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.

istritorholesaler SPPAPP 1215 3 of 5 Complete below for all applicable products: Appliance Distributor q N/A 26. Does Applicant dispose of or recycle old appliances or electronic equipment in

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