COMMERCIAL INSURANCE APPLICATION DATE (MM/DD/YYYY ...

1 NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)NAICSBUSINESS PHONE #:TRUSTAND MANAGERS:SUBCHAPTER "S" CORPORATIONNO. OF MEMBERSNOT FOR PROFIT ORGJOINT VENTURECORPORATIONPARTNERSHIPINDIVIDUALL LCWEBSITE ADDRESSSICGL CODEFEIN OR SOC SEC #NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)NAICSBUSINESS PHONE #:TRUSTAND MANAGERS:SUBCHAPTER "S" CORPORATIONNO. OF MEMBERSNOT FOR PROFIT ORGJOINT VENTURECORPORATIONPARTNERSHIPINDIVIDUALL LCWEBSITE ADDRESSSICGL CODEFEIN OR SOC SEC #VEHICLE SCHEDULEVACANT BUILDING SUPPLEMENTSTATE SUPPLEMENT (If applicable)

2 STATEMENT / SCHEDULE OF VALUESRESTAURANT / TAVERN SUPPLEMENTPROFESSIONAL LIABILITY SUPPLEMENTPREMIUM PAYMENT SUPPLEMENTLOSS SUMMARYINTERNATIONAL PROPERTY EXPOSURE SUPPLEMENTINTERNATIONAL LIABILITY EXPOSURE SUPPLEMENTADDITIONAL INTEREST SCHEDULEATTACHMENTSCONTRACTORS SUPPLEMENTCONDO ASSN BYLAWS (for D&O Coverage only)APARTMENT BUILDING SUPPLEMENTADDITIONAL PREMISES INFORMATION SCHEDULECOVERAGES SCHEDULEDRIVER INFORMATION SCHEDULENAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)NAICSBUSINESS PHONE #:TRUSTAND MANAGERS:SUBCHAPTER "S" CORPORATIONNO.

3 OF MEMBERSNOT FOR PROFIT ORGJOINT VENTURECORPORATIONPARTNERSHIPINDIVIDUALL LCWEBSITE ADDRESSSICGL CODEFEIN OR SOC SEC #ACORD 125 (2016/03)$$METHOD OF PAYMENTPREMIUMMINIMUM$DEPOSITPOLICY PREMIUMAUDITPAYMENT PLANBILLING PLANDIRECTAGENCYPROPOSED EXP DATEPROPOSED EFF DATEPOLICY INFORMATIONLINES OF BUSINESSCOMMERCIAL GENERAL LIABILITY$$$$$$$$$$$$$PREMIUMPREMIUMPREM IUMBUSINESS OWNERSBUSINESS AUTOUMBRELLABOILER & MACHINERYGARAGE AND DEALERSCRIMECOMMERCIAL PROPERTYINDICATE LINES OF BUSINESSYACHT 1993-2015 ACORD CORPORATION.

4 All rights 1 of 4 The ACORD name and logo are registered marks of ACORDAPPLICANT INFORMATIONUNDERWRITER OFFICEUNDERWRITERDATE (MM/DD/YYYY) COMMERCIAL INSURANCE APPLICATIONAPPLICANT INFORMATION SECTIONFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONESUBCODE:CODE:AGENCY CUSTOMER ID:ADDRESS:E-MAILSTATUS OFTRANSACTIONRENEWQUOTEISSUE POLICYBOUND (Give Date and/or Attach Copy):CANCELCHANGEDATETIMEAMPMNAIC CODECARRIERPOLICY NUMBERCOMPANY POLICY OR PROGRAM NAMEPROGRAM CODEHOTEL / MOTEL SUPPLEMENTCYBER AND PRIVACYFIDUCIARY LIABILITY$LIQUOR LIABILITY$ COMMERCIAL INLAND MARINE$TRUCKERSMOTOR CARRIER$ACCOUNTS RECEIVABLE / VALUABLE PAPERSDEALERS SECTIONELECTRONIC DATA PROCESSING SECTIONGLASS AND SIGN SECTIONINSTALLATION / BUILDERS RISK SECTIONOPEN CARGO SECTION$$$$E-MAIL ADDRESS:REASON FOR INTEREST:OWNERLEASEBACKWARRANTYBREACH OFTRUSTEEREGISTRANTFAX (A/C, No).

