ACORD Logo and Other PROTECTION
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1 BUSINESS OWNERS SECTION AGENCY NAME CARRIER Metropolitan Insurance Services POLICY NUMBER EFFECTIVE DATE FIRST NAMED INSURED DATE (MM/DD/YYYY) NAIC CODE POLICY TYPE STANDARD SPECIAL PERSONAL PROPERTY LIABILITY OPTIONAL S MINIMUM GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWIS SCHEDULE CREDITS UCTIBLE CREDITS TAXES SURCHARGE TOTAL ESTIMATED 1. DO / HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) 2. ARE ATHLETIC TEAMS SPONSORED? 3. TYPE OF SPORT EXTENT OF SPONSORSHIP: CONTACT SPORT (Y/N) AGE GROUP TYPE OF SPORT CONTACT AGE GROUP SPORT (Y/N) & UNDER OVER & UNDER OVER 18 EXTENT OF SPONSORSHIP: DO YOU OBTAIN AND VERIFY CERTIFICATES OF INSURANCE OBTAINED FROM SUBCONTRACTORS, MANUFACTURERS AND/OR SUPPLIERS? (If "NO", explain) 4. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? LEASE TO WORKERS COMPENSATION CARRIED (Y/N) LEASE FROM WORKERS COMPENSATION CARRIED (Y/N) 5. DO YOU OWN OR OPERATE ANY OTHER BUSINESS? STREET, CITY, STATE, ZIP TYPE OF BUSINESS OR LOC INTEREST OPERATIONS SERVICE OFFICE OWN LEASE RETAIL WHOLESALE RENT SERVICE OFFICE OWN LEASE RETAIL WHOLESALE RENT 6. IN ADDITION TO YOUR PRIMARY NATURE OF BUSINESS ARE YOU ALSO INVOLVED IN THE MANUFACTURE, RELABELING OR REPACKAGING OF OTHERS PRODUCTS? 7. IN ADDITION TO YOUR PRIMARY NATURE OF BUSINESS, ARE YOU ALSO INVOLVED IN THE MIXING OF OTHERS PRODUCTS? 8. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (Y/N) 9. DOES THE OPERATION HAVE HOURS AFTER 9:00 P.M. AND/OR 24 HOUR OPERATIONS? START TIME: END TIME: 24 HOUR OPERATIONS REMARKS SMALL TOOLS SMALL TOOLS LARGE EQUIPMENT LARGE EQUIPMENT Attach to ACORD ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD
2 LIABILITY S - POLICY LEVEL BODILY INJURY & PROPERTY DAMAGE OCCURRENCE AGGREGATE TOTAL AMOUNT UCTIBLE INCLU FORM NUMBER FORM DATE MEDICAL EXPENSE(per person) PERSONAL & ADVERTISING INJURY PRODUCTS & COMPLETED OPERATIONS PROFESSIONAL LIABILITY EMPLOYMENT PRACTICES LIABILITY (EPLI) DIRECTORS & OFFICERS TENANTS LEGAL LIABILITY AUTO - HIRED PHYSICAL DAMAGE AUTO - HIRED LIABILITY BODILY INJURY PROPERTY DAMAGE AUTO - NON-OWNED EMPLOYEE BENEFITS LIABILITY EXTEN EMPLOYEE DISHONESTY FREIGHT OR PASSENGER ELEVATORS INSPECTION FEE GARAGE COLLISION COMPREHENSIVE / OTC GARAGE KEEPERS LOC #: LOC #: LOC #: LEGAL DIRECT LIQUOR LIABILITY GENERAL AGGREGATE PER PERSON OTHER: MEDICAL PAYMENTS MOBILE EQUIPMENT SUBJECT TO MOTOR VEHICLE LAWS LIABILITY ADDITIONAL S - POLICY LEVEL CODE Coverages Schedule Attached APPLIES UCTIBLE OF LIMIT UCTIBLE TO TYPE OPTIONS TERR Y/N CREDIT / SURCHARGE AMOUNT Page 2 of 5
