Distributor/Wholesaler Supplemental Application

1 Carrier: A Berkshire Hathaway Company Distributor/Wholesaler Supplemental Application Complete in addition to Acord Applications NAME OF APPLICANT Location Address: Website Address: I. GENERAL INFORMATION. 1. Applicant operates as a: (check all that apply) q Wholesaler q Distributor q Retailer 2. Does the Applicant engage in any business operations at another location other than those disclosed on this Application ? If "Yes," explain: q Yes q No 3. Are there any other persons or organizations, subsidiaries, affiliates or other entities related to the Applicant (including DBAs) for which coverage is desired? q Yes q No If "Yes," please list and describe the relationship to the Applicant: Note: There is no coverage for any such person, organization or entities unless endorsed to the policy. The following questions relate to Applicant only. 4. How many years has Applicant operated under present ownership? 5. How many years has Applicant operated at the above location?

2 6. Does Applicant now handle or, in the next twelve (12) months, does Applicant expect to handle raw materials, petroleum, gases, chemicals or related flammable or combustible substances other than common household substances? q Yes q No 7. Does Applicant now sell, distribute or store or, in the next twelve (12) months does Applicant expect to sell, distribute or store, fireworks, pyrotechnics, firearms or other weapons? q Yes q No 8. Is Applicant a freight forwarder? q Yes q No 9. Does Applicant now sell or distribute or, in the next twelve (12) months, does Applicant expect to sell or distribute used, salvaged, antique or collectible merchandise? q Yes q No 10. Does Applicant now operate or, in the next twelve (12) months, does Applicant expect to operate a merchandise liquidation facility at the above location? q Yes q No 11. Does Applicant currently maintain and, in the next twelve (12) months, will Applicant continue to maintain functioning and operational smoke and/or heat detectors in the above location?

3 Q Yes q No 12. For any building built prior to 1978, is 100 percent of the electric connected to functioning and operational circuit breakers and without any aluminum or knob and tube wiring? q Yes q No 13. Indicate which of the following products you distribute or sell: (check all that apply). q Appliances (large Books, q Fabrics q Hearing aids and q Plumbing supplies q household) newspapers, Floor coverings q optical goods and fixtures Arts and crafts/. q magazines and Frozen foods q Home furniture q Printer supplies q Artwork periodicals Ice q Seasonal and q Fruits, vegetables q Automobiles q Candles and q or flowers Jewelry or q holiday items Automobile parts q aromatherapy gemstones Gardening and q Sporting goods q and supplies Canned food q light farming Luggage q Toys and games q Barber or beauty q Clothing, wearing q supplies Marketing and q supplies or footwear Other q Gift basket and gift q promotional items Cosmetics, q Bed linens q basket supplies Mobile equipment q Beverages q fragrances or both Groceries q Office machines q (alcoholic, other Dollar store q Hardware and q and supplies than beer) inventory tools Paper and q Beverages (non- q Dried foods q Health and q stationery products alcoholic and beer) Electrical q nutrition items Pet supplies q Boats q equipment Distributor/Wholesaler SUPP-APP 12/15 1 of 5.

4 II. GENERAL LIABILITY. 14. Does the Applicant require and verify that all manufacturers for which Applicant sells, distributes or handles goods: a. Maintain products/completed operations liability coverage? q Yes q No b. List the Applicant as an additional insured? q Yes q No 15. What percentage of goods are imported directly from foreign countries? %. a. Indicate types of products imported: 16. Does Applicant manufacture, design, alter, assemble, enhance, repackage, label or re-label any products? q Yes q No 17. Is there any installation, servicing or repair of products? q Yes q No a. If "Yes," provide details: 18. Does Applicant currently engage in retail operations or does Applicant expect to engage in such operations in the next twelve (12) months? q Yes q No a. If "Yes," provide type(s) of products and total annual sales by product type: $ 19. Are customers permitted in any warehouse/storage areas? q Yes q No 20. Does Applicant use forklifts or other mobile equipment to handle goods at the above location or at customers' locations?

5 If "Yes": q Yes q No a. How many forklifts? # b. Are all employees and others who operate the equipment fully trained to do so? q Yes q No c. Are customers and non-employees prohibited from areas where such equipment is operated? q Yes q No d. Is all such equipment equipped with back-up alarms or similar devices? q Yes q No 21. Does Applicant make off-site deliveries? If "Yes": q Yes q No a. Does the Applicant stock shelves or set up any merchandise displays on customer premises? q Yes q No b. Are deliveries generally made through the same entrance used by customers? q Yes q No 22. Does Applicant rent any equipment to others? q Yes q No 23. Is Applicant responsible for building maintenance? q Yes q No a. If "Yes," who is the maintenance performed by? Employees Subcontractors (if checking employees, skip question b.). b. If subcontractors: i. Is written contract in place for services? q Yes q No ii. Is Applicant named as an additional insured on the subcontractor's policy?