5 PHONE (A/C, No, Ext):LIEN AMOUNT:INTEREST END DATE:ITEM:CLASS:AIRPORT:AIRCRAFT:CO-OWNE ROWNERSEND BILLPOLICYEVIDENCE:AS LESSORINSUREDITEM DESCRIPTIONINTERESTRANK:NAME AND ADDRESSREFERENCE / LOAN #:CERTIFICATEINTEREST IN ITEM NUMBERADDITIONALLOSS PAYEEMORTGAGEELIENHOLDEREMPLOYEELOCATION :BUILDING:VEHICLE:BOAT:ITEM$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:SQ FTOPEN TO PUBLIC AREA:ANNUAL REVENUES:INTERESTCITY LIMITSOCCUPIED AREA:SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT$SQ FTANY AREA LEASED TO OTHERS?

6 Y / NTOTAL BUILDING AREA:SQ FTOPEN TO PUBLIC AREA:ANNUAL REVENUES:INTERESTCITY LIMITSOCCUPIED AREA:SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:SQ FTOPEN TO PUBLIC AREA:ANNUAL REVENUES:INTERESTCITY LIMITSOCCUPIED AREA:SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANTADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional InterestsPHONE #SECONDARYCELLHOMEBUSPHONE #CELLHOMEBUSPRIMARYPHONE #SECONDARYCELLHOMEBUSPHONE #CELLHOMEBUSPRIMARY$SQ FTANY AREA LEASED TO OTHERS?

7 Y / NTOTAL BUILDING AREA:SQ FTOPEN TO PUBLIC AREA:ANNUAL REVENUES:INTERESTCITY LIMITSOCCUPIED AREA:SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT%%DESCRIPTIO N OF OPERATIONS OF OTHER NAMED INSUREDSOFF PREMISES INSTALLATION, SERVICE OR REPAIR WORKDESCRIPTION OF PRIMARY OPERATIONSRETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:INSTALLATION, SERVICE OR REPAIR WORKNATURE OF BUSINESSMANUFACTURINGINSTITUTIONALDATE BUSINESSSTARTED (MM/DD/YYYY)CONTRACTORRESTAURANTCONDOMIN IUMSAPARTMENTSWHOLESALERETAILSERVICEOFFI CEPREMISES INFORMATION (Attach ACORD 823 for Additional Premises)CONTACT NAME:SECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:CONTACT TYPE:CONTACT INFORMATIONSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:CONTACT NAME:CONTACT TYPE:AGENCY CUSTOMER ID.

8 ACORD 125 (2016/03)LENDER'SLOSS PAYABLEPage 2 of 4$$$$EFFECTIVE DATEYEAREXPIRATION DATEPREMIUMPOLICY NUMBERCARRIEROTHER:PROPERTYAUTOMOBILEGEN ERAL LIABILITYCATEGORYPRIOR CARRIER INFORMATIONREMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?SAFETY POSITIONOSHAMONTHLY MEETINGSSAFETY A FORMAL SAFETY PROGRAM IN OPERATION?

9 Y / NEXPLAIN ALL "YES" RESPONSESSUBSIDIARY COMPANY NAMERELATIONSHIP DESCRIPTION% OWNEDPARENT COMPANY NAMERELATIONSHIP DESCRIPTION% OWNEDDOES THE APPLICANT HAVE ANY SUBSIDIARIES?IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)POLICY NUMBERPOLICY NUMBERLINE OF BUSINESSLINE OF BUSINESSNAME OF trust :HAS BUSINESS BEEN PLACED IN A trust ? APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?

10 CORRECTED (Describe):UNDERWRITINGAGENT NO LONGER REPRESENTS CARRIERNON-RENEWALNON-PAYMENTANY 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) INFORMATIONANY 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 ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?