COMMERCIAL INSURANCE APPLICATION ... - …

1 CONDO ASSN BYLAWS (for D&O Coverage only)PROGRAM CODECOMPANY POLICY OR PROGRAM NAMEPOLICY NUMBERCARRIERNAIC CODEPMAMTIMEDATECHANGECANCELBOUND (Give Date and/or Attach Copy):ISSUE POLICYQUOTERENEWSTATUS OFTRANSACTIONE-MAILADDRESS:AGENCY CUSTOMER ID:CODE:SUBCODE:PHONE(A/C, No, Ext):CONTACTNAME:AGENCY(A/C, No):FAXAPPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONDATE (MM/DD/YYYY)UNDERWRITERUNDERWRITER OFFICEAPPLICANT INFORMATIONThe ACORD name and logo are registered marks of ACORDPage 1 of 4 1993-2009 ACORD CORPORATION. All rights CARGODEALERSTRANSPORTATION /MOTOR TRUCK CARGOVALUABLE PAPERSACCOUNTS RECEIVABLE /INDICATE SECTIONS ATTACHEDPROPERTYGLASS AND SIGNCRIME / MISCELLANEOUS CRIMEGARAGE AND DEALERSBOILER & MACHINERYTRUCKERS / MOTOR CARRIERUMBRELLABUSINESS AUTOELECTRONIC DATA PROCINSTALLATION / BUILDERS RISKEQUIPMENT FLOATERBUSINESS OWNERSPREMIUMPREMIUMPREMIUM$$$$$$$$$$$$$ $$$$$$$ COMMERCIAL GENERAL LIABILITYSECTIONS ATTACHED$POLICY INFORMATIONPROPOSED EFF DATE PROPOSED EXP DATEAGENCYDIRECTBILLING PLANPAYMENT PLANAUDITPOLICY

2 PREMIUMDEPOSIT$MINIMUMPREMIUMMETHOD OF PAYMENT$$ACORD 125 (2009/08)FEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATI ONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)DRIVER INFORMATION SCHEDULECOVERAGES SCHEDULEADDITIONAL PREMISESAPARTMENT BUILDING SUPPLEMENTCONTRACTORS SUPPLEMENTATTACHMENTSADDITIONAL INTERESTINTERNATIONAL LIABILITY EXPOSURE SUPPLEMENTINTERNATIONAL PROPERTY EXPOSURE SUPPLEMENTLOSS SUMMARYPREMIUM PAYMENT SUPPLEMENTPROFESSIONAL LIABILITY SUPPLEMENTRESTAURANT / TAVERN SUPPLEMENTSTATEMENT / SCHEDULE OF VALUESSTATE SUPPLEMENT (If applicable)

3 VACANT BUILDING SUPPLEMENTVEHICLE SCHEDULEFEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATI ONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)FEIN OR SOC SEC #GL CODESICWEBSITE ADDRESSLLCINDIVIDUALPARTNERSHIPCORPORATI ONJOINT VENTURENOT FOR PROFIT ORGNO. OF MEMBERSSUBCHAPTER "S" CORPORATIONAND MANAGERS:TRUSTBUSINESS PHONE #:NAICSNAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)AGENCY CUSTOMER ID:CONTACT TYPE:CONTACT NAME:PRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS:CONTACT INFORMATIONCONTACT TYPE:PRIMARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS:CONTACT NAME.

4 PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)Page 2 of 4 OFFICESERVICERETAILWHOLESALEAPARTMENTSCO NDOMINIUMSRESTAURANTCONTRACTORSTARTED (MM/DD/YYYY)DATE BUSINESSINSTITUTIONALMANUFACTURINGNATURE OF BUSINESSINSTALLATION, SERVICE OR REPAIR WORKRETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:DESCRIPTION OF PRIMARY OPERATIONSOFF PREMISES INSTALLATION, SERVICE OR REPAIR WORKDESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS%%TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPT ION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS?

5 Y / NSQ FT$ACORD 125 (2009/08)PRIMARYPHONE #SECONDARYPHONE #PRIMARYPHONE #SECONDARYPHONE #ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional InterestsTENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPT ION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPT ION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS?

6 Y / NSQ FT$TENANTOWNEROUTSIDEINSIDE# FULL TIME EMPL# PART TIME EMPLSTREETCITY:COUNTY:STATE:ZIP:DESCRIPT ION OF OPERATIONS:LOC #BLD #SQ FTOCCUPIED AREA:CITY LIMITSINTERESTANNUAL REVENUES:OPEN TO PUBLIC AREA:SQ FTTOTAL BUILDING AREA:ANY AREA LEASED TO OTHERS? Y / NSQ FT$ITEMBOAT:VEHICLE:BUILDING:LOCATION:EM PLOYEELIENHOLDERMORTGAGEELOSS PAYEEADDITIONALINTEREST IN ITEM NUMBERCERTIFICATEREFERENCE / LOAN #:NAME AND ADDRESS RANK:INTERESTITEM DESCRIPTIONINSUREDAS LESSOREVIDENCE:POLICYSEND BILLOWNERCO-OWNERAIRCRAFT:AIRPORT:CLASS: ITEM:INTEREST END DATE:LIEN AMOUNT:PHONE (A/C, No, Ext):FAX (A/C, No):REGISTRANTTRUSTEEBREACH OFWARRANTYLEASEBACKOWNERREASON FOR INTEREST:E-MAIL ADDRESS:CELLBUSHOMECELLBUSCELLBUSHOMECEL LBUSHOMEHOMEAGENCY CUSTOMER ID:12.

7 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) UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD,BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?(In RI, this question must be answered by any applicant for property INSURANCE .)

8 Failure to disclose the existence of an arson conviction is a misdemeanor punishableby a sentence of up to one year of imprisonment). PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?GENERAL POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OROPERATIONS? (Missouri Applicants - Do not answer this question) NON-PAYMENTNON-RENEWALAGENT NO LONGER REPRESENTS CARRIERCONDITION CORRECTED (Describe) APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?

9 APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?OCCURRENCEDATEEXPLANATIONRESOLUTIO NDATERESOLUTION11. HAS BUSINESS BEEN PLACED IN A TRUST?NAME OF TRUSTLINE OF BUSINESSLINE OF BUSINESSPOLICY NUMBERPOLICY NUMBERANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?DOES THE APPLICANT HAVE ANY SUBSIDIARIES?% OWNEDRELATIONSHIP DESCRIPTIONPARENT COMPANY NAME% OWNEDRELATIONSHIP DESCRIPTIONSUBSIDIARY COMPANY NAMEEXPLAIN ALL "YES" RESPONSESY / NIS A FORMAL SAFETY PROGRAM IN OPERATION?

10 MANUALMONTHLY MEETINGSOSHASAFETY POSITIONANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? 3 of 4 REMARKS / PROCESSING INSTRUCTIONS (Attach ACORD 101, Additional Remarks Schedule, if more space is required)ACORD 125 (2009/08)AGENCY CUSTOMER ID:PRIOR CARRIER INFORMATIONCATEGORYGENERAL LIABILITYAUTOMOBILEPROPERTYOTHER:CARRIER POLICY NUMBERPREMIUMEXPIRATION DATEYEAREFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$CARRIERPOLICY NUMBERPREMIUMEXPIRATION DATEEFFECTIVE DATE$$$$LOSS HISTORYTYPE / DESCRIPTION OF OCCURRENCE OR CLAIMLINEENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED)