GN NM: DDSS: CY: COMMC NSUNC PPCON PPCN NFOMON SCON NC COD: POCS O POGM QUSD UNDW POCY NUMB D (MM/DD/YYYY) UNDW OFF. S: FX (/C, No): -M DDSS: COD: GNCY CUSOM D: SUS OF NSCON D SUB COD: M NM (First Named nsured & Other Named nsureds) NDC SCONS CHD POPY GSS ND SGN CCOUNS CVB/ VUB PPS CM/MSCNOUS CM NSPOON/ MOO UCK CGO QUPMN FO NSON/BUDS SK CONC D POC COMMC GN BY BUSNSS UO UCKS/MOO GG ND DS VHC SCHDU BO & MCHNY POPOSD FF D POPOSD XP D BNG PN PYMN PN UD MNG DDSS NC ZP+4 (of First Named nsured) WOKS COMPNSON UMB QUO SSU POCY NW N HS NFOMON WHN COMMON DS ND MS PPY O SV NS, O FO MONON POCS. BOUND (Give Date and/or ttach Copy): CHNG CNC PPCN NFOMON ZP COD: M PM PCKG POCY NFOMON S: DC B GNCY B City: State: FN O SOC SC # (of First Named nsured): -M DDSS(S): NDVDU COPOON SUBCHP "S" COPOON C PNSHP JON VNU NO FO POF OG NO. OF MMBS ND MNGS NSPCON CONC: PMSS NFOMON OC # BD # -M DDSS: S, CY, COUNY, S, ZP+4 C BUU NM Zip Code: WBS DDSS(S): D NUMB CCOUNNG CODS CONC: CY MS NS Y BU -M DDSS: # MPOYS NNU VNUS D BUS SD % OCCUPD NSD OUSD OWN NN NSD OUSD OWN NN NU OF BUSNSS - DSCPON OF OPONS BY PMS(S) US 10 WODS O MO O DSCB: GN NFOMON XPN "YS" SPONSS YS NO XPN "YS" SPONSS 1a. S H PPCN SUBSDY OF NOH NY? 8. DUNG H S FV YS (N N ), HS NY PPCN BN NDCD FO O CONVCD OF NY DG OF H CM OF FUD, 1b. DOS H PPCN HV NY SUBSDS? BBY, SON O NY OH SON-D CM N CONNCON WH HS O NY OH POPY? 2. S FOM SFY POGM N OPON? (n, this question must be answered by any applicant for property insurance. Failure 3. NY XPOSU O FMMBS, XPOSVS, CHMCS? to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 4. NY CSOPH XPOSU? 9. NY UNCOCD F COD VOONS? 5. NY OH NSUNC WH HS COMPNY O BNG SUBMD? 10. NY BNKUPCS, X O CD NS GNS H PPCN N H PS 5 YS? 6. NY POCY O COVG DCND, CNCD O NON-NWD DUNG 11. HS BUSNSS BN PCD N US? H PO 3 YS? (Not applicable in MO) 7. NY PS OSSS O CMS NG O SXU BUS O MOSON GONS, DSCMNON O NGGN HNG? /POCSSNG NSUCONS (ttach additional sheets if more space is required) 12. F YS, NM OF US: NY FOGN OPONS, FOGN PODUCS DSBUD N US, O US PODUCS SOD/DSBUD N FOGN COUNS? (f "YS", attach COD 815 for iability xposure and/or COD 816 for Property xposure) YS NO NY PSON WHO KNOWNGY ND WH NN O DFUD NY NSUNC COMPNY O NOH PSON FS N PPCON FO NSUNC O SMN OF CM CONNNG NY MY FS NFOMON, O CONCS FO H PUPOS OF MSDNG, NFOMON CONCNNG NY FC M HO, COMMS FUDUN NSUNC C, WHCH S CM ND SUBJCS H PSON O CMN ND [NY: SUBSN] CV PNS. (Not applicable in CO, H, N, OH, OK, O, or V; in DC,, M, N and V, insurance benefits may also be denied) H UNDSGND S N UHOZD PSNV OF H PPCN ND CFS H SONB NQUY HS BN MD O OBN H NSWS O QUSONS ON HS PPCON. H/SH CFS H H NSWS U, COC ND COMP O H BS OF HS/H KNOWDG. PPCN S SGNU D PODUC S SGNU NON PODUC NUMB COD 125 (2005/06) PS COMP VS SD COD COPOON 1993-2005
