COMMERCIAL INSURANCE APPLICATION DATE …

1 ACCOUNTING RECORDS CONTACT:PHONE(A/C, No, Ext):E-MAILADDRESS:INSPECTION CONTACT:PHONE(A/C, No, Ext):E-MAILADDRESS:WEBSITEADDRESS(ES):MA ILING ADDRESS INCL ZIP+4 (of First Named Insured)ADDRESS(ES):E-MAILNAME (First Named Insured & Other Named Insureds)(of First Named Insured):FEIN OR SOC SEC #PHONE(A/C, No, Ext):APPLICANT INFORMATIONAND MANAGERSNO. OF MEMBERSPROFIT ORGNOT FORLLCCORPORATIONSUBCHAPTER "S"STARTEDDATE BUSID NUMBER:INDIVIDUALPARTNERSHIPCORPORATIONJ OINT VENTURECR BUREAU NAME:NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)ACORD 823 attached for additional premisesPREMISES INFORMATIONTENANTOWNEROUTSIDEINSIDETENAN TOWNEROUTSIDEINSIDETENANTOWNEROUTSIDEINS IDETENANTOWNEROUTSIDEINSIDEANNUAL REVENUES#EMPLOYEES%OCCUPIEDYRBUILTINTERE STCITY LIMITSSTREET, CITY, COUNTY, STATE, ZIP+4 BLD #LOC #YACHTOPEN CARGODRIVER INFO SCHEDULEDEALERSUNDERWRITER OFFICE:UNDERWRITER.

2 POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERGENERAL LIABILITYCOMMERCIALTRANSPORTATION/MOTOR TRUCK CARGOVALUABLE PAPERSACCOUNTS RECEIVABLE/INDICATE SECTIONS ATTACHEDCARRIERNAIC CODEPROPERTYGLASS AND SIGNCRIME/MISCELLANEOUS CRIMEGARAGE AND DEALERSVEHICLE SCHEDULEBOILER & MACHINERYWORKERS COMPENSATIONTRUCKERS/MOTOR CARRIERUMBRELLABUSINESS AUTOELECTRONIC DATA PROCINSTALLATION/BUILDERS RISKEQUIPMENT FLOATERSUB CODE:E-MAILADDRESS:(A/C, No):FAX(A/C, No, Ext):PHONEAGENCYCODE:AGENCY CUSTOMER ID:NAME:CONTACTThe ACORD name and logo are registered marks of ACORDPage 1 of 3 1993-2007 ACORD CORPORATION.

3 All rights 125 (2007/10)PACKAGE POLICY INFORMATIONPROPOSED EFF DATEPROPOSED EXP DATEAGENCY BILLDIRECT BILLBILLING PLANPAYMENT PLANAUDITENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICY PREMIUM: $APPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONDATE (MM/DD/YYYY)PMAMTIMEDATECHANGECANCELBOUN D (Give Date and/or Attach Copy):ISSUE POLICYQUOTERENEWSTATUS OF TRANSACTIONACORD 125 (2007/10)Page 2 of POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (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 ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES.

4 (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, INSURANCE benefits may also be denied)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) BUSINESS BEEN PLACED IN A TRUST?IF "YES", NAME OF TRUST:ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST FIVE (5) YEARS? UNCORRECTED FIRE 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 ANYOTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?

5 (In RI, this question must be answered by any applicant for property INSURANCE . Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to oneyear of imprisonment). PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? CATASTROPHE EXPOSURE? EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? A FORMAL SAFETY PROGRAM IN OPERATION? THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

6 EXPLAIN ALL "YES" RESPONSESTHE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAINTHE ANSWERS TO QUESTIONS ON THIS APPLICATION . HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OFHIS/HER INFORMATIONREMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)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.)NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTEDFROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS.

7 SUCH INFORMATION ASWELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRDPARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OFANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO PRODUCER LICENSE NOPRODUCER'S NAME (Please Print)Y/NAPPLICANT'S SIGNATUREDATEPRODUCER'S SIGNATURE(Required in Florida)

8 NATIONAL PRODUCER NUMBERIN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD CUSTOMER ID:OCCURRENCEMADECLAIMSOCCURRENCEMADECLA IMSOCCURRENCEMADECLAIMSOCCURRENCEMADECLA IMSOCCURRENCEMADECLAIMSCARRIERPOLICY NUMBERPOLICY TYPERETRO DATEEFF-EXP DATEGENERAL AGGREGATEPRODUCTS COMP OPAGGREGATEPERSONAL & ADV INJEACH OCCURRENCEFIRE DAMAGEMEDICAL EXPENSEBODILYINJURYOCCURRENCEAGGREGATEPR OPERTYDAMAGEOCCURRENCEAGGREGATECOMBINED SINGLE LIMITMODIFICATION FACTORTOTAL PREMIUMLIMITSGENERALLIABILITYCOMMERCIALC ARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATELIMITMODIFICATION FACTORTOTAL PREMIUMPROPERTYCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATEBUILDINGAMTPERS PROPAMTMODIFICATION

9 FACTORTOTAL PREMIUMAUTOMOBILELIABILITYCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATECOMBINED SINGLE LIMITBODILYINJURYEA PERSONEA ACCIDENTPROPERTY DAMAGEMODIFICATION FACTORTOTAL PREMIUMPRIOR CARRIER INFORMATIONLINECATEGORYACORD 125 (2007/10)Page 3 of 3 CLSDOPENLOSS SUMMARYSEE ATTACHEDIF NONECHK HERESTATUSCLAIMRESERVEDAMOUNTPAIDAMOUNTO F CLAIMDATETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMLINEOCCURRENCEDATE OFENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMSFOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)ATTACHMENTSREMARKS NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORYLOSS HISTORYSTATE SUPPLEMENT(S) (If applicable)AGENCY CUSTOMER ID.