LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT PART OCCUPIED OUTSIDE TENANT
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1 M COMMERCIAL INSURANCE APPAION APPAN INFORMAION SECION AGENCY NAIC CODE: UNDERWRIER FAX (A/C, No.): POIES OR PROGRAM REQUESED POY NUMBER UNDERWRIER OFF. CODE: AGENCY CUSOMER ID: SAUS OF RANSACION SUB CODE: INDICAE SECIONS AACHED EQUIPMEN FLOAER GARAGE AND DEALERS PROPERY INSALLAION/BUILDERS RISK VEHICLE SCHEDULE GLASS AND SIGN ELECRONIC DAA PROC BOILER & MACHINERY ACCOUNS RECEIVABLE/ VALUABLE PAPERS COMMERCIAL GENERAL LIALIY WORKERS ENSAION CRIME/MISCELLANEOUS CRIME BUSINESS AUO UMBRELLA RANSPORAION/ MOOR RUCK CARGO RUCKERS/MOOR QUOE ISSUE POY RENEW ENER HIS INFORMAION WHEN COMMON DAES AND ERMS APPLY O SEVERAL LINES, OR FOR MONOLINE POIES. BOUND (Give Date and/or Attach Copy): PROPOSED EFF DAE PROPOSED EXP DAE LLING PLAN PAYMEN PLAN AUDI CHANGE DAE IME AM DIREC LL CANCEL PM AGENCY LL APPAN INFORMAION NAME (First Named Insured & Other Named Insureds) PACKAGE POY INFORMAION FEIN OR SOC SEC # (of First Named Insured): MAILING ADDRESS INCL ZIP+4 (of First Named Insured) ADDRESS(ES): INDIVIDUAL CORPORAION SUBCHAPER "S" CORPORAION LIMIED LIAB CORP PARNERSHIP JOIN VENURE NO FOR PROFI ORG NO. OF MEMBERS AND MANAGERS INION CONAC WEBSIE ADDRESS(ES): CR BUREAU ID NUMBER NAME ACCOUNING RECORDS CONAC DAE BUS SARED PREMISES INFORMAION LOC # BLD # SREE, CIY, COUNY,, ZIP+4 CIY LIMIS INERES YR BUIL PAR OCCUPIED OUSIDE ENAN OUSIDE ENAN OUSIDE ENAN NAURE OF BUSINESS/DESCRIPION OF OPERAIONS BY PREMISE(S) GENERAL INFORMAION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES 1a. IS HE APPAN A SUBSIDIARY OF AN ENIY? 7. ANY PAS LOSSES OR CLAIMS RELAING O SEXUAL AB OR MOLESAION ALLEGAIONS, DISCRIMINAION OR NEGLIGEN HIRING? 1b. DOES HE APPAN HAVE ANY SUBSIDIARIES? 8. DURING HE LAS FIVE YEARS (EN IN RI), HAS ANY APPAN BEEN CONVICED OF ANY DEGREE OF HE CRIME OF ARSON? 2. IS A FORMAL SAFEY PROGRAM IN OPERAION? (In RI, this question must be answered by any applicant for property insurance. 3. ANY EXPOSURE O FLAMMABLES, EXPLOSIVES, CHEMICALS? Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 4. ANY CAASROPHE EXPOSURE? 9. ANY UNCORRECED FIRE CODE VIOLAIONS? 5. ANY INSURANCE WIH HIS ANY OR BEING SUBMIED? 10. ANY BANKRUPCIES, AX OR CREDI LIENS AGAINS HE APPAN IN HE PAS 5 YEARS? 6. ANY POY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED 11. HAS BUSINESS BEEN PLACED IN A RUS? DURING HE PRIOR 3 YEARS? (Not applicable in MO) IF YES, NAME OF RUS: REMARKS/PROCESSING INSRUCIONS YES NO ANY PERSON WHO KNOWINGLY AND WIH INEN O DEFRAUD ANY INSURANCE ANY OR AN PERSON FILES AN APPAION FOR INSURANCE OR MEN OF CLAIM CONAINING ANY MAERIALLY FALSE INFORMAION, OR CONCEALS FOR HE PURPOSE OF MISLEADING, INFORMAION CONCERNING ANY FAC MAERIAL HEREO, COMMIS A FRAUDULEN INSURANCE AC, WHICH IS A CRIME AND SUBJECS HE PERSON O CRIMINAL AND [NY: SUBSANIAL] CIVIL PENALIES. (Not applicable in CO, HI, NE, OH, OK, OR, or V; in DC, LA, ME, N and VA, insurance benefits may also be denied) APPAN S SIGNAURE DAE PRODUCER S SIGNAURE NAIONAL PRODUCER NUMBER ACORD 125 (2002/01) PLEASE LEE REVERSE SIDE ACORD CORPORAION 1993
