ACORD ™ 

COMMERCIAL GENERAL LIABILITY SECTION
DATE  
PRODUCER
PHONE: (A/C, No, EXT)
CODE:
SUBCODE:
AGENCY CUSTOMER ID:
APPLICANT (First Named Insured)
EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT
AGENCY BILL
COVERAGES LIMITS
COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ PREMIUMS
CLAIMS MADE OCCURRENCE PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ PREMISES/OPERATIONS
OWNER'S & CONTRACTOR'S PROTECTIVE PERSONAL & ADVERTISING INJURY $
EACH OCCURRENCE $
DEDUCTIBLES DAMAGE TO RENTED PREMISES (each occurrence) $ PRODUCTS
PROPERTY DAMAGE $ PER CLAIM MEDICAL EXPENSE (Any one person) $
BODILY INJURY $ PER OCCURENCE EMPLOYEE BENEFITS $
$ $ OTHER
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the Business Auto Section, ACORD 127)
TOTAL
SCHEDULE OF HAZARDS
LOCATION # CLASSIFICATION CLASS
CODE		 PREMIUM
BASIS		 EXPOSURE TERR RATE PREMIUM
PREM/OPS PRODUCTS 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
CLAIMS MADE (Explain all "Yes" responses) EMPLOYEE BENEFITS LIABILITY
1.  PROPOSED RETROACTIVE DATE:
2.  ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV:
   
Yes/No
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?
1.  DEDUCTIBLE PER CLAIM:   $
2.  NUMBER OF EMPLOYEES:
3.  NUMBER OF EMPLOYEES
COVERED BY EMPLOYEE
BENEFITS PLANS:
4.  RETROACTIVE DATE:
REMARKS
 REMARKS
CONTRACTORS
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
Yes/No
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?
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
Yes/No
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?
REMARKS/DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUBCONTRACTORS:
 % OF WORK SUBCONTRACTED:
 # FULL
 # PART TIME STAFF:
PRODUCTS/COMPLETED OPERATIONS
PRODUCTS
ANNUAL GROSS SALES #
# OF UNITS
TIME IN MARKET
EXPECTED LIFE
INTENDED USE
PRINCIPAL COMPONENTS
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
INTEREST RANK: NAME AND ADDRESS REFERENCE #:
CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER
ADDITIONAL INSURED

LOCATION: BUILDING:
LOSS PAYEE VEHICLE: BOAT:
MORTGAGEE SCHEDULED ITEM NUMBER:
LIENHOLDER OTHER
EMPLOYEE AS LESSOR
  ITEM DESCRIPTION:
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
Yes/No
1.  ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
2.  ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?
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)
4.  ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN
LAST 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?
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
Yes/No
12.  PRODUCTS RECALLED, DISCONTINUED, CHANGED?
13.  PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER
APPLICANT LABEL?
14.  PRODUCTS UNDER LABEL OF OTHERS?
15.  VENDORS COVERAGE REQUIRED?
16.  DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
17.  ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
18.  HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON
YOUR PREMISES WITHIN THE LAST THREE 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?
REMARKS
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; IN DC, LA, ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)
ACORD 126 (2000/04)