Transcription of ACORD COMMERCIAL INSURANCE APPLICATION …
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ACORD COMMERCIAL INSURANCE APPLICATION …
TMDATE (MM/DD/YYYY)PHONEUNDERWRITER CODE:(A/C, No, Ext):FAX(A/C, No.):POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDCODE:SUB CODE:AGENCY CUSTOMER ID:PROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMEFEIN OR SOC SEC #NAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP+4 (of First Named Insured)(of First Named Insured):PHONE(A/C, No, Ext):CR BUREAUDATE BUSID NUMBERNAMESTARTEDPHONEPHONEINSPECTION CONTACTACCOUNTING RECORDS CONTACT(A/C, No, Ext):(A/C, No, Ext):LOC #BLD #STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITSINTERESTYR BUILTPART OCCUPIEDYES NOEXPLAIN ALL "YES" RESPONSESYES NO EXPLAIN ALL "YES" RESPONSESREMARKS/PROCESSING INSTRUCTIONSAPPLICANT'S SIGNATUREDATEPRODUCER'S SIGNATURENATIONAL PRODUCER NUMBEREQUIPMENT FLOATERGARAGE AND DEALERSPROPERTYINSTALLATION/BUILDERS RISKVEHICLE SCHEDULEGLASS AND SIGNELECTRONIC DATA PROCBOILER & MACHINERYWORKERS COMPENSATIONACCOUNTS RECEIVABLE/COMMERCIALVALUABLE PAPERSGENERAL LIABILI
loc. # tm date producer applicant proposed eff. date proposed exp. date billing plan payment plan audit for company use only % mo. in …
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