3 PREMISES BLANKET RATE (): OF ALL OCCUPANCIES AT THIS PREMISESCHECK IF PRIMARY PREMISES SURROUNDING EXPOSURES & OTHER OCCUPANCIES RIGHT EXPOSURE LEFT EXPOSURE REAR EXPOSURE FRONT EXPOSURE DISTANCE: DISTANCE: DISTANCE: DISTANCE: ANNUAL SALES / RECEIPTS TOTAL PAYROLL CLASS CODE RATE # RATE GROUP PROT CLASS DISTANCE TO HYDRANT FIRE STAT FT PROPERTY BLDG PROP PERS YEAR BUILT FIRE DISTRICT LIMIT % COINS VALU- RC ACV INFL % ATION: FVRC LIMIT % COINS VALU- RC ATION: FVRC IMPROVEMENTS MI CONSTRUCTION TYPE PROPERTY S ACV # % STORIES SPRNK WIRING ROOFING PLUMBING HEATING ROOF TYPE BLDG CODE YEAR YEAR YEAR YEAR GRADE FIRE DISTRICT CODE NUMBER UCTIBLE TYPE: UCTIBLE TYPE: BUSINESS INCOME ACTUAL LOSS SUSTAINED NO. OF MONTHS BUSINESS INCOME CHANGES - TIME PERIOD RATE TERRITORY INFL % UCTIBLE TYPE: UCTIBLE TYPE: INSPECTED? (Y/N) WIND CLASS RESISTIVE COMMUNITY SEMI-RESISTIVE SPECIFIC PROPERTY POL PREM TOTAL AMOUNT LEVEL LEVEL (including Base Limit) UCTIBLE INCLU FORM NUMBER FORM DATE ACCOUNTS RECEIVABLE ANIMAL BAILEES LIABILITY BUILDERS RISK ONLY THEFT OF BLDG MATERIALS COLLAPSE DUE TO HYDRO-STATIC PRESSURE BUSINESS INCREASE FROM DEPENDENT PROPERTIES BUSINESS INCOME WITH EXTRA EXPENSE COMBINED DEMOLITION COST AND INCREASED CONST COST DEBRIS REMOVAL CONDO UNIT OWNER'S LOSS ASSESSMENT OWNER'S MISCELLANEOUS REAL PROPERTY CRIME EMPLOYEE DISHONESTY FORGERY OR ALTERATION MONEY & SECURITIES - INSIDE MONEY & SECURITIES - OUTSIDE WELFARE & PENSION PLAN (ERISA) EARTHQUAKE EDP / COMPUTER TERR: RETROFIT TYPE: MASONRY VENEER: % EQUIPMENT EXTRA EXPENSE DATA / MEDIA EQUIPMENT BREAKDOWN BASIC BROAD SPOILAGE BASEMENT PRESENT? (Y/N): IS IT FINISHED? (Y/N): Page 3 of 5 % GRADE DEVELOPED FOR TAX CODE
4 PROPERTY S (continued) POL PREM TOTAL AMOUNT LEVEL LEVEL (including Base Limit) UCTIBLE INCLU FORM NUMBER FORM DATE EXTRA EXPENSE ACTUAL LOSS SUSTAINED NO. OF MONTHS FINE ARTS FLOATER CONTRACTOR'S EQUIPMENT INSTALLATION LEASED / RENTED EQUIPMENT FLOOD CONTENTS FUNGI / BACTERIA / MOLD HAIL EXCLUSION N / A N / A N / A MINE SUBSIDENCE NEWLY ACQUIRED PROPERTY LIMIT CONST MATERIAL: PROP DESC: PERSONAL ORDINANCE ORDINANCE OR LAW ORDINANCE DEMOILITION COST ORDINANCE INCREASED CONST COST AGG INCREASED % REBUILD OUTDOOR PROPERTY PEAK SEASON REGULAR ADDITIONAL PROPERTY BPP - IMPROVEMENTS & BETTERMENTS / RC / ACV PROPERTY S - PREMISES LEVEL GLASS TENANTS LOCATION IN # PLATES AREA SQ FT LENGTH LINEAR FT GLASS TYPE INTERIOR EXT VALUE GROUND FLOOR GLASS POL PREM LEVEL LEVEL SIGN TERRORISM DOMESTIC N / A N / A FOREIGN ACCEPT REJECT N / A TRANSIT VALUABLE PAPERS WIND EXCLUSION N / A N / A ABOVE GROUND FLOOR GLASS PROPERTY ADDITIONAL S CODE Coverages Schedule Atached TOTAL AMOUNT (including Base Limit) UCTIBLE INCLU FORM NUMBER FORM DATE Page 4 of 5
