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
ATTACHMENTS
CONTRACTORS SUPPLEMENT
CONDO ASSN BYLAWS (for D&O Coverage only)
APARTMENT BUILDING SUPPLEMENT
ADDITIONAL PREMISES
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 (2013/01)
$$
METHOD OF PAYMENT
PREMIUM
MINIMUM
$
DEPOSIT POLICY PREMIUMAUDITPAYMENT PLANBILLING PLAN
DIRECT AGENCY
PROPOSED EXP DATEPROPOSED EFF DATE
POLICY INFORMATION
$
SECTIONS ATTACHED
COMMERCIAL GENERAL LIABILITY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
PREMIUMPREMIUMPREMIUM
BUSINESS OWNERS
EQUIPMENT FLOATER
INSTALLATION / BUILDERS RISK
ELECTRONIC DATA PROC
BUSINESS AUTO UMBRELLA
TRUCKERS / MOTOR CARRIERBOILER & MACHINERY
GARAGE AND DEALERS
CRIME / MISCELLANEOUS CRIME
GLASS AND SIGN
PROPERTY
INDICATE SECTIONS ATTACHED
ACCOUNTS RECEIVABLE /
VALUABLE PAPERS MOTOR TRUCK CARGO
TRANSPORTATION /
DEALERS
OPEN CARGO
YACHT
© 1993-2013 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
ACORD 125 (2013/01)
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
Page 2 of 4
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 (2013/01)
$$$$
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)
Page 3 of 4
13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
SAFETY POSITION OSHA
MONTHLY 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.
RESOLUTION
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
DATE
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
10.
RESOLUTION
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
DATE
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
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
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:
(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 Puerto Rico: 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 Maine, Tennessee, Virginia and 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 may include imprisonment, fines or a denial of insurance benefits.
Applicable in Kansas: 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 Florida and Oklahoma: 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 (In FL, a person is guilty of a felony of the third degree).
Applicable in Colorado: 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, AZ, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines or
confinement in prison.
Any person who knowingly and with intent to defraud any insurance company or other 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 that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a
crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the
claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PR, RI, TN, VA, VT, WA and WV).
ACORD 125 (2013/01)
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.
Page 4 of 4
(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:
Attach to ACORD 125
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
© 1993-2011 ACORD CORPORATION. All rights reserved.ACORD 126 (2011/09)
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
CLASS
CODE
PREMIUM
BASIS
TERR
EXPOSURE
HAZ
#
(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
PRODUCTSPREM/OPS
PREMIUM
PRODUCTSPREM/OPS
RATE
SCHEDULE OF HAZARDS
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)
ACORD 126 (2011/09) 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 (2011/09)
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)
ACORD 126 (2011/09)
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?
IN KANSAS, 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.
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. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF
FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
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 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 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.
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, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
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?
REFERENCE / LOAN #:
EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS
ACORD 45 attached for additional names
ADDITIONAL INTEREST
ITEM:
CLASS:
ITEM
ITEM DESCRIPTION
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
MORTGAGEE
LOSS PAYEE
INTEREST
REMARKS
PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK
Y / N
SOLID FUELBOILER
SECONDARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N
SOLID FUELBOILER
PRIMARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?
GONG
LOCAL
STATION
CODE NUMBERFIRE DISTRICT
# OF OPEN SIDES ON STRUCTURE:
VALU-
ATION
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BREAKDOWN OR CONTAMINATION
SELLING
PRICE
POWER OUTAGE
LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)
OPTIONS
REFRIG MAINT
AGREEMENT
(Y/N)
$
DEDUCTIBLE
$
LIMITDESCRIPTION OF PROPERTY COVERED
SPOILAGE
COVERAGE
(Y/N)
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION
SUBJECT OF INSURANCE AMOUNT COINS % CAUSES OF LOSS
INFLATION
GUARD %
DED FORMS AND CONDITIONS TO APPLY
BLKT
#
CONSTRUCTION TYPE
DISTANCE TO
HYDRANT FIRE STAT
FT MI
PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA
OTHER OCCUPANCIESROOF TYPETAX CODE
GRADE
BLDG CODE
SEMI- RESISTIVE
RESISTIVE
WIND CLASS
INSTALLED:
DATE
MANUFACTURER:
STOVE OR FIREPLACE INSERT
HEATING SOURCE INCL WOODBURNING
% SPRNK
CENTRAL STATION
LOCAL GONG
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems)
FIRE ALARM MANUFACTURER
HEATING, YR:
PLUMBING, YR:
OTHER:
ROOFING, YR:
WIRING, YR:
BUILDING IMPROVEMENTS
YR:
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
EXTENT GRADE
CENTRAL
WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN
CLOCK HOURLY
EFFECTIVE DATE
NAIC CODE
CARRIER
POLICY NUMBER
NAMED INSURED(S)
AGENCY NAME
AGENCY CUSTOMER ID:
© 1985-2011 ACORD CORPORATION. All rights reserved.Attach to ACORD 125
The ACORD name and logo are registered marks of ACORD
ACORD 140 (2011/10)
BLDG DESCRIPTION:
STREET ADDRESS:PREMISES #:
BUILDING #:
PREMISES INFORMATION
DATE (MM/DD/YYYY)
PROPERTY SECTION
ACORD 140 (2011/10)
REFERENCE / LOAN #:
EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS
ACORD 45 attached for additional names
ADDITIONAL INTEREST
ITEM:
CLASS:
ITEM
ITEM DESCRIPTION
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
MORTGAGEE
LOSS PAYEE
INTEREST
REMARKS
PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK
Y / N
SOLID FUELBOILER
SECONDARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N
SOLID FUELBOILER
PRIMARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?
GONG
LOCAL
STATION
CODE NUMBERFIRE DISTRICT
# OF OPEN SIDES ON STRUCTURE:
VALU-
ATION
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BREAKDOWN OR CONTAMINATION
SELLING
PRICE
POWER OUTAGE
LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)
OPTIONS
REFRIG MAINT
AGREEMENT
(Y/N)
$
DEDUCTIBLE
$
LIMITDESCRIPTION OF PROPERTY COVERED
SPOILAGE
COVERAGE
(Y/N)
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION
SUBJECT OF INSURANCE AMOUNT COINS % CAUSES OF LOSS
INFLATION
GUARD %
DED FORMS AND CONDITIONS TO APPLY
BLKT
#
CONSTRUCTION TYPE
DISTANCE TO
HYDRANT FIRE STAT
FT MI
PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA
OTHER OCCUPANCIESROOF TYPETAX CODE
GRADE
BLDG CODE
SEMI- RESISTIVE
RESISTIVE
WIND CLASS
INSTALLED:
DATE
MANUFACTURER:
STOVE OR FIREPLACE INSERT
HEATING SOURCE INCL WOODBURNING
% SPRNK
CENTRAL STATION
LOCAL GONG
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems)
FIRE ALARM MANUFACTURER
HEATING, YR:
PLUMBING, YR:
OTHER:
ROOFING, YR:
WIRING, YR:
BUILDING IMPROVEMENTS
YR:
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
EXTENT GRADE
CENTRAL
WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN
CLOCK HOURLY
AGENCY CUSTOMER ID:
Page 2 of 3
BLDG DESCRIPTION:
STREET ADDRESS:PREMISES #:
BUILDING #:
ADDITIONAL
PREMISES INFORMATION
ACORD 140 (2011/10)
AGENCY CUSTOMER ID:
REMARKS
FRAUD NOTICES
Page 3 of 3
IN KANSAS, 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.
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. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF
FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT
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 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 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.
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, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
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