AGENCY CARRIER NAIC CODE: UNDERWRITER …

1 PHONE(A/C, No, Ext):PROPOSED EFF DATEPROPOSED EXP DATEDATE (MM/DD/YYYY) UNDERWRITER CODE: POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDPHONE(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS: CODE: SUB code : AGENCY CUSTOMER ID:BILLING PLANPAYMENT PLANAUDITDATETIMENAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP+4 (of First Named Insured)PHONE(A/C, No, Ext):DATE BUSSTARTEDID NUMBER:INSPECTION CONTACT:ACCOUNTING RECORDS CONTACT:E-MAILADDRESS:PHONE(A/C, No, Ext):E-MAILADDRESS:QUOTEISSUE 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"CORPORATIONINDIVIDUALCORPORATIONNOT FORPROFIT ORGNO. OF MEMBERSAND MANAGERSPARTNERSHIPJOINT VENTUREE-MAILADDRESS(ES):WEBSITEADDRESS( ES):STATUS OF TRANSACTIONPACKAGE POLICY INFORMATIONAPPLICANT INFORMATIONCOMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTIONFEIN OR SOC SEC #(of First Named Insured):ANNUAL REVENUES#EMPLOYEES%OCCUPIEDYRBUILTINTERE STCITY LIMITSSTREET, CITY, COUNTY, STATE, ZIP+4 BLD #LOC #PREMISES INFORMATIONTENANTOWNEROUTSIDEINSIDETENAN TOWNEROUTSIDEINSIDETENANTOWNEROUTSIDEINS IDETENANTOWNEROUTSIDEINSIDEACORD 125 (2006/08)The ACORD name and logo are registered marks of ACORDPage 1 of 3 ACORD CORPORATION 1993-2006.

2 All rights OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)YACHTWORKERS COMPENSATIONVEHICLE SCHEDULEUMBRELLATRUCKERS/MOTOR CARRIERMOTOR TRUCK CARGOTRANSPORTATION/PROPERTYOPEN CARGOINSTALLATION/BUILDERS RISKGLASS AND SIGNGARAGE AND DEALERSEQUIPMENT FLOATERELECTRONIC DATA PROCDRIVER INFO SCHEDULEDEALERSCRIME/MISCELLANEOUS CRIMEGENERAL LIABILITYCOMMERCIALBUSINESS AUTOBOILER & MACHINERYACCOUNTS RECEIVABLE/VALUABLE PAPERSCR BUREAU NAME:ACORD 823 attached for additional premises6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWEDDURING THE PRIOR 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 STATEMENT OF CLAIMCONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.

3 (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA andWA, insurance benefits may also be denied)ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR USPRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES", attachACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) YES, NAME OF TRUST:11. HAS BUSINESS BEEN PLACED IN A TRUST?ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THEAPPLICANT IN THE PAST 5 YEARS? ANY UNCORRECTED FIRE code VIOLATIONS?8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEENINDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD,BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTIONWITH THIS OR ANY OTHER PROPERTY?(In RI, this question must be answered by any applicant for property insurance. Failureto disclose the existence of an arson conviction is a misdemeanor punishable by asentence of up to one year of imprisonment).7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATIONALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

4 ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? CATASTROPHE EXPOSURE? EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? A FORMAL SAFETY PROGRAM IN OPERATION? IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?DOES THE APPLICANT HAVE ANY SUBSIDIARIES?EXPLAIN ALL "YES" RESPONSESYES NOEXPLAIN ALL "YES" RESPONSESYES NOTHE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THISAPPLICATION. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER PRODUCER NUMBERPRODUCER'S SIGNATUREDATEAPPLICANT'S SIGNATUREGENERAL INFORMATIONREMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)Page 2 of 3 ACORD 125 (2006/08)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.

5 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 US. COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)AMTEA ACCIDENTCLAIMSMADECLAIMSMADECLAIMSMADECL AIMSMADECLAIMSMADEOCCURRENCEOCCURRENCEOC CURRENCEOCCURRENCEOCCURRENCESTATE SUPPLEMENT(S) (If applicable)LINECATEGORYDATE OFOCCURRENCEDATEOF CLAIMAMOUNTPAIDAMOUNTRESERVEDCLAIMSTATUS LINETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMREMARKS NOTE.

6 FIDELITY REQUIRES A FIVE YEAR LOSS HISTORYCARRIERPOLICY NUMBERPOLICY TYPERETRO DATEEFF-EXP DATEGENERAL AGGREGATEPRODUCTS COMP OPAGGREGATEPERSONAL & ADV INJEACH OCCURRENCEFIRE DAMAGEMEDICAL EXPENSEOCCURRENCEAGGREGATEBODILYINJURYOC CURRENCEPROPERTYDAMAGEAGGREGATECOMBINED SINGLE LIMITMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATECOMBINED SINGLE LIMITEA PERSONBODILYINJURYPROPERTY DAMAGEMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATEBUILDINGAMTPERS PROPMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATELIMITMODIFICATION FACTORTOTAL PREMIUMCHK HEREIF NONESEE ATTACHEDLOSS SUMMARYENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)ATTACHMENTSPRIOR CARRIER INFORMATIONLOSS HISTORYACORD 125 (2005/06)PROPERTYLIABILITYAUTOMOBILELIMI TSLIABILITYGENERAL COMMERCIALOPENCLSDPage 3 of 3