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PROGRAM CODECOMPANY POLICY OR PROGRAM NAMEPOLICY NUMBERCARRIERNAIC CODEPMAMTIMEDATECHANGECANCELBOUND (Give Date and/or Attach Copy):ISSUE POLICYQUOTERENEWSTATUS OFTRANSACTIONE-MAILADDRESS:AGENCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No):FAXAPPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONDATE (MM/DD/YYYY)UNDERWRITERUNDERWRITER OFFICEAPPLICANT INFORMATIONThe ACORD name and logo are registered marks of ACORDPage 1 of 4© 1993-2009 ACORD CORPORATION. All rights reserved.YACHTOPEN CARGODEALERSTRANSPORTATION /MOTOR TRUCK CARGOVALUABLE PAPERSACCOUNTS RECEIVABLE /INDICATE SECTIONS ATTACHEDPROPERTYGLASS AND SIGNCRIME / MISCELLANEOUS CRIMEGARAGE AND DEALERSBOILER & MACHINERYTRUCKERS / MOTOR CARRIERUMBRELLABUSINESS AUTOELECTRONIC DATA PROCINSTALLATION / BUILDERS RISKEQUIPMENT FLOATERBUSINESS OWNERSPREMIUMPREMIUMPREMIUM$$$$$$$$$$$$$$$$$$$$COMMERCIAL GENERAL LIABILITYSECTIONS ATTACHED$POLICY INFORMATIONPROPOSED EFF DATEPROPOSED EXP DATEAGENCYDIRECTBILLING PLANPAYMENT PLANAUDITPOLICY PREMIUMDEPOSIT$MINIMUMPREMIUMMETHOD OF PAYMENT$$ACORD 125 (2009/08)FEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATIONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)DRIVER INFORMATION SCHEDULECOVERAGES SCHEDULEADDITIONAL PREMISESAPARTMENT BUILDING SUPPLEMENTCONDO ASSN BYLAWS (for D&O Coverage only)CONTRACTORS SUPPLEMENTATTACHMENTSADDITIONAL INTERESTINTERNATIONAL LIABILITY EXPOSURE SUPPLEMENTINTERNATIONAL PROPERTY EXPOSURE SUPPLEMENTLOSS SUMMARYPREMIUM PAYMENT SUPPLEMENTPROFESSIONAL LIABILITY SUPPLEMENTRESTAURANT / TAVERN SUPPLEMENTSTATEMENT / SCHEDULE OF VALUESSTATE SUPPLEMENT (If applicable)VACANT BUILDING SUPPLEMENTVEHICLE SCHEDULEFEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATIONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)FEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATIONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977AGENCY CUSTOMER ID:CONTACT TYPE:CONTACT NAME:PRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS:CONTACT INFORMATIONCONTACT TYPE:PRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS:CONTACT NAME:PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)Page 2 of 4OFFICESERVICERETAILWHOLESALEAPARTMENTSCONDOMINIUMSRESTAURANTCONTRACTORSTARTED (MM/DD/YYYY)DATE BUSINESSINSTITUTIONALMANUFACTURINGNATURE OF BUSINESSINSTALLATION, SERVICE OR REPAIR WORKRETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:DESCRIPTION OF PRIMARY OPERATIONSOFF PREMISES INSTALLATION, SERVICE OR REPAIR WORKDESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS%%TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPTION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$PRIMARYBUSHOMECELLPHONE #BUSHOMECELLSECONDARYPHONE #PRIMARYBUSHOMECELLPHONE #BUSHOMECELLSECONDARYPHONE #ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional InterestsTENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPTION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPTION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPTION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$ITEMBOAT:VEHICLE:BUILDING:LOCATION:EMPLOYEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONALINTEREST IN ITEM NUMBERCERTIFICATEREFERENCE / LOAN #:NAME AND ADDRESSRANK:INTERESTITEM DESCRIPTIONINSUREDAS LESSOREVIDENCE:POLICYSEND BILLOWNERCO-OWNERAIRCRAFT:AIRPORT:CLASS:ITEM:INTEREST END DATE:LIEN AMOUNT:PHONE (A/C, No, Ext):FAX (A/C, No):REGISTRANTTRUSTEEBREACH OFWARRANTYLEASEBACKOWNERREASON FOR INTEREST:E-MAIL ADDRESS:ACORD 125 (2009/08)AGENCY CUSTOMER ID:12.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)8.ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?OCCURRENCEDATEEXPLANATIONRESOLUTIONDATERESOLUTION7.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 punishableby a sentence of up to one year of imprisonment).6.ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?GENERAL INFORMATION5.ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OROPERATIONS? (Missouri Applicants - Do not answer this question)NON-PAYMENTNON-RENEWALAGENT NO LONGER REPRESENTS CARRIERUNDERWRITINGCONDITION CORRECTED (Describe):9.HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?OCCURRENCEDATEEXPLANATIONRESOLUTIONDATERESOLUTION10.HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?OCCURRENCEDATEEXPLANATIONRESOLUTIONDATERESOLUTION11.HAS BUSINESS BEEN PLACED IN A TRUST?NAME OF TRUSTLINE OF BUSINESSLINE OF BUSINESSPOLICY NUMBERPOLICY NUMBERANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)4.1b.1a.IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?DOES THE APPLICANT HAVE ANY SUBSIDIARIES?% OWNEDRELATIONSHIP DESCRIPTIONPARENT COMPANY NAME% OWNEDRELATIONSHIP DESCRIPTIONSUBSIDIARY COMPANY NAMEEXPLAIN ALL "YES" RESPONSESY / NIS A FORMAL SAFETY PROGRAM IN OPERATION?2.SAFETY MANUALMONTHLY MEETINGSOSHASAFETY POSITIONANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?3.DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?13.Page 3 of 4REMARKS / PROCESSING INSTRUCTIONS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)ACORD 125 (2009/08)AGENCY CUSTOMER ID:PRIOR CARRIER INFORMATIONCATEGORYGENERAL LIABILITYAUTOMOBILEPROPERTYOTHER:CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEYEAREFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$LOSS HISTORYTYPE / DESCRIPTION OF OCCURRENCE OR CLAIMLINEENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMSFOR THE LAST YEARSCLAIMOPENY / NAMOUNT RESERVEDSUBRO-GATIONY / NAMOUNT PAIDDATE OF CLAIMDATE OFOCCURRENCETOTAL LOSSES: $Check if none(Attach Loss Summary for Additional Loss Information)Page 4 of 4THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HERKNOWLEDGE.COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU INCONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY USOR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEWYOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS ANDOUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMITA REQUEST TO US.STATE PRODUCER LICENSE NOPRODUCER'S NAME (Please Print)APPLICANT'S SIGNATUREDATEPRODUCER'S SIGNATURE(Required in Florida)NATIONAL PRODUCER NUMBERSIGNATUREANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (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 ANAPPLICATION 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 ORANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FORTHE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BEA 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 OFDEFRAUDING 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 DEFRAUDINGTHE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.ACORD 125 (2009/08)