PO NFOMON N C O M M C G N B Y U O M B O B Y P O P Y CGOY POCY NUMB POCY YP O D FF-XP D GN GGG PODUCS COMP OP GGG PSON & DV NJ CH OCCUNC F DMG M MDC XPNS S BODY OCCUNC NJUY GGG POPY OCCUNC DMG GGG COMBND SNG M MODFCON FCO O PMUM POCY NUMB POCY YP FF-XP D COMBND SNG M BODY PSON NJUY CCDN POPY DMG MODFCON FCO O PMUM POCY NUMB POCY YP FF-XP D BUDNG M PS POP M MODFCON FCO O PMUM POCY NUMB POCY YP FF-XP D M MODFCON FCO O PMUM OSS HSOY CMS CMS CMS CMS CMS OCCUNC OCCUNC OCCUNC OCCUNC OCCUNC MD MD MD MD MD N CMS O OSSS (GDSS OF FU ND WHH O NO NSUD) O OCCUNCS H MY GV S O CMS FO H PO 5 YS (3 YS N KS & NY) CHK H F NON D OF D MOUN MOUN N YP/DSCPON OF OCCUNC O CM OCCUNC OF CM PD SVD S CHD OSS SUMMY CM SUS OPN CSD NO: FDY QUS FV Y OSS HSOY CHMNS S SUPPMN(S) (f applicable) COPY OF H NOC OF NFOMON PCCS (PVCY) HS BN GVN O H PPCN. (Not applicable in all states, consult your agent or broker for your state s requirements.) NOC OF NSUNC NFOMON PCCS PSON NFOMON BOU YOU, NCUDNG NFOMON FOM CD PO, MY B COCD FOM PSONS OH HN YOU N CONNCON WH HS PPCON FO NSUNC ND SUBSQUN POCY NWS. SUCH NFOMON S W S OH PSON ND PVGD NFOMON COCD BY US O OU GNS MY N CN CCUMSNCS B DSCOSD O HD PS WHOU YOU UHOZON. YOU HV H GH O VW YOU PSON NFOMON N OU FS ND CN QUS COCON OF NY NCCUCS. MO DD DSCPON OF YOU GHS ND OU PCCS GDNG SUCH NFOMON S VB UPON QUS. CONC YOU GN O BOK FO NSUCONS ON HOW O SUBM QUS O US. COD 125 (2005/06)
COMMC GN BY SCON D (MM/DD/YYYY) GNCY FX (/C, No): PPCN (First Named nsured) COD: GNCY CUSOM D: COVGS SUB COD: FFCV D XPON D DC B PYMN PN UD GNCY B FO COMPNY US ONY MS COMMC GN BY GN GGG $ PMUMS CMS MD OCCUNC PODUCS & COMPD OPONS GGG $ PMSS/OPONS OWN S & CONCO S POCV PSON & DVSNG NJUY $ CH OCCUNC $ DDUCBS DMG O ND PMSS (each occurrence) $ POPY DMG $ MDC XPNS (ny one person) $ BODY NJUY $ $ P CM P OCCUNC MPOY BNFS $ OH COVGS, SCONS ND/O NDOSMNS (For hired/non-owned auto coverages attach the applicable state Business uto Section, COD 137) PODUCS OH O SCHDU OF HZDS OCON CSSFCON CSS # COD PMUM BSS XPOSU PMUM PM/OPS PODUCS PM/OPS PODUCS NG ND PMUM BSS (P) PYO - P $1,000/PY (C) O COS - P $1,000/COS (U) UN - P UN (S) GOSS SS - P $1,000/SS () - P 1,000/SQ F (M) DMSSONS - P 1,000/DM () OH CMS MD (xplain all "Yes" responses) MPOY BNFS BY 1. POPOSD OCV D: 1. DDUCB P CM: $ 2. NY D NO UNNUPD CMS MD COV: 2. NUMB OF MPOYS: 3. HS NY PODUC, WOK, CCDN, O OCON YS NO 3. NUMB OF MPOYS COVD BY MPOY BNFS PNS: BN XCUDD, UNNSUD O SF-NSUD FOM NY PVOUS COVG? 4. OCV D: 4. WS COVG PUCHSD UND NY PVOUS POCY? COD 126 (2004/03) PS COMP VS SD COD COPOON 1993
