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1 You may fax your application to: (304) However, all original applications should be mailed to the address shown above. Coverage will not be bound without receipt of an original application. If you have any questions, please call Valerie Toney at (800)

2 Pennsylvania National Mutual Casualty Insurance Company Penn National Security Insurance Company P.O. Box 2361 Harrisburg, PA COMMERCIAL GENERAL SIMPLIFIED ISO OCCURRENCE OR CLAIMS-MADE FORM BUSINESSOWNERS Staff Rated Other than Staff Rated COMMERCIAL AUTOMOBILE 0 5 vehicles 6 or more vehicles EMPLOYERS LIMITS Limits are available up to 10 million INSURANCE AGENT S COMMERCIAL - PERSONAL UMBRELLA STATE RATES AND MINIMUM UNDERLYING LIMITS ARKANSAS, KENTUCKY, MISSISSIPPI, WEST VIRGINIA COMMERCIAL MINIMUM UNDERLYING LIMITS REQUIREMENTS 1,000,000 General.Aggregate 1,000,000 Prod/Co Aggregate 500,000 Each Occurrence 500,000 Personal/Advertising 50,000 Fire Damage Limit 5,000 Med Expense Limit 500,000 CSL 1,000,000 CSL 500,000 CSL 1,000,000 CSL Bodily Injury By Accident 100,000 Each accident Bodily Injury By Disease 500,000 Policy Limit 100,000 Each Employee ERRORS AND OMISSIONS Gross Commission Income 0 500, ,001-1,000,000 1,000,001-1,500,000 1,500,001-8,000,000 EMPLOYMENT PRACTICES (Coverage Is Subject To Prior Approval)) (No Coverage For Jet Skis & Wave Runners) Less Than 35 Feet in Length More Than 35 Feet but Less Than 50 Feet In Length 1,000,000 Each Claim 1,000,000 Aggregate 1,000,000 Each Claim 2,000,000 Aggregate 1,000,000 Each Claim 3,000,000 Aggregate 2,000,000 Each Claim 4,000,000 Aggregate 1,000,000 CSL Each Accident or Occurrence 500,000 1,000,000 COMMERCIAL RATES 1 9 TOTAL STAFF (Does not include EPLI) MILLION MILLION MILLION SUBMIT FOR QUOTATION Not Staff Rated Eligible 1. Limits greater than 3 million. 2. Annual gross commission income exceeding 8,000, Total staff exceeding Owned and/or leased vehicles in excess of Any driver under the age of 25 who is driving a vehicle listed on the 6. Has any watercraft exceeding 26 ft. in length or 60 HP and/or any aircraft exposure agency s commercial auto policy. (owned or non-owned). 7. Greater than 25% of total premium is written through Brokers, 8. Greater than 20% of total premium written in the following lines of business (any MGA s, Other Retail Agencies, Insurance Intermediaries, or as a combination): Flood, Med Mal, all other Professional, Aviation, Bonds, Wet Marine, Broker (incl Surplus lines). Life Insurance, Accident & Health. 9. Greater than 15% of total premium written in coastal Property 10. Greater than 10% of total premium is placed in the following: Self Insured Captives, business. Risk Retention Groups, Multiple Employer Trusts, Multiple Employer Welfare Trust. 11. Additional revenue activities generating in excess of 75,00 income for Loss Control, PEO Marketing, Fee Based Consulting, Mutual Funds Sales. 12. Gross Commission income from real estate operations greater than 10% of total agency commission income or 500,000, whichever is greater. 13. Agency engaged in any business other than insurance. 14. Any underlying claim (incl E&O) in excess of 250,000 within the past 5 years. 15. Any of top 5 companies Agency represents has a Best rating of less than B Agency is a cluster or involved in a cluster arrangement 17. Excess EPLI limit > 2,000,000. PERSONAL MINIMUM UNDERLYING LIMITS REQUIREMENTS PERSONAL AUTOMOBILE 500,000/500,000 BI and 100,000 PD OR 500,000 CSL PERSONAL 300,000 Each Occurrence Without Swimming Pools 500,000 Each Occurrence With Swimming Pools (No Coverage For Jet Skis & Wave Runners) Less Than 35 Feet in Length More Than 35 Feet but Less Than 50 Feet In Length 500,000 Each Accident or Occurrence 1,000,000 Each Accident or Occurrence ANNUAL RATE PER INSURED includes 2 vehicles written on a Personal Auto Policy, 1 residence and any watercraft under 26 feet in length and less 60 HP. PERSONAL UMBRELLA RATES LIMITS ANNUAL RATE Limits are available up to 5 million PER INSURED 1 MILLION MILLION 250 SUBMIT FOR QUOTATION 1. Limits in excess of 2 million. 4. Any aircraft exposure (owned or non-owned) 2. Any additional residence. 5. Any driver under the age of 25 who drives a vehicle listed on the insured s personal auto policy. 3. Owned and/or leased vehicles in excess of Any watercraft exceeding 26 ft. in length or with motor(s) exceeding 60 HP

