WORKERS COMPENSATION APPLICATION DATE …

AGENCY CUSTOMER ID: COMMERCIAL GENERAL …

attach to acord 125 agency customer id: effective date carrier naic code policy number applicant / first named insured agency 4. retroactive date: 3. number of employees covered by employee benefits plans:

  Policy, General, Customer, Commercial, Agency, Agency customer id, Commercial general

UMBRELLA / EXCESS SECTION DATE (MM/DD/YYYY)

ACORD 131 (2013/12) $ $ VOLUNTARY Attach to ACORD 125 IMPORTANT - If CLAIMS MADE is checked in the POLICY INFORMATION section below, this is an application for a claims-made policy.

  Date, Section, Umbrella excess section date, Umbrella, Excess

EVIDENCE OF COMMERCIAL PROPERTY INSURANCE

EVIDENCE OF COMMERCIAL PROPERTY INSURANCE REMARKS - Including Special Conditions (Use only if more space is required) ACORD 28 (2014/01) Page 2 of 2

  Property, Commercial, Evidence, Insurance, Evidence of commercial property insurance

CANCELLATION REQUEST / POLICY RELEASE

insured mortgagee company loss payee lienholder finance company name and address request / release distribution producer's signature date reason for cancellation

  Policy, Date, Release, Request, Cancellation, Cancellation request policy release

AGENCY CUSTOMER ID: BUSINESS OWNERS SECTION

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ACORD 160 (2014/12) AGENCY CUSTOMER ID: START TIME: END TIME: 24 HOUR OPERATIONS

  Customer, Agency, Agency customer id

PROPERTY SECTION DATE (MM/DD/YYYY) - Free …

ded blkt # amount type blkt # amount type mine subsidence coverage (required in il, in, ky and wv) accept coverage reject coverage limit: $ type

  Date, Section, Property, Mm dd, Property section date

ACORD 0080 2013-09

acord 80 (2013/09) years, at this or any location? any losses, whether or not paid by insurance, during the last $ applicant's initials: y / n if yes, indicate below loss history

  2013, 2013 09

EVIDENCE OF PROPERTY INSURANCE - Frequently …

loan # authorized representative name and address additional interest loss payee mortgagee additional insured remarks (including special conditions)

  Property, Evidence, Insurance, Evidence of property insurance

DWELLING FIRE APPLICATION DATE (MM/DD/YYYY)

acord 84 (2013/09) explain all "yes" responses unless stated otherwise y / n 1.any other insurance with this company? (list policy numbers) line of business policy number line of business policy number

  Date, Applications, Fire, Dwelling, Dwelling fire application date

ACORD Forms Index - Frequently Used

Page 3 of 12 ACORD Forms Index All packages contain 100 forms - Please specify number of packages required STATE P&C FORMS 61 CT 66 CT 90 CT 137 CT 138 CT

  Form, States, Index, Acord, Acord forms index

COMMERCIAL INSURANCE APPLICATION DATE …

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

  Date, Applications, Commercial, Insurance, Commercial insurance application date

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) …

The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01)

  Acord, Yyyy, Mm dd yyyy

PROPERTY LOSS NOTICE DATE (MM/DD/YYYY)

AGENCY CUSTOMER ID: Page 3 of 3 Applicable in Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

  Property, Notice, Loss, Property loss notice, Yyyy, Mm dd yyyy

ACORD CERTIFICATE OF LIABILITY INSURANCE DATE …

ACORD 25 (2001/08) If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to …

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions.

  Date, Liability, Certificate, Insurance, Certificate of liability insurance date, Yyyy, Mm dd yyyy

Document No: Version No: 1.0-d2 Date Issued: dd/mm/yyyy

A large number of DSC’s are already in use in the offices of Indian Railways. Thesenumbers are likely to increase substantially with the introduction of applications like eOffice / SPARROW / PRISM etc.

  Date, Issued, Date issued, Yyyy, Mm dd yyyy

COMMERCIAL INSURANCE APPLICATION DATE …

acord 125 (2013/01) $ $ $ $ effective date year expiration date premium policy number carrier category general liability automobile property other: prior carrier information

  Applications, Commercial, Insurance, Commercial insurance application

COMMERCIAL INSURANCE APPLICATION DATE …

AGENCY CUSTOMER ID: 12. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure)

  Applications, Commercial, Insurance, Commercial insurance application