Fillable BUSINESS OWNERS APPLICATION (Cluett Commercial Insurance Agency)

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BUSINESS OWNERS APPLICATION (Cluett Commercial Insurance Agency)

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NATURE OF BUSINESS
DATE (MM/DD/YYYY)
PHONE
(A/C, No, Ext):
AGENCY COMPANY NAIC CODE:
FAX
(A/C, No):
COMPANY POLICY OR PROGRAM NAME
PROGRAM
CODE:
EFFECTIVE DATE EXPIRATION DATE
PAYMENT PLAN
CODE: SUB CODE:
AGENCY CUSTOMER ID
DEPOSIT
POLICY TYPE
GL CODE SIC FEIN OR SOC SEC #
NAME (First Named Insured)
MAILING ADDRESS (INCLUDING ZIP+4)
PHONE
(A/C, No, Ext):
CONTACT FOR INSPECTION
CREDIT BUREAU NAME ID NUMBER
INTERNET ADDRESS:
DATE BUSINESS
STARTED
DESCRIPTION OF OPERATIONS
RETAIL STORES: % INSTALLATION, SERVICE OR REPAIR WORK
DIRECT BILL
NEW
AGENCY BILL
RNWL
QUOTE ISSUE POLICY
BOUND (DATE): $
STD SPEC
L L C
INDIVIDUAL
PARTNERSHIP
JOINT VENTURE
CORPORATION OTHER
OFFICE RETAIL APARTMENTS RESTAURANT
SERVICE WHOLESALE CONTRACTORCONDOMINIUMS
APPLICANT INFORMATION
BUSINESS OWNERS APPLICATION
E-MAIL
ADDRESS:
TOTAL
PREMIUM:
$
POLICY #:
16. ANY UNCORRECTED FIRE CODE VIOLATIONS?
15. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR
MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
ANY CATASTROPHE EXPOSURE?
14.
ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES OR CHEMICALS?13.
12.
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY,
JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS?
11. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS?
10. ARE YOU INVOLVED IN MANUFACTURING, MIXING, RELABELING
OR REPACKAGING OF PRODUCTS?
9. ANY OTHER INSURANCE WITH THIS COMPANY? (LIST POLICY NUMBERS)
8. DO YOU OWN OR OPERATE ANY OTHER BUSINESS?
ANY WORKERS COMPENSATION CARRIED?7.
6. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED
DURING THE PRIOR 3 YEARS? (NOT APPLICABLE IN MO)
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, failure to disclose the existence of an arson conviction is a misdemeanor
punishable by a sentence of up to one year of imprisonment).
4.
3.
ARE SUB CONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING A
CERTIFICATE OF INSURANCE? IF NOT, WHO CHECKS CERTIFICATES?
2. ARE ATHLETIC TEAMS SPONSORED?
1.
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)
PLEASE EXPLAIN ALL "YES" RESPONSES
YES NO PLEASE EXPLAIN ALL "YES" RESPONSES YES NO
DESCRIBE ANY LOCATION / BUSINESS INTEREST OWNED / OPERATED BY INSURED BUT NOT LISTED
GENERAL INFORMATION
ACORD 160 (2006/08)
The ACORD name and logo are registered marks of ACORD
Page 1 of 4
© ACORD CORPORATION 1993-2006. All rights reserved.
