Distributor/Wholesaler Supplemental Application

Distributor/Wholesaler SUPP-APP 12/15 1 of 5 Carrier:A Berkshire Hathaway CompanyDistributor/ wholesaler Supplemental ApplicationComplete in addition to Acord ApplicationsNAME OF APPLICANT Location Address: Website Address: I. GENERAL INFORMATION 1. Applicant operates as a: (check all that apply) q wholesaler q distributor q Retailer 2. Does the Applicant engage in any business operations at another location other than those disclosed on this Application ? If "Yes," explain: q Yes q No 3. Are there any other persons or organizations, subsidiaries, affiliates or other entities related to the Applicant (including DBAs) for which coverage is desired? q Yes q No If "Yes," please list and describe the relationship to the Applicant: Note: There is no coverage for any such person, organization or entities unless endorsed to the policy. The following questions relate to Applicant only.

Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the

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