and logo are registered marks of ACORD
ACORD 126 (2009/08) © 1993-2009 ACORD CORPORATION. All rights reserved.
EMPLOYEE BENEFITS LIABILITY
1. DEDUCTIBLE PER CLAIM: $
2. NUMBER OF EMPLOYEES:
3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS
AGENCY
APPLICANT / FIRST NAMED INSURED
POLICY NUMBER
CARRIER
NAIC CODE
EFFECTIVE DATE
AGENCY CUSTOMER ID:
Attach to ACORD 125
Clear All
10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
9. VENDORS COVERAGE REQUIRED?
8. PRODUCTS UNDER LABEL OF OTHERS?
7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?
6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?
5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?
2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
EXPLAIN ALL "YES" RESPONSES (For all past or present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y / N
PRODUCTS ANNUAL GROSS SALES # OF UNITS
TIME IN
MARKET
EXPECTED
LIFE
INTENDED USE PRINCIPAL COMPONENTS
PRODUCTS / COMPLETED OPERATIONS
EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N
1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?
2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?
3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?
4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?
5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?
DESCRIBE THE TYPE OF WORK SUBCONTRACTED
$ PAID TO SUB-
CONTRACTORS:
% OF WORK
SUBCONTRACTED:
# FULL-
TIME STAFF:
# PART-
TIME STAFF:
CONTRACTORS
ACORD 126 (2009/08)
AGENCY CUSTOMER ID:
Page 2 of 4
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EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N
1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?
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)
3.
4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?
5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS?
6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?
7. ANY PARKING FACILITIES OWNED/RENTED?
8. IS A FEE CHARGED FOR PARKING?
9. RECREATION FACILITIES PROVIDED?
10. IS THERE A SWIMMING POOL ON THE PREMISES?
11. SPORTING OR SOCIAL EVENTS SPONSORED?
12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?
13. ANY DEMOLITION EXPOSURE CONTEMPLATED?
GENERAL INFORMATION
14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?
15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
INTEREST
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE AS LESSOR
INTEREST IN ITEM NUMBER
LOCATION: BUILDING:
ITEM DESCRIPTION
ITEM
CLASS:
ITEM:
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT
ACORD 45 attached for additional names
NAME AND ADDRESS CERTIFICATERANK: EVIDENCE:
REFERENCE / LOAN #:
Page 3 of 4ACORD 126 (2009/08)
AGENCY CUSTOMER ID:
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18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?
19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?
20. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?
Page 4 of 4
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
Y / N
GENERAL INFORMATION (continued)
REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
ACORD 126 (2009/08)
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, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in 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, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE
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.
16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?
AGENCY CUSTOMER ID:
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