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ACTUAL LOSS SUSTAINED
NO. OF MONTHS
ACTUAL LOSS SUSTAINED
NO. OF MONTHS
MONEY & SEC
OUTSIDE
ORD OR LAW
EARTHQUAKE
COMPUTERS
B & M BROAD
MONEY &
SEC - INSIDE
COVERAGE TOTAL AMOUNT DED END #s COVERAGE TOTAL AMOUNT DED
END #s
RESTAURANTS - ATTACH ACORD 185 FOR EACH LOCATION
RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
PREMISES: BUILDING:
LOSS PAYEE
VEHICLE: BOAT:
MORTGAGEE SCHEDULED ITEM NUMBER:
OTHER
LIENHOLDER
ITEM DESCRIPTION:
NOTICE OF INSURANCE INFORMATION PRACTICES
DATE
PRODUCER'S SIGNATURE
NATIONAL PRODUCER NUMBER
EXTRA EXP
$
$
$
$
$
$
ERISA
$
$
LOSS OF
INC
$
FLOOD
$
$
$
VAL
PAPERS
$
$
$
$
ACCNTS
REC
B & M BASIC
$$ $$
SIGN
$$ $$
EMPL
DISHON
B & M
SPOILAGE
$$ $$
BRG/ROB
STK
TRANSIT
$$ $$
BRG/ROB
MNY
$$ $$
$$ $$
$$ $$
SPOILAGE
$
$
$$
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH
THIS APPLICATION AND SUBSEQUENT 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.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS
TO QUESTIONS ON THIS APPLICATION. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
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, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA, and WA insurance benefits may also be denied)
ADDITIONAL COVERAGES - Total Amount of Policy Coverage Desired
ACORD 45 ATTACHED
ADDITIONAL INTEREST
Page 2 of 4ACORD 160 (2006/08)
CONTRACTORS - ATTACH ACORD 186 FOR EACH LOCATION
PROFESSIONAL LIABILITY - ATTACH ACORD 187 FOR BARBER AND BEAUTY SHOPS, FUNERAL HOMES, OPTICAL AND HEARING AID ESTABLISHMENTS, PRINTERS OR VETERINARIANS
INTEREST
SPECIALTY PROGRAMS
APPLICANT'S SIGNATURE
# LOSSES
LAST
YRS
GEN. AGGREGATE
PER PERSON
OTHER:
BODILY INJURY
& PROP
DAMAGE
PREVIOUS CARRIER
POLICY NUMBER
TOTAL PREMIUM EXP DATE
TOTAL LOSSES
DESCRIPTION OF LOSSES, WHETHER OR NOT INSURED (Date, cause, amt paid, claim status)
$
COMBINED SINGLE LIMIT HIRED AUTO
$ $
OCCURRENCE NON-OWNED AUTO
$ $
AGGREGATE EMPLOYEE BENEFITS
$ $
MEDICAL EXPENSE
(PER PERSON)
$ $
DAMAGE TO RENTAL PREMISES
$
$
PROFESSIONAL LIABILITY
$
$
LIQUOR LIABILITY
$
$
$
$
$
$
$
COVERAGE LIMIT DED COVERAGE LIMIT DED
PRIOR POLICY(IES)/LOSS HISTORY
See attached loss summary
POLICY LEVEL COVERAGES
LIABILITY (Choose the limit options compatible with the program you are requesting)
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ACTUAL LOSS SUSTAINED
NO. OF MONTHS
ACTUAL LOSS SUSTAINED
NO. OF MONTHS
GEN. AGGREGATE
PER PERSON
OTHER:
MONEY & SEC
OUTSIDE
ORD OR LAW
EARTHQUAKE
COMPUTERS
B & M BROAD
MONEY &
SEC - INSIDE
BLANKET RATE YES ACORD 139 ATTACHED
PREM #:
PERCENTAGE
OCCUPIED
SURROUNDING EXPOSURES & OTHER OCCUPANCIES
ADDRESS
(Street, City, State)
INTEREST
FRONT RIGHT
SQUARE FEET
OCCUPIED
REAR LEFT
YEAR BUILT
PROT
CLASS
RATE
TERR
DISTANCE TO
FIRE DISTRICT/CODE NUMBER
HYDRANT FIRE STAT
ZIP:
COUNTY:
BUILDING DESCRIPTIONDESCRIPTION OF OPERATIONS AT THIS PREMISES
HOURS OF OPERATION ANNUAL SALES/RECEIPTS
TOTAL PAYROLL
START TIME: CLOSING TIME:
DESCRIPTION OF ALL OCCUPANCIES AT THIS PREMISESCLASS CODE RATE # RATE GROUP
LIMIT % COINS INFL % DED CONSTRUCTION TYPE TOT SQ FT AREA
VALU-
ATION:
BLDG
#
STORIES
%
SPRNK
LIMIT % COINS DED
PERS
PROP
(N/A)
VALU-
ATION:
INSPECTED?
WIND CLASS
WIRING
YEAR
ROOFING
YEAR
PLUMBING
YEAR
HEATING
YEAR
BLDG CODE
GRADE
ROOF TYPE
TAX CODE
BUILDING
IMPROVEMENTS
NO
CLASS
CODE
PREMIUM BASIS
CLASSIFICATION
EXPOSURE
CODE
TENANTS
EXT
LOCATION IN BUILDING # PLATES
AREA SQ FT LENGTH LINEAR FT GLASS TYPE INTERIOR VALUE DED
YES NO YES NO
CHECK IF PRI-
MARY PREMISES
OWNER
TENANT
ANY AREA LEASED? YES NO
INSIDE CITY LIMITS?