3 Pennsylvania National Mutual Casualty Insurance Company P.O. Box 2361 Harrisburg, PA phone fax GENERAL INFORMATION 1. APPLICANT 2. DATE 3. NEW RENEWAL 5. MAILING ADDRESS INSURANCE AGENTS UMBRELLA SUPPLEMENTAL APPLICATION 4. EXPIRING POLICY NUMBER 6. PROPOSED POLICY PERIOD (12:01 a.m. Standard Time) FROM: TO: 7. TELEPHONE (Incl Area Code) 8. BUSINESS ADDRESS (Enter Same or indicate address, if different from above) 9. FAX NUMBER (Incl Area Code) 10. CONTACT PERSON 11. ADDRESS 12. AGENCY WEBSITE ADDRESS 13. UMBRELLA LIMITS REQUESTED COMMERCIAL UMBRELLA COVERAGE LIMITS 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 INSURED S RETAINED LIMIT: 10,000 (Standard) 0 (Optional) Other (specify) PERSONAL UMBRELLA ENDORSEMENT (Optional) 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 N/A INSURED S RETAINED LIMIT: 250 (Standard) 0 (Optional) APPLICABLE ONLY IN NEW YORK: IF ANY UNDERLYING INSURANCE INCLUDES DEFENSE WITHIN LIMITS, THIS INSURANCE WILL ALSO PROVIDE DEFENSE WITHIN LIMITS. THE DEFENSE COSTS CHARGED AGAINST THE LIMITS OF INSURANCE WILL NOT EXCEED 50% OF SUCH LIMITS; AND, WE WILL ASSUME ANY DEFENSE COSTS OVER THIS AMOUNT. ERRORS & OMISSIONS SUPPLEMENTAL INFORMATION 14. RETROACTIVE DATE OF PRIMARY E&O POLICY (if any) 15. EXTENDED DISCOVERY PERIOD? YES NO IF YES, LENGTH OF TIME 16. DEFENSE COSTS AND SUPPLEMENTAL PAYMENTS PROVIDED? YES NO IF NO, EXPLAIN IN REMARKS 17. LIST ALL COMPANIES YOU WRITE BUSINESS WITH THAT ARE NOT RATED B+ OR BETTER BY AM BEST DOLLARS PERCENTAGE (%) 18. TOTAL GROSS COMMISSION INCOME OF AGENCY (Do not include Profit Sharing/Contingent Commission) 19. HAVE YOU PLACED ANY BUSINESS WITH A COMPANY THAT IS PRESENTLY INSOLVENT? YES NO IF YES, EXPLAIN IN REMARKS SECTION. 20. DOES YOUR AGENCY DERIVE REVENUE THROUGH INTERNET TRANSACTIONS? YES NO IF YES, WHAT PERCENTAGE? 21. IDENTIFY THE PERCENTAGE OF TOTAL WRITTEN PREMIUM IN THE FOLLOWING LINES OF BUSINESS (if any) FLOOD % MEDICAL MALPRACTICE % COASTAL PROPERTY % 22. IDENTIFY THE PERCENTAGE OF TOTAL WRITTEN PREMIUM PLACED IN THE FOLLOWING (if any) SELF INSURED CAPTIVES % RISK RETENTION GROUPS % MULTIPLE EMPLOYER TRUSTS % MULTIPLE EMPLOYER WELFARE TRUSTS % 23. DOES YOUR PRIMARY E&O POLICY CONTAIN ANY COVERAGE(S) WITH SUBLIMITS? YES NO COVERAGE SUBLIMIT (EA CLAIM/AGG) / COVERAGE SUBLIMIT (EA CLAIM/AGG) / BUSINESS OTHER THAN INSURANCE: (Complete this section only if engaged in any business other than insurance) 24. IS AGENCY LICENSED FOR SELLING REAL ESTATE? YES NO 25. GROSS INCOME 27. OTHER BUSINESS YES NO (If yes, explain in Remarks section) 28. GROSS INCOME 30. ARE OTHER BUSINESS OPERATIONS COVERED BY UNDERLYING POLICIES? (to include E &O) YES NO IF NO, EXPLAIN 26. # OF EMPLOYEES 29. # OF EMPLOYEES Page 1 of 3