2 PRIOR INFORMAION LINE A U L I O A M B O I B L I I L E Y P R O P E R Y CAEGORY POY NUMBER POY YPE RERO DAE G E GENERAL AGGREGAE N PRODUCS OP C E AGGREGAE 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 I S BODILY OCCURRENCE Y INJURY AGGREGAE PROPERY OCCURRENCE DAMAGE AGGREGAE COMNED SINGLE LIMI MODIFICAION IUM POY NUMBER POY YPE COMNED SINGLE LIMI BODILY EA PERSON INJURY EA ACCIDEN PROPERY DAMAGE MODIFICAION IUM POY NUMBER POY YPE BUILDING AM PERS PROP AM MODIFICAION IUM POY NUMBER POY YPE LIMI MODIFICAION IUM LOSS HISORY CLAIMS CLAIMS CLAIMS CLAIMS CLAIMS OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE MADE MADE MADE MADE MADE ENER ALL CLAIMS OR LOSSES (REGARDLESS OF AND WHEHER OR NO INSURED) OR OCCURRENCES HA MAY GIVE RISE O CLAIMS FOR HE PRIOR 5 YEARS (3 YEARS IN KS & NY) CHK HERE IF NONE SEE AACHED LOSS SUMMARY DAE OF DAE AMOUN AMOUN CLAIM LINE YPE/DESCRIPION OF OCCURRENCE OR CLAIM OCCURRENCE OF CLAIM PAID RESERVED SAUS OPEN CLOSED OPEN REMARKS NOE: FIDELIY REQUIRES A FIVE YEAR LOSS HISORY AACHMENS CLOSED SUPPLEMEN(S) (If applicable) COPY OF HE NOICE OF INFORMAION PRACICES (PRIVACY) HAS BEEN GIVEN O HE APPAN. (Not applicable in all states, consult your agent or broker for your state s requirements.) NOICE OF INSURANCE INFORMAION PRACICES PERSONAL INFORMAION ABOU YOU, INCLUDING INFORMAION FROM A CREDI REPOR, MAY BE COLLECED FROM PERSONS HAN YOU IN CONNECION WIH HIS APPAION FOR INSURANCE AND SUBSEQUEN POY RENEWALS. SUCH INFORMAION AS WELL AS PERSONAL AND PRIVILEGED INFORMAION COLLECED BY US OR OUR AGENS MAY IN CERAIN CIRCUMSANCES BE DISCLOSED O HIRD PARIES. YOU HAVE HE RIGH O REVIEW YOUR PERSONAL INFORMAION IN OUR FILES AND CAN REQUES CORRECION OF ANY INACCURACIES. A MORE DEAILED DESCRIPION OF YOUR RIGHS AND OUR PRACICES REGARDING SUCH INFORMAION IS AVAILABLE UPON REQUES. CONAC YOUR AGEN OR BROKER FOR INSRUCION ON HOW O SUBMI A REQUES O US. ACORD 125 (2002/01)
3 M BUSINESS AUO SECION PRODUCER APPAN (First FAX (A/C, No): Named Insured) CODE: AGENCY CUSOMER ID: COVERAGES/LIMIS DRIVER INFORMAION SUB CODE: EFFECIVE DAE FOR ANY ONLY EXPIRAION DAE DIREC LL AGENCY LL ACORD 137 FOR YOUR O PROVIDE COVERAGES/LIMIS INFORMAION ACORD 163 attached for additional drivers PAYMEN PLAN LIS ALL DRIVERS, INCLUDING FAMILY MEMBERS HA WILL DRIVE ANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON ANY BUSINESS. DRIVER MAR YRS YEAR DRIVERS ENSE NUMBER/ DAE BROADEN. DOC % # NAME (Include address, if required) SEX SA DAE OF RH EXP SOCIAL SECURIY NUMBER HIRE VEH # AUDI GENERAL INFORMAION EXPLAIN ALL "YES" RESPONSES 1. WIH HE EXCEPION OF ENCUMBRANCES, ARE ANY VEHICLES NO SOLELY OWNED BY AND REGISERED O HE APPAN? DESCRIPION OF GARAGE/SORAGE LOCAIONS YES NO EXPLAIN ALL "YES" RESPONSES 8. ANY HOLD HARMLESS AGREEMENS? 9. ANY VEHICLES D BY FAMILY MEMBERS? IF SO, IDENIFY IN REMARKS. 2. DO OVER 50% OF HE EMPLOYEES HEIR AUOS IN HE BUSINESS? 10. DOES HE APPAN OBAIN MVR VERIFICAIONS? 3. IS HERE A VEHICLE MAINENANCE PROGRAM IN OPERAION? 11. DOES HE APPAN HAVE A IFIC DRIVER RECRUIING MEHOD? 4. ARE ANY VEHICLES LEASED O S? 12. ARE ANY DRIVERS NO COVERED BY WORKERS ENSAION? 