COMMERCIAL INSURANCE APPLICATION DATE …

ACCOUNTING RECORDS CONTACT:PHONE(A/C, No, Ext):E-MAILADDRESS:INSPECTION CONTACT:PHONE(A/C, No, Ext):E-MAILADDRESS:WEBSITEADDRESS(ES):MA ILING ADDRESS INCL ZIP+4 (of First Named Insured)ADDRESS(ES):E-MAILNAME (First Named Insured & Other Named Insureds)(of First Named Insured):FEIN OR SOC SEC #PHONE(A/C, No, Ext):APPLICANT INFORMATIONAND MANAGERSNO. OF MEMBERSPROFIT ORGNOT FORLLCCORPORATIONSUBCHAPTER "S"STARTEDDATE BUSID NUMBER:INDIVIDUALPARTNERSHIPCORPORATIONJ OINT VENTURECR BUREAU NAME:NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)ACORD 823 attached for additional premisesPREMISES INFORMATIONTENANTOWNEROUTSIDEINSIDETENAN TOWNEROUTSIDEINSIDETENANTOWNEROUTSIDEINS IDETENANTOWNEROUTSIDEINSIDEANNUAL REVENUES#EMPLOYEES%OCCUPIEDYRBUILTINTERE STCITY LIMITSSTREET, CITY, COUNTY, STATE, ZIP+4 BLD #LOC #YACHTOPEN CARGODRIVER INFO SCHEDULEDEALERSUNDERWRITER OFFICE:UNDERWRITER:POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERGENERAL LIABILITYCOMMERCIALTRANSPORTATION/MOTOR TRUCK CARGOVALUABLE PAPERSACCOUNTS RECEIVABLE/INDICATE SECTIONS ATTACHEDCARRIERNAIC CODEPROPERTYGLASS AND SIGNCRIME/MISCELLANEOUS CRIMEGARAGE AND DEALERSVEHICLE SCHEDULEBOILER & MACHINERYWORKERS COMPENSATIONTRUCKERS/MOTOR CARRIERUMBRELLABUSINESS AUTOELECTRONIC DATA PROCINSTALLATION/BUILDERS RISKEQUIPMENT FLOATERSUB CODE:E-MAILADDRESS:(A/C, No):FAX(A/C, No, Ext):PHONEAGENCYCO

page 2 of 3 6. any policy or coverage declined, cancelled or non-renewed during the prior three (3) years? (not applicable in mo) any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or

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