COMMERCIAL INSURANCE APPLICATION DATE …

1 date (MM/DD/ yyyy )NAIC CODEAGENCYUNDERWRITER:UNDERWRITER OFFICE:POLICIES OR PROGRAM REQUESTEDPOLICY NUMBERINDICATE SECTIONS ATTACHEDCONTACTNAME:PHONE(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS:CODE:SUB CODE:AGENCY CUSTOMER ID:PROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMEPACKAGE POLICY PREMIUM: $NAME (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 BUREAU NAME: date BUSSTARTEDID NUMBER:INSPECTION CONTACT:ACCOUNTING RECORDS CONTACT:PHONEE-MAILPHONEE-MAIL(A/C, No, Ext):ADDRESS:(A/C, No, Ext):ADDRESS:LOC #BLD #STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITSINTERESTYRBUILT%OCCUPIEDELECTRONIC DATA PROCTRUCKERS/MOTOR CARRIEREQUIPMENT FLOATERUMBRELLAACCOUNTS RECEIVABLE/VALUABLE PAPERSBOILER & MACHINERYGARAGE AND DEALERSVEHICLE SCHEDULEBUSINESS AUTOGLASS AND SIGNWORKERS COMPENSATIONINSTALLATION/BUILDERS RISKYACHTCOMMERCIALGENERAL LIABILITYCRIME/MISCELLANEOUS CRIMEOPEN CARGODEALERSPROPERTYDRIVER INFO SCHEDULETRANSPORTATION/MOTOR TRUCK CARGOQUOTEISSUE POLICYRENEWENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE (Give date and/or Attach Copy):CHANGEAMDIRECT BILLCANCELPMAGENCY BILLLLCNO.

2 OF MEMBERSSUBCHAPTER "S"INDIVIDUALCORPORATIONAND MANAGERSCORPORATIONNOT FORPARTNERSHIPJOINT VENTUREPROFIT ORGINSIDEOWNEROUTSIDETENANTINSIDEOWNEROU TSIDETENANTINSIDEOWNEROUTSIDETENANTINSID EOWNEROUTSIDETENANTE-MAILWEBSITEADDRESS( ES):ADDRESS(ES):#EMPLOYEESANNUAL REVENUESCARRIERSTATUS OF TRANSACTIONPACKAGE POLICY INFORMATIONAPPLICANT INFORMATIONPREMISES INFORMATIONACORD 823 attached for additional premisesNATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)Page 1 of 3 ACORD 125 (2007/10) 1993-2007 ACORD CORPORATION. All rights ACORD name and logo are registered marks of ACORDAPPLICANT INFORMATION SECTIONCOMMERCIAL INSURANCE APPLICATIONY/NEXPLAIN ALL "YES" RESPONSESREMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)PRODUCER'S SIGNATUREPRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NO(Required in Florida)APPLICANT'S SIGNATUREDATENATIONAL PRODUCER THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?

3 1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? A FORMAL SAFETY PROGRAM IN OPERATION? EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? CATASTROPHE EXPOSURE? OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS? (Not applicable in MO) PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 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?(In RI, this question must be answered by any applicant for property INSURANCE .)

4 Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to oneyear of imprisonment). UNCORRECTED FIRE CODE VIOLATIONS?10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST FIVE (5) YEARS?HAS BUSINESS BEEN PLACED IN A TRUST? "YES", NAME OF TRUST: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) 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.

5 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. 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 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.

6 (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)IN 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 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 CUSTOMER ID:GENERAL INFORMATIONPage 2 of 3 ACORD 125 (2007/10)CLAIMSCLAIMSCLAIMSCLAIMSCLAIMSO CCURRENCEOCCURRENCEOCCURRENCEOCCURRENCEO CCURRENCEMADEMADEMADEMADEMADESTATE SUPPLEMENT(S) (If applicable)LINECATEGORYGENERALLIABILITYC OMMERCIALALUITAOBMIOLBIITLYEPROPERTYCLAI MSTATUSDATE OFDATEAMOUNTAMOUNTLINETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMOPEN CLSDOCCURRENCEOF CLAIMPAIDRESERVEDREMARKS NOTE.

7 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 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)ATTACHMENTSAGENCY CUSTOMER ID:PRIOR CARRIER INFORMATIONLOSS HISTORYPage 3 of 3 ACORD 125 (2007/10)PERCLAIMPEROCCURRENCEDATE (MM/DD/ yyyy )PHONEAGENCYAPPLICANT(A/C, No, Ext):(FirstFAXN amed(A/C, No):Insured)EFFECTIVE DATEEXPIRATION DATEPAYMENT PLANAUDITFORCOMPANYUSE ONLYCODE:SUB CODE:AGENCYCUSTOMER ID.

8 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$TOTALOTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)RATEPREMIUMLOCHAZCLASSIFICATIONPREMI UMEXPOSURETERRCLASS##BASISCODEPREM/OPSPR ODUCTSPREM/OPSPRODUCTSRATING AND PREMIUM BASISEXPLAIN ALL "YES" RESPONSESY / NDIRECT BILLAGENCY BILLCLAIMS MADEOCCURRENCE$PROPERTY DAMAGEBODILY INJURY$$(P) PAYROLL - PER $1,000/PAY(C) TOTAL COST - PER $1,000/COST(U) UNIT - PER UNIT(S) GROSS SALES - PER $1,000/SALES(A) AREA - PER 1,000/SQ FT(M) ADMISSIONS - PER 1,000/ADM(T) OTHER1.

9 PROPOSED RETROACTIVE date :2. ENTRY date INTO UNINTERRUPTED CLAIMS MADE COVERAGE3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:1. DEDUCTIBLE PER CLAIM:$2. NUMBER OF EMPLOYEES:4. RETROACTIVE date :COVERAGESLIMITSSCHEDULE OF HAZARDSCLAIMS MADE (Explain all "Yes" responses)EMPLOYEE BENEFITS LIABILITYPage 1 of 4 ACORD 126 (2007/05) ACORD CORPORATION 1993-2007. All rights ACORD name and logo are registered marks of ACORDCOMMERCIAL GENERAL LIABILITY SECTIONY / NEXPLAIN ALL "YES" RESPONSES (For past or present operations)DESCRIBE THE TYPE OF WORK SUBCONTRACTED$ PAID TO SUB-% OF WORK# FULL-# PART-CONTRACTORS:SUBCONTRACTED:TIME STAFF:TIME STAFF:TIME INEXPECTEDPRODUCTSANNUAL GROSS SALES# OF UNITSINTENDED USEPRINCIPAL COMPONENTSMARKETLIFEEXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, / N1.

10 DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE ?6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?