5. ARE ANY VEHICLES CUSOMIZED, ALERED OR HAVE IAL EQUIPMEN? 13. ANY VEHICLES OWNED BU NO SCHEDULED ON HIS APPAION? 6. ARE ICC, PUC OR FILINGS REQUIRED? 14. ANY DRIVERS WIH MOVING RAFFIC VIOLAIONS? 7. DO OPERAIONS INVOLVE RANSPORING HAZARDOUS MAERIAL? 15. HAS AGEN INED VEHICLES? YES NO MAXIMUM DOLLAR VALUE SUBJEC O LOSS ADDIIONAL INERES/CERIFICAE RECIPIEN ACORD 45 attached for additional names INERES RANK: NAME AND ADDRESS REFERENCE #: CERIFICAE REQUIRED INERES IN IEM NUMBER ADDIIONAL INSURED VEHICLE: LOSS PAYEE SCHEDULED IEM NUMBER: LIENHOLDER EMPLOYEE AS LESSOR REMARKS IEM DESCRIPION: ACORD 127 (2001/08) PLEASE LEE REVERSE SIDE ACORD CORPORAION 1993
4 AGENCY M Ramsgate Managing Insurance EXAS COMMERCIAL AUO COVERAGES/LIMIS SECION APPAN (First Named Insured) Policy Number: X 4/16/2008 BUSINESS AUO SECION COVERAGES COVERED AUO SYMBOLS LIMIS COVERAGES COVERED AUO SYMBOLS LIMIS CSL EA PER LIALIY 2 7 EACH ACCIDEN 3 8 PROPERY DAMAGE 5 EACH PERSON PERSONAL INJURY AUO DEAH OAL 7 PROECION INDEMNIY DISALIY PHYAL DAMAGE 3 7 REHENSIVE MEDICAL IFIED EACH PERSON PAYMENS CAS OF LOSS 2 6 CSL EA PER URED/ COLLISION UNDERINSURED EACH ACCIDEN MOORIS 4 PROPERY DAMAGE DED YES S COS OF HIRE IF ANY BASIS S # DAYS # VEH COVERAGE/DEDUCIBLE HIRED/BORROWED LIALIY NO YES S HIRED GROUP YPE NUMBER OF PHYAL NO NON-OWNED EMPLOYEES DAMAGE COLL LIALIY VOLUNEERS PARNERS COVERAGE IS: PRIMARY SECONDARY COVERED AUO SYMBOLS RUCKERS SECION (1) ANY AUO (4) OWNED AUOS HAN PRIVAE PASSENGER (7) AUOS IFIED ON SCHEDULE (2) ALL OWNED AUOS (5) ALL OWNED AUOS WHICH REQUIRE COVERAGE (8) HIRED AUOS (3) OWNED PRIVAE PASSENGER AUOS (6) OWNED AUOS SUBJEC O ULSORY U.M. LAW (9) NON-OWNED AUOS COVERAGES COVERED AUO SYMBOLS LIMIS PHYAL DAMAGE COVERED CSL EA PER COVERAGES AUO SYMBOLS LIMIS DEDUCIBLE LIALIY EACH ACCIDEN REHENSIVE PROPERY DAMAGE PERSONAL INJURY 44 EACH PERSON IFIED SCL LSP AUO DEAH OAL PROECION 46 CAS OF LOSS INDEMNIY DISALIY F COLLISION MEDICAL EACH PERSON PAYMENS CSL EA PER URED/ UNDERINSURED 43 EACH ACCIDEN MOORIS 45 PROPERY DAMAGE DED 48 REHENSIVE 49 RAILER INERCHANGE COVERAGES SYMBOL # RAILERS # DAYS RADIUS DEDUCIBLE IFIED 48 CAS OF LOSS 49 YES S NON-RUCKERS COS OF HIRE IF ANY BASIS 48 COLLISION HIRED/BORROWED NO 49 HIRED/BORROWED YES S COS OF HIRE IF ANY BASIS LIALIY NO S # DAYS # VEH YES S GROUP YPE NUMBER OF HIRED PHYAL NON-OWNED NO EMPLOYEES DAMAGE AUO LIALIY VOLUNEERS PARNERS COVERAGE IS: PRIMARY SECONDARY COVERED AUO SYMBOLS (44) OWNED AUOS SUBJEC O (46) IFICALLY DESCRIBED AUOS (49) YOUR RAILERS IN HE POSSESSION OF (41) ANY AUO (45) OWNED AUOS SUBJEC O A (47) HIRED AUOS ONLY AN RUCKER UNDER A RAILER (42) OWNED AUOS ONLY ULSORY URED (48) RAILERS IN YOUR POSSESSION UNDER INERCHANGE AGREEMEN (43) OWNED COMMERCIAL AUOS ONLY MOORIS LAW A RAILER INERCHANGE AGREEMEN (50) NON-OWNED AUOS ONLY ACORD 137 X (2002/02) PLEASE LEE REVERSE SIDE ACORD CORPORAION 1996
5 VEHICLE DESCRIPION ACORD 129 attached for additional vehicles PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL PP COML CIY,, NE VEH DR/CR: S AM COLL COLL ACORD 127 (2001/08)
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