CONCOS XPN "YS" SPONSS (For past or present operations) YS NO XPN "YS" SPONSS (For past or present operations) YS NO 1. DOS PPCN DW PNS, DSGNS, O SPCFCONS 4. DO YOU SUBCONCOS CY COVGS O MS FO OHS? SS HN YOUS? 2. DO NY OPONS NCUD BSNG O UZ O SO 5. SUBCONCOS OWD O WOK WHOU XPOSV M? POVDNG YOU WH CFC OF NSUNC? 3. DO NY OPONS NCUD XCVON, UNNNG, 6. DOS PPCN S QUPMN O OHS WH O UNDGOUND WOK O H MOVNG? WHOU OPOS? /DSCB H YP OF WOK SUBCONCD $ PD O SUB- % OF WOK # FU- # P- CONCOS: SUBCONCD: M SFF: M SFF: PODUCS/COMPD OPONS M N XPCD PODUCS NNU GOSS SS # OF UNS MK F NNDD US PNCP COMPONNS XPN "YS" SPONSS (For any past or present product or operation) YS NO XPN "YS" SPONSS (For any past or present product or operation) YS NO 1. DOS PPCN NS, SVC O DMONS PODUCS? 6. PODUCS CD, DSCONNUD, CHNGD? 2. FOGN PODUCS SOD, DSBUD, USD S COMPONNS? 7. PODUCS OF OHS SOD O -PCKGD UND 3. SCH ND DVOPMN CONDUCD O NW PPCN B? PODUCS PNND? 8. PODUCS UND B OF OHS? 4. GUNS, WNS, HOD HMSS GMNS? 9. VNDOS COVG QUD? 5. PODUCS D O CF/SPC NDUSY? 10. DOS NY NMD NSUD S O OH NMD NSUDS? PS CH U, BOCHUS, BS, WNNGS, C DDON NS/CFC CPN NS NK: NM ND DDSS FNC #: CFC QUD NS N M NUMB DDON NSUD OCON: BUDNG: OSS PY VHC: BO: MOGG NHOD MPOY S SSO GN NFOMON M DSCPON: SCHDUD M NUMB: OH XPN "YS" SPONSS (For all past or present operations) YS NO XPN "YS" SPONSS (For all past or present operations) YS NO 1. NY MDC FCS POVDD O MDC POFSSONS MPOYD O CONCD? COD 45 attached for additional names 12. NY SUCU ONS CONMPD? 13. NY DMOON XPOSU CONMPD? 2. NY XPOSU O DOCV/NUC MS? 14. HS PPCN BN CV N O S CUNY CV N 3. DO/HV PS, PSN O DSCONNUD OPONS JON VNUS? NVOV(D) SONG, NG, DSCHGNG, PPYNG, DSPOSNG, O NSPONG OF HZDOUS M? 15. DO YOU S MPOYS O O FOM OH MPOYS? (e.g. landfills, wastes, fuel tanks, etc) 16. S H BO NCHNG WH NY OH BUSNSS O SUBSDS? 4. NY OPONS SOD, CQUD, O DSCONNUD N S 5 YS? 17. DY C FCS OPD O CONOD? 5. MCHNY O QUPMN OND O ND O OHS? 18. HV NY CMS OCCUD O BN MPD ON 6. NY WCF, DOCKS, FOS OWND, HD O SD? YOU PMSS WHN H S H YS? 7. NY PKNG FCS OWND/ND? 19. S H FOM, WN SFY ND SCUY 8. S F CHGD FO PKNG? POCY N FFC? 9. CON FCS POVDD? 20. DOS H BUSNSSS POMOON U MK 10. S H SWMMNG POO ON H PMSS? NY PSNONS BOU H SFY O SCUY 11. SPONG O SOC VNS SPONSOD? OF H PMSS? NY PSON WHO KNOWNGY ND WH NN O DFUD NY NSUNC COMPNY O NOH PSON FS N PPCON FO NSUNC O SMN OF CM CONNNG NY MY FS NFOMON, O CONCS FO H PUPOS OF MSDNG NFOMON CONCNNG NY FC M HO, COMMS FUDUN NSUNC C, WHCH S CM ND SUBJCS H PSON O CMN ND [NY:SUBSN] CV PNS. (Not applicable in CO, H, N, OH, OK, O or V; in DC,, M, N and V, insurance benefits may also be denied). COD 126 (2004/03) CH O PPCN NFOMON SCON