6 Q Yes q No iii. Does subcontractor carry general liability limits of at least $1,000,000? q Yes q No iv. Are certificates of insurance obtained from all subcontractors? q Yes q No 24. Is the Applicant responsible for snow and ice removal? q Yes q No a. If "Yes," who is the maintenance performed by? Employees Subcontractors (if checking employees, skip question b.). b. If subcontractors: i. Is written contract in place for services? q Yes q No ii. Is Applicant named as an additional insured on the subcontractor's policy? q Yes q No iii. Does subcontractor carry general liability limits of at least $1,000,000? q Yes q No iv. Are certificates of insurance obtained from all subcontractors? q Yes q No 25. Does Applicant now use, or in the next twelve (12) months, does Applicant expect to use armed security at the above location? q Yes q No (If "Yes," Firearms and Assault or Battery exclusions will apply). Distributor/Wholesaler SUPP-APP 12/15 2 of 5. Complete below for all applicable products: Appliance Distributor q N/A.

7 26. Does Applicant dispose of or recycle old appliances or electronic equipment in accordance with applicable statutes, regulations or ordinances? q Yes q No Clothing, Wearing, Apparel or Footwear q N/A. 27. Is there any sale of children's clothing? q Yes q No 28. Does Applicant sell or store furs or costumes? q Yes q No Fruits, Vegetables or Flowers q N/A. 29. Is Applicant involved in farming, harvesting or treating fruits or vegetables in any way? q Yes q No Gardening and Light Farming Supplies q N/A. 30. Are there any nursery operations? q Yes q No Seasonal and Holiday q N/A. 31. Are there any sales or storage of furs or costumes? q Yes q No III. BUILDING INFORMATION (IF APPLICABLE). 32. Does the Applicant own the building? If "Yes": q Yes q No a. What is the total square footage of the building? sq. ft. b. Is any portion of the building vacant? If "Yes," provide square footage: q Yes q No sq. ft. q Unknown c. Is any portion leased to others? If "Yes": q Yes q No i.

8 Provide a list of tenants and square footage occupied by each. sq. ft. sq. ft. sq. ft. sq. ft. ii. Is there a lease agreement in place with all tenants? q Yes q No iii. Does the lease require all commercial tenants to maintain general liability coverage with limits of at least $1,000,000? q Yes q No iv. Are tenants required to name Applicant as an additional insured? q Yes q No v. Does applicant obtain certificates of Insurance from all commercial tenants? q Yes q No vi. Are tenants permitted to sublease to others? q Yes q No d. Is there any existing damage to the building? q Yes q No 33. What type of plumbing is within the building? (check all that apply). Copper Galvanized Iron Lead PVC Other 34. Is the entire building at the above location equipped with a functioning and operational sprinkler or fire suppressant system? If "Yes": q Yes q No a. What type of sprinkler system? q Wet system q Dry system q Other q Unknown b. Was the sprinkler system designed for the current type of occupant?

9 Q Yes q No c. Is a certified contractor responsible for the sprinkler system inspection, testing and maintenance? q Yes q No d. How often is the sprinkler system maintenance and inspection performed? Monthly Quarterly Semi-Annual Annual Unknown e. Is the sprinkler system tied to a central station alarm? q Yes q No q Unknown 35. What type of security is within the building? (check all that apply). Local alarm Central station burglar alarm Central station fire alarm 24-hour security Smoke detection Fire extinguisher(s) Other Unknown 36. What is the smoking policy for the premise? 37. Does Applicant use any portion of the above location for warehousing or storage of goods? If "Yes": q Yes q No a. What is the maximum height of storage? ft. b. Are storage racks positioned so that the goods stored at the highest levels are at least 18 inches below any overhead sprinklers? q N/A q Yes q No Distributor/Wholesaler SUPP-APP 12/15 3 of 5. c. Is solid shelving used in rack storage?

10 Q Yes q No d. Is there any cold storage warehousing? If "Yes": q Yes q No i. Total square footage of cold storage warehouse: sq. ft. ii. Are the temperature control valves tied to a central station alarm? q Yes q No iii. Does the Applicant use ammonia-based refrigerants? q Yes q No 1) If "Yes," is there an ammonia detection system? q Yes q No iv. Does the Applicant have backup generators to provide a continuous power source for refrigeration and freezer equipment in the event of a power failure? q Yes q No 1) If "Yes," when was it last inspected/tested? / /. e. Does the Applicant store any goods of others? q Yes q No i. If "Yes," provide type of goods stored and total values: $. 38. Is any commercial cooking done at the above location? q Yes q No IV. HIRED AND NON-OWNED AUTO INFORMATION (IF COVERAGE IS DESIRED). 39. Does the Applicant have a commercial automobile policy in place? q Yes q No 40. Does the Applicant own any autos, or lease any autos in excess of 30 days?