5 PREMISES GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES UNLESS INDICATED OTHERWISE 1. DOES APPLICANT HAVE A HEATING OR PROCESSING BOILER? DATE OF LAST INSPECTION CURRENT CARRIER FOR BOILER & MACHINERY 2. ANY SPECIALIZED EQUIPMENT, SUCH AS MEDICAL EQUIPMENT OR OTHER, VALUED OVER 100,000? IF "YES", DESCRIBE. 3. IS ALL EQUIPMENT INSPECTED ANNUALLY AND WELL MAINTAINED? (No explanation needed) 4. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD 5. IS THE UNDER CONSTRUCTION? APARTMENTS AND CONDOMINIUMS EXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISE 1. IS THERE A PLAYGROUND ON PREMISES? 2. IS ALUMINUM WIRE USED? INSTALLATION DATE 3. IS DEVELOPER OR CONTRACTOR A BOARD MEMBER? (No explanation needed) 4. IS A PROPERTY MANAGER EMPLOYED? (No explanation needed) APPLIES TO SMOKE DETECTORS: # OF FIRE DIVISIONS # UNITS PER FIRE DIVISION # UNITS OWNER OCCUPIED CRIME BARE WALLS FINISHED WALLS NONE BATTERY WIRED ALARM TYPE ALARM EXTENT OF PROTECTION SAFE / VAULT / RECEPTACLE MANUFACTURER'S NAME LABEL HOLD-UP LOCAL GONG GRADE SAFE / VAULT PREMISES ALARM UL PREMISES CNTRL STAT W/ KEYS PARTIAL SMNA SAFE / VAULT CNTRL STAT W/O KEYS COMPLETE POLICE CONNECT CERT #: EXP MAXIMUM CASH MAXIMUM CASH MONEY ON FREQUENCY DEADBOLT SAFE DOOR CONSTRUCTION ON PREMISES WITH MESSENGER PREMISES OVERNIGHT OF DEPOSITS CYLINDER DOOR LOCKS? (Y/N): OTHER PROTECTION (Lighting, fences, watchpersons, etc.) CLASS REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 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, DC, FL, HI, MA, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied) IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, 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 MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS. Page 5 of 5
BUSINESS OWNERS SECTION
AGENCY NAME BUSINESS OWNERS SECTION CARRIER DATE (MM/DD/YYYY) NAIC CODE POLICY NUMBER EFFECTIVE DATE FIRST NAMED INSURED POLICY TYPE PERSONAL PROPERTY LIABILITY OPTIONAL S 1. STANDARD MINIMUM GENERAL INFORMATION
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Property/Casualty Insurance Renewal Survey Multi-State
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Exterminator Liability Application
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Child Care Center - Request for Insurance Quote
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Submissions: quotes@firestoneagency.com ACORD Applications
Insurance Underwriters Excess & Surplus Lines Brokers MGA 1500 University Drive, Suite #212, Coral Springs FL 33071 954.341.8331; 1.800.683.1150; Fax: 954.345.7620 www.firestoneagency.com Submissions: