ACORD ™

COMMERCIAL INSURANCE APPLICATION

DATE

APPLICANT INFORMATION SECTION

AGENCY
PHONE: (A/C,Ext)
FAX: (A/C, No)
E-MAIL ADDRESS
CODE:
SUBCODE:
AGENCY CUSTOMER ID:

CARRIER	NAIC CODE	UNDERWRITER	UNDERWRITER OFF.
POLICIES OR PROGRAM REQUESTED		POLICY NUMBER

INDICATE SECTIONS ATTACHED
PROPERTY
GLASS AND SIGN
ACCTS RECEIVABLE/VALUABLE PAPERS
CRIME/MISC. CRIME
TRANSPORT/MOTOR TRUCK CARGO

EQUIPMENT FLOATER
INSTALLATION BUILDERS RISK
ELECTRONIC DATA PROC.
COMMERCIAL GENERAL LIAB.
BUSINESS AUTO
TRUCKERS/MOTOR CARRIER

GARGE AND DEALERS
VEHICLE SCHEDULE
BOILER & MACHINERY
WORKERS COMP
UMBRELLA

STATUS OF TRANSACTION

PACKAGE POLICY INFORMATION

QUOTE	ISSUE POLICY		RENEW
BOUND (Give date and/or attach copy)
CHANGE	DATE	TIME	AM
CANCEL			PM

ENTER INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES
PROPOSED EFF DATE	PROPOSED EXP DATE	BILLING PLAN	PAYMENT PLAN	AUDIT
		DIRECT BILL
		AGENCY BILL

APPLICANT INFORMATION

NAME (First Named Insured & Other Named Insureds)

FEIN OR SOC SEC#
(of First Named Insued:

MAILING ADDRESS INCL ZIP+4 (of First Named Insured)

PHONE (A/C, No, Ext):

E-MAIL ADDRESS(ES): WEBSITE ADDRESS(ES):

INDIVIDUAL	CORPORATION	SUB "S" CORP	LLC		CR BUREAU NAME	ID NUMBER	DATE BUS STARTED
PARTNERSHIP	JOINT VENTURE	NOT FOR PROF	NO. OF MEMBERS AND MANAGERS

INSPECTION CONTACT		ACCOUNTING RECORDS CONTACT
PHONE:		PHONE:

PREMISES INFORMATION
LOC#	BLD#	STREET, CITY, COUNTY, STATE, ZIP CODE	CITYLIMITS	INTEREST	YR BUILT	# EMPLOYEES	ANNUAL REVENUES	PART OCCUPIED
			INSIDE	OWNER
			OUTSIDE	TENANT
			INSIDE	OWNER
			OUTSIDE	TENANT

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)

GENERAL INFORMATION

EXPLAIN ALL YES RESPONSES

Yes/No

EXPLAIN ALL YES RESPONSES

Yes/No

1a.

IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY?

ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

1b.

DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, this quetion 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).

IS A FORMAL SAFETY PROGRAM IN OPERATION?

ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?

ANY CATASTROPHE EXPOSURE?

ANY UNCORRECTED FIRE CODE VIOLATIONS?

ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?

10.

HAS BUSINESS BEEN PLACED IN A TRUST? IF YES, LIST IN REMARKS.

ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR 3 YEARS? (Not applicable in MO)

11.

ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST 5 YEARS?

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 THERTO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWER TO QUESTIONS ON THIS APPLICAITON. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

APPLICANT'S SIGNATURE	DATE	PRODUCER'S SIGNATURE	NATIONAL PRODUCER NUMBER

ACORD125 (2004/03)

PRIOR CARRIER INFORMATION
C O M M E R C I A L G E N E R A L L I A B	CARRIER
	POLICY NUMBER
	POLICY TYPE - Claims Made or Occurrence			CM OCC	CM OCC	CM OCC	CM OCC	CM OCC
	RETRO DATE
	EFF-EXP DATE
	L I M I T S	GENERAL AGGREGATE
		PRODUCTS COMP OP AGGREGATE
		PERSONAL & ADV INJ
		EACH OCCURRENCE
		FIRE DAMAGE
		MEDICAL EXPENSE
		BODILY INJURY	OCCURRENCE
		BODILY INJURY	AGGREGATE
		PROPERTY DAMAGE	OCCURRENCE
		PROPERTY DAMAGE	AGGREGATE
		COMBINED SINGLE LIMIT
	MODIFICATION FACTOR
	TOTAL PREMIUM
A U T O L I A B I L I T Y	CARRIER
	POLICY NUMBER
	POLICY TYPE
	EFF- EXP DATE
	COMBINED SINGLE LIMIT
	BODILY INJURY		OCCURRENCE
	BODILY INJURY		AGGREGATE
	PROPERTY DAMAGE
	MODIFICATION FACTOR
	TOTAL PREMIUM
P R O P E R T Y	CARRIER
	POLICY NUMBER
	POLICY TYPE
	EFF-EXP DATE
	BUILDING AMT
	PERS PROP AMT
	MODIFICATION FACTOR
	TOTAL PREMIUM

LOSS HISTORY

CHECK HERE IF NONE SEE ATTACHED LOSS SUMMARY

ENTER ALL CLAIMS OR LOSSES (Regardless of fault and whether or not insured)OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEARS (3 Years in KS & NY)
OCCURENCE DATE	LINE	TYPE/DESCRIPTION OF OCCURRENCE OR CLAIMS	CLAIM DATE	AMOUNT PAID	RESERVED	STATUS
						Open Clsd
						Open Clsd

ATTACHMENTS
STATE SUPPLEMENT(S) (if applicable)

COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent for your state's requirements.)

NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU, SUCH INFORMA TION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE TO 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 INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.

ACORD 125 (2004/03)