Fillable COMMERCIAL GENERAL LIABILITY SECTION

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COMMERCIAL GENERAL LIABILITY SECTION

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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?
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COMMERCIAL GENERAL LIABILITY SECTION

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Completed 22 February 2022

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