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ACORD COMMERCIAL INSURANCE APPLICATION DATE

TM
APPLICANT INFORMATION SECTION
8/18/08
PRODUCER PHONE CARRIER UNDERWRITER
(A/C, No, Ext): FAX NAIC CODE:

POLICIES OR PROGRAM REQUESTED

INDICATE SECTIONS ATTACHED EQUIPMENT FLOATER GARAGE AND DEALERS

PROPERTY INSTALLATION/BUILDERS RISK VEHICLE SCHEDULE
EMAIL
GLASS AND SIGN ELECTRONIC DATA PROC BOILER & MACHINERY
ACCOUNTS RECEIVABLE/ COMMERCIAL
CODE: SUB CODE: VALUABLE PAPERS GENERAL LIABILITY WORKERS COMPENSATION
AGENCY CUSTOMER ID CRIME/MISCELLANEOUS CRIME BUSINESS AUTO UMBRELLA
TRANSPORTATION/
MOTOR TRUCK CARGO TRUCKERS/MOTOR CARRIER
STATUS OF SUBMISSION PACKAGE POLICY INFORMATION
QUOTE ISSUE POLICY ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES.

BOUND (Give Date and/or Attach Copy): PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN AUDIT

DATE TIME AM DIRECT BILL

PM AGENCY BILL
APPLICANT INFORMATION
NAME (First Named Insured & Other Named Insureds) FEIN OR SOC SEC # MAILING ADDRESS INCL ZIP+4 (of First Named Insured)
(of First Named Ins):
PHONE
(A/C, No, Ext):

SUBCHAPTER "S" NOT FOR CR BUREAU ID NUMBER YEAR BUS

INDIVIDUAL CORPORATION CORPORATION PROFIT ORG NAME STARTED
LIMITED
PARTNERSHIP JOINT VENTURE CORPORATION
INSPECTION CONTACT PHONE ACCOUNTING RECORDS CONTACT PHONE
(A/C, No, Ext): (A/C, No, Ext):

PREMISES INFORMATION
LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT PART OCCUPIED

INSIDE OWNER

OUTSIDE TENANT

INSIDE OWNER

OUTSIDE TENANT

INSIDE OWNER

OUTSIDE TENANT

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)

GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES YES NO
1. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES THE APPLICANT HAVE ANY 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION
SUBSIDIARIES? ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
2. IS A FORMAL SAFETY PROGRAM IN OPERATION? 8. DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTED OF ANY
DEGREE OF THE CRIME OF ARSON? (In RI, this question must be answered by any
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? applicant for property insurance. Failure to disclose the existence of an arson
conviction is a misdemeanor punishable by a sentence of up to one year of
4. ANY CATASTROPHE EXPOSURE? imprisonment).
5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? 9. ANY UNCORRECTED FIRE CODE VIOLATIONS?
6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE 10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST
PRIOR 3 YEARS? NOT APPLICABLE IN MO 5 YEARS?
REMARKS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL
PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)

APPLICANT'S PRODUCER'S
SIGNATURE SIGNATURE

ACORD 125 (7/98) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

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PRIOR CARRIER INFORMATION
LINE CATEGORY

CARRIER

POLICY NUMBER
CLAIMS CLAIMS CLAIMS CLAIMS CLAIMS
POLICY TYPE MADE
OCCURRENCE
MADE
OCCURRENCE
MADE
OCCURRENCE
MADE
OCCURRENCE
MADE
OCCURRENCE

RETRO DATE

EFF-EXP DATE
G
E GENERAL AGGREGATE
N PRODUCTS COMP OP
C E AGGREGATE
O R
M A PERSONAL & ADV INJ
M L
E L EACH OCCURRENCE
R I L
C A I FIRE DAMAGE
I B M
A I I MEDICAL EXPENSE
L L T
I S BODILY OCCURRENCE
T
Y INJURY AGGREGATE

PROPERTY OCCURRENCE
DAMAGE AGGREGATE

COMBINED SINGLE LIMIT

MODIFICATION FACTOR
TOTAL PREMIUM

CARRIER

POLICY NUMBER

A POLICY TYPE
U L
T I EFF-EXP DATE
O A
M B COMBINED SINGLE LIMIT
O I
B L BODILY EA PERSON
I I
T INJURY EA ACCIDENT
L
E Y
PROPERTY DAMAGE
MODIFICATION FACTOR

TOTAL PREMIUM

CARRIER
POLICY NUMBER
P
R POLICY TYPE
O
P EFF-EXP DATE
E
R BUILDING AMT
T
Y PERS PROP AMT

MODIFICATION FACTOR
TOTAL PREMIUM

CARRIER

POLICY NUMBER
POLICY TYPE

EFF-EXP DATE

LIMIT
MODIFICATION FACTOR

TOTAL PREMIUM
LOSS HISTORY
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS CHK HERE SEE ATTACHED
FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY) IF NONE LOSS SUMMARY

DATE OF DATE AMOUNT AMOUNT CLAIM

LINE TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM
OCCURRENCE OF CLAIM PAID RESERVED STATUS

OPEN

CLOSED

OPEN

CLOSED

REMARKS NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORY

NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED
FROM PERSONS OTHER THAN YOU. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS
MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND
CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH
INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
ACORD 125 (7/98)
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