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ACORD COMMERCIAL INSURANCE APPLICATION …

commercial insurance application applicant information section acord 125 (7/98) oc acord corporation 1993 status of submission package policy information

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Text of ACORD COMMERCIAL INSURANCE APPLICATION …

COMMERCIAL INSURANCE APPLICATIONAPPLICANT INFORMATION SECTIONcOACORD CORPORATION 1993ACORD 125 (7/98)STATUS OF SUBMISSIONPACKAGE POLICY INFORMATIONAPPLICANT INFORMATIONPREMISES INFORMATIONNATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)GENERAL INFORMATIONPLEASE COMPLETE REVERSE SIDEDATEPRODUCERPHONE(A/C, No, Ext):CODE:SUB CODE:AGENCY CUSTOMER IDCARRIERNAIC CODE:UNDERWRITERPOLICIES OR PROGRAM REQUESTEDINDICATE SECTIONS ATTACHEDPROPOSED EFF DATEPROPOSED EXP DATEBILLING PLANPAYMENT PLANAUDITDATETIMENAME (First Named Insured & Other Named Insureds)FEIN OR SOC SEC #(of First Named Ins):PHONE(A/C, No, Ext):MAILING ADDRESS INCL ZIP+4 (of First Named Insured)CR BUREAUNAMEID NUMBERYEAR BUSSTARTEDINSPECTION CONTACTPHONE(A/C, No, Ext):ACCOUNTING RECORDS CONTACTPHONE(A/C, No, Ext):LOC #BLD #STREET, CITY, COUNTY, STATE, ZIP+4CITY LIMITSINTERESTYR BUILTPART OCCUPIEDEXPLAIN ALL "YES" RESPONSESYES NO EXPLAIN ALL "YES" RESPONSESYES NOREMARKSAPPLICANT SSIGNATUREPRODUCER THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOESTHE APPLICANT HAVE ANY SUBSIDIARIES?IS A FORMAL SAFETY PROGRAM IN OPERATION?ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?ANY CATASTROPHE EXPOSURE?ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWEDDURING THE PRIOR 3 YEARS? NOT APPLICABLE IN MOANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE ORMOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?DURING THE LAST TEN YEARS, HAS ANY APPLICANT BEEN CONVICTEDOF ANY DEGREE OF THE CRIME OF ARSON? (In RI, this question must beanswered by any applicant for property insurance. Failure to disclosethe existence of an arson conviction is a misdemeanor punishable by asentence of up to one year of imprisonment).ANY UNCORRECTED FIRE CODE VIOLATIONS?ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANTIN THE PAST 5 YEARS?PROPERTYGLASS AND SIGNACCOUNTS RECEIVABLE/VALUABLE PAPERSCRIME/MISCELLANEOUS CRIMETRANSPORTATION/MOTOR TRUCK CARGOEQUIPMENT FLOATERINSTALLATION/BUILDERS RISKELECTRONIC DATA PROCCOMMERCIALGENERAL LIABILITYBUSINESS AUTOTRUCKERS/MOTOR CARRIERGARAGE AND DEALERSVEHICLE SCHEDULEBOILER & MACHINERYWORKERS COMPENSATIONUMBRELLAQUOTEISSUE POLICYENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE (Give Date and/or Attach Copy):AMPMDIRECT BILLAGENCY BILLINDIVIDUALPARTNERSHIPCORPORATIONJOIN T VENTURESUBCHAPTER "S"CORPORATIONLIMITEDCORPORATIONNOT FORPROFIT ORGINSIDEOUTSIDEOWNERTENANTINSIDEOUTSIDE OWNERTENANTINSIDEOUTSIDEOWNERTENANTANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHERPERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLYFALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNINGANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME ANDSUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE INCO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)ACORDTMPRIOR CARRIER INFORMATIONLOSS HISTORYACORD 125 (7/98)LINECATEGORYCOMMERCIALGENERALLIABI LITYAUTOMOBILELIABILITYPROPERTYDATE OFOCCURRENCELINETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMDATEOF CLAIMAMOUNTPAIDAMOUNTRESERVEDCLAIMSTATUS REMARKS NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORYNOTICE OF INSURANCE INFORMATION PRACTICESPERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU. SUCHINFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCESBE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTIONOF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPONREQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO NUMBERPOLICY TYPERETRO DATEEFF-EXP DATEGENERAL AGGREGATEPRODUCTS COMP OPAGGREGATEPERSONAL & ADV INJEACH OCCURRENCEFIRE DAMAGEMEDICAL EXPENSEBODILYINJURYOCCURRENCEAGGREGATEPR OPERTYDAMAGEOCCURRENCEAGGREGATECOMBINED SINGLE LIMITMODIFICATION FACTORTOTAL PREMIUMLIMITSCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATECOMBINED SINGLE LIMITBODILYINJURYEA PERSONEA ACCIDENTPROPERTY DAMAGEMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATEBUILDINGAMTPERS PROPAMTMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATELIMITMODIFICATION FACTORTOTAL PREMIUMENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMSFOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)CHK HEREIF NONESEE ATTACHEDLOSS SUMMARYCLAIMSMADEOCCURRENCECLAIMSMADEOCC URRENCECLAIMSMADEOCCURRENCECLAIMSMADEOCC URRENCECLAIMSMADEOCCURRENCEOPENCLOSEDOPE NCLOSED

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