Fillable COMMERCIAL GENERAL LIABILITY SECTION

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COMMERCIAL GENERAL LIABILITY SECTION

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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
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 (2007/05) © ACORD CORPORATION 1993-2007. All rights reserved.Page 1 of 4
EMPLOYEE BENEFITS LIABILITY
1. DEDUCTIBLE PER CLAIM: $
2. NUMBER OF EMPLOYEES:
3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:
4. RETROACTIVE DATE:
PHONE
(A/C, No, Ext):
DATE (MM/DD/YYYY)
AGENCY
APPLICANT
EFFECTIVE DATE EXPIRATION DATE
PAYMENT PLAN AUDIT
CODE:
SUB CODE:
COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ PREMIUMS
PREMISES/OPERATIONS
PRODUCTS & COMPLETED OPERATIONS AGGREGATE $
OWNER'S & CONTRACTOR'S PROTECTIVE PERSONAL & ADVERTISING INJURY $
PRODUCTS
EACH OCCURRENCE $
DEDUCTIBLES DAMAGE TO RENTED PREMISES (each occurrence) $
OTHER
MEDICAL EXPENSE (Any one person) $
EMPLOYEE BENEFITS $
TOTAL
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)
DIRECT BILL
AGENCY BILL
CLAIMS MADE
OCCURRENCE
$
PROPERTY DAMAGE
BODILY INJURY
$
$
COVERAGES
LIMITS
COMMERCIAL GENERAL LIABILITY SECTION
FAX
(A/C, No):
(First
Named
Insured)
FOR
COMPANY
USE ONLY
AGENCY
CUSTOMER ID:
PER
CLAIM
PER
OCCURRENCE
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 any past or present product or operation) 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 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
ATTACH TO ACORD 125ACORD 126 (2007/05)
Clear All
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?
16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?
INTEREST RANK:
ADDITIONAL INSURED
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE AS LESSOR
ITEM DESCRIPTION:
CERTIFICATE REQUIREDREFERENCE #: INTEREST IN ITEM NUMBER
LOCATION: BUILDING:
VEHICLE: BOAT:
SCHEDULED ITEM NUMBER:
OTHER
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
ACORD 45 attached for additional names
NAME AND ADDRESS
Page 3 of 4ACORD 126 (2007/05)
Clear All
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 or VT. In DC, LA, ME, TN, VA and WA 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.
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 4ACORD 126 (2007/05)
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
Y / N
GENERAL INFORMATION (continued)
REMARKS
17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
Clear All
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COMMERCIAL GENERAL LIABILITY SECTION

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Completed 9 February 2022

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