COMMERCIAL INSURANCE APPLICATION DATE …

CONDO ASSN BYLAWS (for D&O Coverage only)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 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$$$$$$$$$$$$$ $$$$$$$ COMMERCIAL GENERAL LIABILITYSECTIONS ATTACHED$POLICY INFORMATIONPROPOSED EFF DATE PROPOSED EXP DATEAGENCYDIRECTBILLING PLANPAYMENT PLANAUDITPOLICY PREMIUMDEPOSIT$MINIMUMPREMIUMMETHOD OF PAYMENT$$ACORD 125 (2009/08)FEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATI ONJOINT VENTURENOT FOR PROFIT ORGNO.

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 may subject the person to criminal and civil penalties.

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