COMMERCIAL INSURANCE APPLICATION DATE …

1 date (MM/DD/YYYY)UNDERWRITER NAME:RETIRWREDNUREIRRACNAIC CODE:POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDPHONE(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS::EDOC BUS:EDOCAGENCY CUSTOMER ID:PROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMENAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP+4 (of First Named Insured)FEIN OR SOC SEC #PHONE(of First Named Insured):(A/C, No, Ext):CR BUREAUDATE BUSID NUMBERNAMESTARTEDINSPECTION CONTACT:ACCOUNTING RECORDS CONTACT:LIAM-EENOHPLIAM-EENOHP:SSERDDA:) txE ,oN ,C/A(:SSERDDA.

2 TxE ,oN ,C/A(TSERETNISTIMIL YTIC4+PIZ ,ETATS ,YTNUOC ,YTIC ,TEERTS# DLB# COLYRBUILT% OCCUPIEDYES NOSESNOPSER "SEY" LLA NIALPXEONSEYSESNOPSER "SEY" LLA NIALPXEREMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)APPLICANT S SIGNATUREDATEPRODUCER S SIGNATURENATIONAL PRODUCER NUMBEREQUIPMENT FLOATERGARAGE AND DEALERSELUDEHCS ELCIHEVKSIR SREDLIUB/NOITALLATSNIYTREPORPYRENIHCAM & RELIOBCORP ATAD CINORTCELENGIS DNA SSALGWORKERS COMPENSATIONACCOUNTS RECEIVABLE/COMMERCIALVALUABLE PAPERSGENERAL LIABILITYALLERBMUOTUA SSENISUBEMIRC SUOENALLECSIM/EMIRCTRUCKERS/MOTOR CARRIERTRANSPORTATION/MOTOR TRUCK CARGOQUOTEISSUE POLICYRENEWENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES.)

3 OR FOR MONOLINE (Give date and/or Attach Copy):MAEGNAHCDIRECT BILLMPLECNACAGENCY BILLLLCSUBCHAPTER "S"INDIVIDUALCORPORATIONCORPORATIONNOT FORNO. OF MEMBERSPARTNERSHIPJOINT VENTUREAND MANAGERSPROFIT THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?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? THE APPLICANT HAVE ANY SUBSIDIARIES?2.

4 IS A FORMAL SAFETY PROGRAM IN OPERATION?(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).3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?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?

5 POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURINGTHE PRIOR 3 YEARS? (Not applicable in MO)HAS BUSINESS BEEN PLACED IN A TRUST? YES, NAME OF TRUST: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) ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATIONALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?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 AFRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES.

6 (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 THE ANSWERS TO QUESTIONS ONTHIS APPLICATION . HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER (ES):ADDRESS(ES):#EMPLOYEESANNUALREVENUE SNOITAMROFNI YCILOP EGAKCAPNOITCASNART FO SUTATSAPPLICANT INFORMATIONAPPLICANT INFORMATIONPREMISES INFORMATIONNATURE OF BUSINESS - DESCRIPTION OF OPERATIONS BY PREMISE(S) USE 10 WORDS OR MORE TO DESCRIBE:GENERAL INFORMATIONPLEASE COMPLETE REVERSE SIDEACORD 125 (2005/06) ACORD CORPORATION 1993-2005 APPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONSTREET:ADDRESS.

7 CITY:STATE:ZIP CODE:City:State:Zip Code:CLAIMSCLAIMSCLAIMSCLAIMSCLAIMSOCCUR RENCEOCCURRENCEOCCURRENCEOCCURRENCEOCCUR RENCEMADEMADEMADEMADEMADESTATE SUPPLEMENT(S) (If applicable)LINECATEGORYGENERALLIABILITYC OMMERCIALALUITAOBMIOLBIITLYEPROPERTYCLAI MSTATUSDATE OFDATEAMOUNTAMOUNTLINETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMOPEN CLSDOCCURRENCEOF CLAIMPAIDRESERVEDREMARKS NOTE: 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

8 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. (Not applicable in all states, consult your agent or broker for your state s requirements.)

9 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.

10 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 (2005/06)PERCLAIMPEROCCURRENCEDATE (MM/DD/YYYY)PHONEAGENCYAPPLICANT(A/C, No, Ext):(FirstFAXN amed(A/C, No):Insured)EFFECTIVE DATEEXPIRATION DATEPAYMENT PLANAUDITFORCOMPANYUSE ONLYCODE:SUB CODE:AGENCYCUSTOMER ID: COMMERCIAL GENERAL LIABILITYGENERAL AGGREGATE$PREMIUMSPREMISES/OPERATIONSPRO DUCTS & COMPLETED OPERATIONS AGGREGATE$OWNER S & CONTRACTOR S PROTECTIVEPERSONAL & ADVERTISING INJURY$PRODUCTSEACH OCCURRENCE$DEDUCTIBLESDAMAGE TO RENTED PREMISES (each occurrence)$OTHERMEDICAL EXPENSE (Any one person)$EMPLOYEE BENEFITS$TOTALOTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)