ACORD SMALL COMMERCIAL ACCOUNT PACKAGE …

1 TMDURING THE LAST FIVE YEARS, (TEN IN RHODE ISLAND), HAS ANY APPLICANT BEENCONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? (In RI, failure to disclose the existenceof an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). ARE CERTIFICATES OF INSURANCE REQUIRED FROM SUB CONTRACTORS?IF SO, WHO CHECKS THEM?5. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANTIN THE PAST 5 YEARS?DATEPRODUCERPHONECOMPANYNAIC CODE:(A/C, No, Ext):FAX(A/C, No.):POLICY OR PROGRAM REQUESTEDPROPOSED EFF. DATEPROPOSED EXP.

2 DATEBILLING PLANPAYMENT PLANCODESUB CODESTATUS OF SUBMISSIONGL CODESICFEDERAL ID #NAME (First Named Insured)PHONEYRS INCONTACT FOR INSPECTIONMAILING ADDRESS (INCLUDING ZIP+4)(A/C, No, Ext):BUSCREDIT BUREAU NAMEID NUMBERCOMPANY (Include Cov. type/Line of Business/Dates)LOSSES WHETHER OR NOT INSURED (Date/Description/Amount)CORRECTIVE ACTIONADDRESSINTERESTAREA EXPOSURES AND OTHER OCCUPANCIESYEAR BUILTDESCRIPTION OF OPERATIONS/OCCUPANCYDESCRIBE ANY LOCATION OR BUSINESS INTEREST OWNED OR OPERATED BY INSUREDPLEASE EXPLAIN ALL "YES" RESPONSESYESNOBUT NOT LISTEDANNUAL SALES/RECEIPTS:TOTAL PAYROLL:SUBJECTCOVERAGELIMITSCAUSE OF LOSSCONSTRUCTIONBUILDINGDISTANCE TO% BLDGFIRE DISTRICT/CODE NUMBERHYDRANTFIRE STATSPRNKLRDPR.

3 AREAROOF TYPE#STORIES#UNITSPERSONAL PROPERTYWIRINGROOFING PLUMBINGHEATINGINSPECTED?WIND CLASSBLDG CODEOTHERTAX CODEYEARYEARYEARYEARGRADEBUILDINGYESNOIM PROVEMENTSGLASSAGENCYDIRECTQUOTEISSUE POLICYBOUND (Give date):LIMITEDINDIVIDUALCORPORATIONPARTNE RSHIPJOINT VENTURECORPORATIONOTHERDURING THE PAST 3 YEARS, HAS ANY COVERAGE BEEN CANCELLED, NON-RENEWED, DECLINED, OR PLACED IN NON-STANDARD MARKETS?YES (Explain)NO(Include county & zip)%:OWNERTENANTSQ. FT.:CHECK HERE IF PRIMARY LOCATIONOFFICERETAILAPTSCONTRACTORSSERVI CEWHOLESALECONDOSOTHER (Describe):DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL?

4 ( landfills, wastes, fuel tanks, etc) ARE ATHLETIC TEAMS SPONSORED? RESISTAMOUNTMASONRYACVJOISTED MASONMOD FIRE RESNON-COMBCOINS/DED%RCFTMIAMOUNTACVCOIN S/DED%RESISTIVESEMI-OTHERRESISTIVEADD L INFO#PANESAREALENGTHTYPEVALUEDEDUCTIBLEG ROUND FLOORABOVE GROUND FLOORAPPLICANT INFORMATIONPRIOR POLICY(IES) / LOSS HISTORYLOCATIONNATURE OF BUSINESSGENERAL INFORMATIONPROPERTYOPTIONAL COVERAGESACORD 165 (2000/11) ACORD CORPORATION 1988 ACORDSMALL COMMERCIAL ACCOUNT PACKAGE APP% OF ALARMEXTENT OF PROTECTIONALARM CERTIFICATE #/EXPIRATION DATE:GRADESAFE/VAULTPREMISESSAFE/VAULT/R ECEPTACLE MANUFACTURERLABELCLASSMAXIMUM CASH ON PREMISESMAXIMUM CASH WITH MESSENGERMONEY ON PREMISES OVERNIGHTFREQUENCY OF DEPOSITSDBL.

5 CYL. DOOR LOCKS$$$OTHER PROTECTIONOTHERLIMITSTERRITORYCLASS CODECLASS DESCRIPTIONEXPOSURE BASEEXPOSUREEMPLOYER NUMBERRATING BUREAU RATING DATEPART 1 SPECIFY ADDITIONAL COVERAGES/ENDORSEMENTSPART 2 - EMPLOYEES LIAB.# EMPLOYEESEST. ANNUALSTATECLASS CODECOMPANY USECATEGORIES, DUTIES, CLASSIFICATIONSFULL TIME PART TIMEREMUNERATIONPARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR %DUTIESINC/EXCCLASS CODEREMUNERATIONPLEASE EXPLAIN ALL "YES" RESPONSESYESNOYESNOCEXTRA EXPENSEEMPLOY. DISHON.# BASICRBAILOSS OF C BROADMIHEVALUABLE ISPOILAGEENACCOUNTS IS THERE A SEPARATE HEATING BOILER?