FT MI YES NO
$
RC ACV
$ FVRC
$
RC
ACV BASEMENT PRESENT? YES NO
$ FVRC
$
IS IT FINISHED? YES NO
COMM
SPEC
RESISTIVE
SEMI-RESISTIVE
LIQUOR LIABILITY
$
$
$
$
$
$
$
$ $
$ $
$ $
(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
EXTRA EXP SPOILAGE
$
$
$
$ $$
$$
LOSS OF
INC
$
FLOOD
$
$
$
VAL
PAPERS
$$ $$
ACCNTS
REC
B & M BASIC
$$ $$
SIGN
$$
$
$
EMPL
DISHON
B & M
SPOILAGE
$$ $$
BRG/ROB
STK
TRANSIT
$$ $$
BRG/ROB
MNY
$
$
$
$
$$ $$
$$ $$
GLASS
GROUND FLOOR GLASS
$
$
ABOVE GROUND FLOOR GLASS
$
$
DOES APPLICANT HAVE A HEATING OR PROCESSING BOILER? (IF YES,
INDICATE DATE OF LAST INSPECTION)
1.
4. IS ALL EQUIPMENT INSPECTED ANNUALLY AND WELL MAINTAINED?
2. CURRENT CARRIER FOR BOILER & MACHINERY COVERAGE:
YES
FENCED
ABOVE
GROUND
LIFE
GUARD
DIVING
BOARD
ANY SPECIALIZED EQUIPMENT, SUCH AS MEDICAL EQUIPMENT OR
OTHER, VALUED OVER $100,000? IF YES, DESCRIBE.
3.
NO
LIMITED
ACCESS
SLIDE
IN -
GROUND
NO
COVERAGE LIMIT DED COVERAGE LIMIT DED
COVERAGE TOTAL AMOUNT DED END #s COVERAGE TOTAL AMOUNT DED END #s
PREMISES
PROPERTY
LIABILITY - PREMISES COVERAGE ONLY (Choose the limit options compatible with the program you are requesting)
PREMISES GENERAL INFORMATION
Page 3 of 4ACORD 160 (2006/08)
# OF EMPLOYEES
ADDITIONAL COVERAGES - PREMISES COVERAGE ONLY - Total Amount of Coverage Desired
REMARKS (Attach additional sheets if more space is required)
$
5. IS THERE A SWIMMING POOL ON PREMISES?
BLDG #:
YES
DED
DED
$
$
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YES NO YES NO
LABELALARM TYPE ALARM DESCRIPTION EXTENT OF PROTECTION
SAFE/VAULT/RECEPTACLE MANUFACTURER'S NAME
GRADE
PREMISES
ALARM
SAFE/VAULT
1 2 3
CLASS
EXP
DATE:
CERT #:
MAXIMUM CASH
ON PREMISES
MAXIMUM CASH
WITH MESSENGER
MONEY ON
PREMISES OVERNIGHT
FREQUENCY
OF DEPOSITS
SAFE DOOR CONSTRUCTION
OTHER PROTECTION
(Lighting, fences, watchpersons, etc)
SMOKE DETECTORS: NONE BATTERY WIRED
IS THERE A PLAYGROUND ON PREMISES?
ATTACH COPY OF CONDO ASSOCIATION BYLAWS IF D&O COVERAGE IS REQUESTED.
# OF FIRE
DIVISIONS:
# UNITS PER
FIRE DIVISION:
# UNITS
OWNER OCCUPIED:
IS DEVELOPER OR CONTRACTOR A BOARD MEMBER?
INDICATE WHERE COVERAGE APPLIES TO: BARE WALLS FINISHED WALLS
IS A PROPERTY MANAGER EMPLOYED?
UL
HOLD-UP LOCAL GONG
SMNA
PREMISES
CNTRL STAT W/ KEYS PARTIAL
SAFE/VAULT CNTRL STAT W/O KEYS COMPLETE
POLICE CONNECT
DEADBOLT CYLINDER
DOOR LOCKS?
$ $ $
YES NO
APARTMENTS AND CONDOMINIUMS
REMARKS (Attach additional sheets if more space is required)
Page 4 of 4ACORD 160 (2006/08)
CRIME
IS ALUMINUM WIRE USED? (IF YES, DESCRIBE PROTECTION)
1.
2.
3.
4.
5.
6.
7.
8.
ATTACHMENTS
STATE SUPPLEMENT(S) (If applicable)
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BUSINESS OWNERS APPLICATION (Cluett Commercial Insurance Agency)

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Completed 17 September 2021

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