ACORD COMMERCIAL INSURANCE APPLICATION …

1 TMDATE (MM/DD/YYYY)PHONEUNDERWRITER code :(A/C, No, Ext):FAX(A/C, No.):POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDCODE:SUB code :AGENCY CUSTOMER ID:PROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMEFEIN OR SOC SEC #NAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP+4 (of First Named Insured)(of First Named Insured): phone (A/C, No, Ext):CR BUREAUDATE BUSID NUMBERNAMESTARTEDPHONEPHONEINSPECTION CONTACTACCOUNTING RECORDS CONTACT(A/C, No, Ext):(A/C, No, Ext):LOC #BLD #STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITSINTERESTYR BUILTPART OCCUPIEDYES NOEXPLAIN ALL "YES" RESPONSESYES NO EXPLAIN ALL "YES" RESPONSESREMARKS/PROCESSING INSTRUCTIONSAPPLICANT'S SIGNATUREDATEPRODUCER'S SIGNATURENATIONAL PRODUCER NUMBEREQUIPMENT FLOATERGARAGE AND DEALERSPROPERTYINSTALLATION/BUILDERS RISKVEHICLE SCHEDULEGLASS AND SIGNELECTRONIC DATA PROCBOILER & MACHINERYWORKERS COMPENSATIONACCOUNTS RECEIVABLE/COMMERCIALVALUABLE PAPERSGENERAL LIABILITYCRIME/MISCELLANEOUS CRIMEBUSINESS AUTOUMBRELLATRUCKERS/MOTOR CARRIERTRANSPORTATION/MOTOR TRUCK CARGOQUOTEISSUE POLICYRENEWENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE (Give Date and/or Attach Copy):CHANGEAMDIRECT BILLCANCELPMAGENCY BILLLLCSUBCHAPTER "S"INDIVIDUALCORPORATIONCORPORATIONNOT FORNO.

2 OF MEMBERSPARTNERSHIPJOINT VENTUREAND MANAGERSPROFIT THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE ORMOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? THE APPLICANT HAVE ANY SUBSIDIARIES? THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANTBEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON?2. IS A FORMAL SAFETY PROGRAM IN OPERATION?(In RI, this question must be answered by any applicant for property ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?Failure to disclose the existence of an arson conviction is a misdemeanorpunishable by a sentence of up to one year of imprisonment).4. ANY CATASTROPHE EXPOSURE? UNCORRECTED FIRE code VIOLATIONS?5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANTIN THE PAST 5 YEARS?HAS BUSINESS BEEN PLACED IN A TRUST?

3 6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR THE PRIOR 3 YEARS? (Not applicable in MO)IF YES, NAME OF TRUST:E-MAILWEBSITEADDRESS(ES):ADDRESS(E S):# EMPLOYEESANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCEOR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATIONCONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND[NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, INSURANCE benefits may also be denied)THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THEANSWERS TO QUESTIONS ON THIS APPLICATION . HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF OF TRANSACTIONPACKAGE POLICY INFORMATIONAPPLICANT INFORMATIONAPPLICANT INFORMATIONPREMISES INFORMATIONNATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)GENERAL INFORMATIONPLEASE COMPLETE REVERSE SIDEACORD 125 (2003/01) ACORD CORPORATION 1993 APPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONACORDCLAIMSCLAIMSCLAIMSCLAIMS CLAIMSOCCURRENCEOCCURRENCEOCCURRENCEOCCU RRENCEOCCURRENCEMADEMADEMADEMADEMADEOPEN CLOSEDOPENCLOSEDSTATE SUPPLEMENT(S) (If applicable)LINECATEGORYGENERALLIABILITYC OMMERCIALALUITAOBMIOLBIITLYEPROPERTYDATE OFDATEAMOUNTAMOUNTCLAIMLINETYPE/DESCRIPT ION OF OCCURRENCE OR CLAIMOCCURRENCEOF CLAIMPAIDRESERVEDSTATUSREMARKS NOTE.

4 FIDELITY REQUIRES A FIVE YEAR LOSS HISTORYCARRIERPOLICY NUMBERPOLICY TYPERETRO DATEEFF-EXP DATEGENERAL AGGREGATEPRODUCTS COMP OPAGGREGATEPERSONAL & ADV INJEACH OCCURRENCELFIRE DAMAGEIMMEDICAL EXPENSEITOCCURRENCESBODILYINJURYAGGREGAT EOCCURRENCEPROPERTYDAMAGEAGGREGATECOMBIN ED SINGLE LIMITMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATECOMBINED SINGLE LIMITEA PERSONBODILYINJURYEA ACCIDENTPROPERTY DAMAGEMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATEBUILDINGAMTPERS PROPAMTMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATELIMITMODIFICATION FACTORTOTAL PREMIUMCHK HERESEE ATTACHEDENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMSIF NONELOSS SUMMARYFOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)ATTACHMENTSCOPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT.

5 (Not applicable in all states, consult your agent or broker for your state's requirements.)NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROMPERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHERPERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOURAUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MOREDETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FORINSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO carrier INFORMATIONLOSS HISTORYACORD 125 (2003/01)LOC.

6 #TMDATEAPPLICANTPRODUCERPROPOSED EFF. DATEPROPOSED EXP. DATEBILLING PLANPAYMENT PLANAUDITFOR COMPANY USE ONLY%MAXIMUM VALUEDESCRIPTIONMAXIMUM ITEMAMT. OF INSURANCECOINSMO. INTYPE OF SECURITYSTORAGEIN BUILDINGOUTSIDE$$$$$$NAME & ADDRESSNAME & ADDRESSINTERESTINTERESTCERTIFICATIONCERT IFICATIONREQUIREDREQUIREDNAME & ADDRESSNAME & ADDRESSINTERESTINTERESTCERTIFICATIONCERT IFICATIONREQUIREDREQUIREDEXPLAIN ALL "YES" ALL "YES" (MM/DD/YY)AGENCYDIRECT## USED UNDERGROUND?1. EQUIPMENT RENTED, LOANED TO/FROM OTHERSWITH/WITHOUT OPERATORS? WORK DONE AFLOAT?2. IS APPLICANT OPERATING EQUIPMENT NOT LISTED HERE?TERRITORY OF OPERATIONTYPE OF OPERATIONCOVERAGE/DEDUCTIBLEEQUIPMENT STORAGEUNSCHEDULED EQUIPMENTADDITIONAL INTEREST/CERTIFICATE RECIPIENTS (Attach separate sheet if necessary)GENERAL INFORMATIONEQUIPMENT SCHEDULE ON REVERSE SIDEACORD 146 (2000/05) ACORD CORPORATION 1988 ACORDEQUIPMENT FLOATER SECTION% COINSURANCETYPEMANUFACTURERMODELCAPACITY OTHERID#/SERIAL OF#YEARPURCHASEDINSURANCE$$$$$$$$$$$$$$$ $$$$$$$$$$$$$SCHEDULED EQUIPMENTATTACH TO APPLICANT INFORMATION SECTIONACORD 146 (2000/05)