6 TOTAL VALUE OF CUSTOMERS GOODS STORED ON PREMISES?AVERAGE VALUE PER DELIVERY VEHICLE?MAXIMUM VALUE PER VEHICLE?ARE GOODS STORED BEYOND NORMAL HANDLING TIME?YESNOESTIMATED ANNUAL AVERAGE VALUE SHIPPED?(Check all that apply)HOLD UPLOCAL GONGBURGLARPOLICE C (Lighting, fences, watchperson, etc.)GENERAL AGGREGATE(Indicate coverage & limit)$PRODUCTS & COMPLETED OPERATIONS AGGREGATE$PERSONAL & ADVERTISING INJURY$EACH OCCURRENCE$DAMAGE TO RENTED PREMISES$MEDICAL EXPENSE (Any one person)$PARTICIPATINGNON-PARTICIPATING(S tates)(If not Basic)$(Each Accident)OTHER & H.

7 $(Disease-Policy Limit)VOL. COMP. $$(Disease-Each Employee)(Remuneration to be included must be part of rating information section.)DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT?ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE?ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET?IS THERE ANY VOLUNTEER OR DONATED LABOR?USE ACORD 127, BUSINESS AUTO SECTION, AND ACORD 137 FOR YOUR STATEOPTIONAL COVERAGES (con t)CRIMEGENERAL LIABILITYWORKERS COMPENSATIONAUTOMOBILE2 ACORD 165 (2000/11)EXPIRING POLICY #RETROACTIVE DATELIMIT OF LIABILITYRETAINED LIMITFIRST DOLLAR DEFENSECURRENTPROPOSEDCHECK IF APPROPRIATECOVERAGEEXPOSURECOVERAGEEXPOS UREPROVIDE INFORMATION FOR ANY UNDERLYING POLICIES IN FORCE IN ADDITION TO THIS NUMBERPOLICY EFF.

8 DATEPOLICY EXP. DATELIMITSANN. RENEW. PREMIUMMODAUTOMOBILELIABILITYGENERALLIAB ILITYEMPLOYERSLIABILITYPLEASE EXPLAIN ALL "YES" RESPONSESYESNO#STORIES#UNITS#POOLS#DVG. OFF PREMISES EXPOSURESNAME & ADDRESSINTERESTEVIDENCEREMARKSNOTICE OF INSURANCE INFORMATION PRACTICESAPPLICANT S SIGNATUREPRODUCER S SIGNATURE$EACH OCCURRENCEYES$AGGREGATENOCGL/CLAIMS MADEAIRCRAFT/WATERCRAFTLIQUOR LIABILITYCGL/OCCURRENCECARE, CUSTODY, CONTROLANY AUTO (Symbol)MEDICAL MALPRACTICE/PROFESSIONAL EA ACC$BI EA PER$PD EA ACC$GEN. AGGRPREM/OPSPROD & C/O AGGR$PERS & ADV INJURYPRODUCTSEACH OCCUR.

9 $FIRE DAMAGEOTHERMEDICAL EXPENSE$EACH ACCIDENTDIS. - EA. EMP.$DIS. - POL. LMTUNDERLYING INSURANCE COVERAGE INFORMATION (Include all restrictions; laser endorsements, discrimination, subrogation waivers, or extensions of coverage - attach separate sheet if necessary)ARE FOREIGN PRODUCTS DISTRIBUTED IN PRODUCTS SOLD OR DISTRIBUTED IN FOREIGN COUNTRIES?ARE THERE ANY SWIMMING POOLS?YESNOATTACH ACORD 185 FOR EACH LOCATIONIS ALUMINUM WIRING USED?YESNO#UNITS IN BUILDING OR FIRE DIVISIONATTACH ACORD 186 FOR EACH LOCATIONCOVERAGE APPLIES TO:BARE WALLSFINISHED WALLSSMOKE DETECTORSNONEBATTERYWIREDCERTIFICATEPOLI CYCERTIFICATEPOLICYCERTIFICATEPOLICYPERS ONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITHTHIS APPLICATION AND SUBSEQUENT RENEWALS.

10 SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OURAGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CANREQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLEUPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO ALL COVERAGES IN UNDERLYING POLICIES. ALSO CHECK IF ANY EXPOSURES ARE PRESENT FOR EACH COVERAGE.