GNCY FX (/C, No): POPY SCON PPCN (First Named nsured) D (MM/DD/YYYY) COD: GNCY CUSOM D: PMSS NFOMON SUB COD: PMSS #: BUDNG #: FFCV D XPON D DC B PYMN PN UD GNCY B FO COMPNY US ONY S DDSS: BDG DSCPON: NFON BK SUBJC OF NSUNC MOUN CONS % VUON CUSS OF OSS GUD % DDUCB(S) # FOMS ND CONDONS O PPY DDON NFOMON BUSNSS NCOM / X XPNS - ttach COD 810 VU PONG NFOMON - ttach COD 811 DDON COVGS, OPONS, SCONS, NDOSMNS ND NG NFOMON SPOG COVG DSCPON OF POPY COVD M DDUCB FG MN GMN OPONS YS NO $ $ YS NO CONSUCON YP DSNC O HYDN F S F DSC/COD NUMB PO C # SOS # BSM S Y BU O F M BUDNG MPOVMNS BDG COD GD X COD OOF YP OH OCCUPNCS WNG, Y: PUMBNG, Y: OOFNG, Y: HNG, Y: WND CSS HNG BO ON PMSS? YS NO OH: SSV SM- SSV OH F YS, S NSUNC PCD SWH? YS NO GH XPOSU & DSNC F XPOSU & DSNC FON XPOSU & DSNC XPOSU & DSNC BUG M YP CFC # XPON D BUG M NSD ND SVCD BY XN GD # GUDS/WCHMN CN SON WH KYS COCK HOUY PMSS F POCON (Sprinklers, Standpipes, CO2/Chemical Systems) % SPNK F M MNUFCU DDON NSS NK: NM ND DDSS: FNC #: CFC QUD NS N M NUMB NS OCON: BUDNG: OSS PY SCHDUD M NUMB: MO- GG OH: M DSCPON: CN SON OC GONG COD 140 (2005/01) CH O PPCN NFOMON SCON COD COPOON 1985-2005
DDON PMSS NFOMON PMSS #: BUDNG #: S DDSS: BDG DSCPON: NFON BK SUBJC OF NSUNC MOUN CONS % VUON CUSS OF OSS GUD % DDUCB(S) # FOMS ND CONDONS O PPY DDON NFOMON BUSNSS NCOM / X XPNS - ttach COD 810 VU PONG NFOMON - ttach COD 811 DDON COVGS, OPONS, SCONS, NDOSMNS ND NG NFOMON SPOG COVG DSCPON OF POPY COVD M DDUCB FG MN GMN OPONS YS NO $ $ YS NO CONSUCON YP DSNC O HYDN F S F DSC/COD NUMB PO C # SOS # BSM S Y BU O F M BUDNG MPOVMNS BDG COD GD X COD OOF YP OH OCCUPNCS WNG, Y: PUMBNG, Y: OOFNG, Y: HNG, Y: WND CSS HNG BO ON PMSS? YS NO OH: SSV SM- SSV OH F YS, S NSUNC PCD SWH? YS NO GH XPOSU & DSNC F XPOSU & DSNC FON XPOSU & DSNC XPOSU & DSNC BUG M YP CFC # XPON D BUG M NSD ND SVCD BY XN GD # GUDS/WCHMN CN SON WH KYS COCK HOUY PMSS F POCON (Sprinklers, Standpipes, CO2/Chemical Systems) % SPNK F M MNUFCU DDON NSS NK: NM ND DDSS: FNC #: CFC QUD NS N M NUMB NS OCON: BUDNG: OSS PY SCHDUD M NUMB: MO- GG OH: M DSCPON: CN SON OC GONG NY PSON WHO KNOWNGY ND WH NN O DFUD NY NSUNC COMPNY O NOH PSON FS N PPCON FO NSUNC O SMN OF CM CONNNG NY MY FS NFOMON, O CONCS FO H PUPOS OF MSDNG NFOMON CONCNNG NY FC M HO, COMMS FUDUN NSUNC C, WHCH S CM ND SUBJCS H PSON O CMN ND [NY: SUBSN] CV PNS. (Not applicable in CO, H, M, N, OH, OK, O or V; in DC,, M, N and V, insurance benefits may also be denied) COD 140 (2005/01)