4 UNDERLYING EXPOSURES (OTHER THAN ERRORS & OMISSIONS) AUTOMOBILE 31. TOTAL NUMBER OF AUTOS OWNED OR LEASED BY THE AGENCY 32. ANY DRIVERS UNDER THE AGE OF 25? YES NO 33. PROVIDE THE NAMES, DATES OF BIRTH, AND OPERATOR NUMBERS FOR ALL DRIVERS NAME OF DRIVER DATE OF BIRTH OPERATOR NO. 34. : LIST ALL WTERCRAFT OWNED IS NUMBER APPLICANT USE OF YEAR MAKE MODEL DOCKED AT HORSE POWER 35. ANY ABOVE USED FOR WATER SKIING? YES NO LENGTH IN- BOARD 37. ANY AIRCRAFT OWNED OR LEASED BY APPLICANT? YES NO OUT- BOARD INBOARD OUTBOAR D 38. ANY AIRCRAFT CHARTERED DURING THIS POLICY PERIOD? YES NO If yes, explain 39. DOES AGENCY INSURE AIR SHOW? YES NO LOSS EXPERIENCE 40. CLAIM EXPERIENCE (OTHER THAN E&O) DESCRIBE ALL CLAIMS DURING THE PAST FIVE YEARS WHICH INVOLVED PAYMENTS/RESERVES IN EXCESS OF 250,000. OF PAS- SENGERS SLEEPS IS OWNER LEASES LOANS/ RENTS TO OTHERS 36. ANY CHARTERED DURING THIS POLICY PERIOD? YES NO If yes, explain AIRCRAFT DATE OF CLAIM MO DAY YR EXCESS EMPLOYMENT PRACTICES AMOUNT RESERVED 41. INCLUDE EXCESS EMPLOYMENT PRACTICES COVERAGE? (1,000,000 minimum underlying limit required) YES NO (If yes attach a copy of your primary EPLI application, or ACORD 188 if no underlying EPLI application is available) 42. EXCESS EMPLOYMENT PRACTICES LIMITS REQUESTED (choose one) 1,000,000 2,000,000 REMARKS BUSINESS PLEASURE % % % % AMOUNT PAID Page 2 of 3

5 PREMIUM CALCULATION for Staff Rated Risks (See State Rate Page for Rates and Eligibility) Commercial Liability Limits # of Staff = Personal Liability Limits # of Insureds X Ann Rate = Total Premium Full time staff members shall be rated as one (1), part time staff members shall be rated as one-half (1/2). Note: part time individuals work 20 hours or less per week. If total number of rating units end in 1/2, round to the next lowest whole number. Exp.: 5 1/2 = rate policy at 5. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE CONTAINING ANY 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 NE, NY, OH or OR. In DC, TN and VA insurance benefits may also be denied.) APPLICABLE IN NEW YORK ONLY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. IMPORTANT THE STATEMENTS (ANSWERS) GIVEN ABOVE ARE TRUE AND ACCURATE. THE APPLICANT HAS NOT WILLFULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCE CONCERNING THIS APPLICATION. THIS APPLICATION DOES NOT CONSTITUTE A BINDER. SIGNATURE OF INDIVIDUAL OWNER, PARTNER OR OFFICER DATE SIGNED IMPORTANT ADDITIONAL INFORMATION: The following additional information is required to complete this application and must be attached to this submission: 1) A copy of the primary Errors and Omissions coverage application 2) A copy of each underlying policy Declarations (to include Automobile, General Liability [or BOP], Employers Liability [WC], Errors & Omissions, Employment Practices Liability, etc.) 3) A copy of Accord 83 (Personal Umbrella Application) for each officer applying for the personal umbrella endorsement 4) If excess Employment Practices Liability is requested, attach a copy of the primary EPLI application; or, if a primary EPLI application is not available, attach a copy of ACORD 188 (Employment Related Practices Liability Section). Minimum Underlying Limit Requirements are shown on the State Rate Pages. Page 3 of 3

6 SUPPLEMENTAL SCHEDULE OF UNDERLYING INSURANCE COVERAGE AUTOMOBILE GENERAL EMPLOYERS ERRORS & OMISSIONS NOTARY PUBLIC E & O EMPLOYMENT PRACTICES LIAB CARRIER/POLICY NUMBER Attach A Copy Of Each Declarations Page. POLICY EFF/EXP DATES LIMITS CSL/BI EA. OCC. BI EA. PER. PD EA. ACC EACH OCCURRENCE GENERAL AGGR PROD & COMP OPS AGGREGATE PERSONAL & ADV INJURY DAMAGE TO RENTED PREMISES MEDICAL EXPENSE EACH ACCIDENT DISEASE EACH EMPLOYEE DISEASE POLICY LIMIT EACH CLAIM AGGREGATE CSL EACH CLAIM AGGREGATE CSL CSL EACH ACCIDENT OR OCCURRENCE ANNUAL PREMIUM Supplemental Page 1

7 PAY PLANS 1 Full pay (no installments). 2 Two pay, 50 percent down payment, one installment of 50 percent due three months later. 3 40/30/30, 40 percent down payment, two installments of 30 percent each due every other month. 4 Quarterly, 25 percent down payment, three installments of 25 percent each due quarterly. 5 Monthly, 20 percent down payment, five installments of 16 percent each due monthly. Please circle the plan # you desire, sign and return with you re application. If you do not choose a plan, #1 will be used. ELIGIBILITY PREMIUM AVAILABLE PAY PLANS 0-1,000 1 OR 2 1,001-5,000 1, 2, 3 OR 4 OVER - 5,000 1, 2, 3, 4 OR 5 SERVICE FEES INSTALLMENT SERVICE FEE: No service fee will be added to the initial payment. A 4 service fee will be added to each installment billing. If an insured prepays an installment before the billing is actually produced no service fee will be charged. RETURN CHECK FEE: For returned checks, we will add a 20 charge to the insured s balance. This charge will be due in full and will not be spread among unbilled installments. Signature Date

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