Example: barber

ACORD UMBRELLA SECTION DATE (MM/DD/YYYY)

tm damage to rented premises date (mm/dd/yyyy) producer phone applicant (a/c, no, ext): fax (first (a/c, no): named insured) effective date expiration date payment ...

Tags:

  Date, Orcad, Umbrella, Acord umbrella, Mm dd yyyy, Yyyy

Information

Domain:

Source:

Link to this page:

Please notify us if you found a problem with this document:

Other abuse

Text of ACORD UMBRELLA SECTION DATE (MM/DD/YYYY)

TMDAMAGE TO RENTEDPREMISESDATE (MM/DD/YYYY)PHONEPRODUCERAPPLICANT(A/C, No, Ext):(FirstFAXNamed(A/C, No):Insured)EFFECTIVE DATEEXPIRATION DATEPAYMENT PLANAUDITFORCOMPANYUSE ONLYCODE:SUBCODE:AGENCYCUSTOMER ID:TRANSACTION TYPELIMIT OF LIABILITYRETAINED LIMITPROPOSED RETROACTIVE DATEEXPIRING POL #:CURRENT RETROACTIVE DATE:FIRST DOLLAR DEFENSE#NAME AND LOCATION OF PRIMARY AND ALL SUBSIDIARY COMPANIES (Describe Operations)ANNUAL PAYROLLANN GROSS SALESFOREIGN GROSS SALES # EMPL+ -RATINGANNUAL RENEWALMODTYPECARRIER/POLICY NUMBERPOLICY EFF DATEPOLICY EXP DATELIMITSPREMIUMUNDERLYING GENERAL LIABILITY INFORMATION (Explain all "YES" responses)EXPLAIN ALL EXPOSURESCHECK IF APPROPRIATECOVERAGEEXPOSURECOVERAGEEXPOS URECOVERAGEEXPOSUREDIRECT BILLAGENCY BILLNEW$EACH OCCURRENCE $RENEWAL$YESNOLIST ALL LIABILITY/COMPENSATION POLICIES IN FORCE TO APPLY AS UNDERLYING INSURANCECSL / BI EA. OCC.$$AUTOMOBILEBI EA. PER.$$LIABILITYPD EA. ACC.$$EACH OCCURRENCE$PREM/OPSGENERALLIABILITYGENER AL AGGR$$POLICY TYPEPROD & COMP OPS$PRODUCTSAGGREGATEPERSONAL & ADVOCCUR$$INJURYCLAIMS$OTHERMADEMEDICAL EXPENSE$$EACH ACCIDENT$DISEASEEMPLOYERS$$EACH EMPLOYEELIABILITYDISEASE$POLICY LIMITCHECK ALL COVERAGES IN UNDERLYING POLICIES. ALSO CHECK IF ANY EXPOSURES ARE PRESENT FOR EACH COVERAGE. PROVIDE AN EXPLANATION. EXPLAIN IFDIFFERENT LIMITS, EXTENSIONS, OR EXCLUSIONS. EXPLAIN ANY SPECIAL COVERAGES BEYOND STANDARD AUTO (SYMBOL 1)CARE, CUSTODY, CONTROLPROFESSIONAL LIABILITY (E&O)CGL - CLAIMS MADEEMPLOYEE BENEFIT LIABILITYVENDORS LIABILITYCGL - OCCURRENCEFOREIGN LIABILITY/TRAVELWATERCRAFT LIABILITYGARAGEKEEPERS LIABILITYAIRCRAFT LIABILITYINCIDENTAL MEDICAL MALPRACTICEAIRCRAFT PASSENGER LIABILITYLIQUOR LIABILITYADDITIONAL INTERESTSPOLLUTION LIABILITYUNDERLYING INSURANCE COVERAGE INFORMATION (INCLUDE ALL RESTRICTIONS; LASER ENDORSEMENTS, DISCRIMINATION, SUBROGATION WAIVERS, OREXTENSIONS OF COVERAGE - ATTACH SEPARATE SHEET IF NECESSARY)PREVIOUS EXPERIENCE: (GIVE DETAILS OF ALL LIABILITY CLAIMS EXCEEDING $10,000 OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS, DURING THE PAST 5 YEARS,WHETHER INSURED OR NOT. SPECIFY DATE, COVERAGE, DESCRIPTION, AMOUNT PAID, AMOUNT OUTSTANDING)NO SUCH CLAIMS1ARE DEFENSE COSTS:WITHIN AGGREGATE LIMITS?A SEPARATE LIMIT?UNLIMITED?2INDICATE THE EDITION DATE OF THE ISO SIMPLIFIED FORM OR SIMILAR FILING FOR THE UNDERLYING COVERAGE:3HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF INSURED FROM ANY PREVIOUS COVERAGE?YESNO4FOR CLAIMS MADE, INDICATE RETROACTIVE DATE OF CURRENT UNDERLYING POLICY:5FOR CLAIMS MADE, INDICATE ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:6FOR CLAIMS MADE, WAS "TAIL" COVERAGE PURCHASED FOR ANY PREVIOUS PRIMARY OR EXCESS POLICY?YES, EFF. DATE:NOATTACH TO APPLICANT INFORMATION AND COMMERCIAL LIABILITY SECTIONSPOLICY INFORMATIONPRIMARY LOCATION & SUBSIDIARIES (ACORD 125)UNDERLYING INSURANCEACORD 131 (2002/01) ACORD CORPORATION 1991ACORDUMBRELLA SECTIONLOCPROPERTY TYPEVALUEA* B* C* D*SQ FT OF BLDG OCCOCCUPANCY / DESCRIPTION OF PERSONAL PROPERTYEXPLAIN ALL "YES" RESPONSES, PROVIDE OTHER INFORMATION REQUIREDYES NO EXPLAIN ALL "YES" RESPONSES, PROVIDE OTHER INFORMATION REQUIREDYES NOADVERTISERS LIABILITYPOLLUTION LIABILITYEPA#:AIRCRAFT LIABILITYAUTO LIABILITYPRODUCT LIABILITYCONTRACTORS LIABILITYPROTECTIVE LIABILITYWATERCRAFT LIABILITYEMPLOYERS LIABILITYINCIDENTAL MALPRACTICE LIABILITYAPARTMENTS / CONDOMINIUMS / HOTELS / MOTELSOVER# NON-TYPE# OWNED# LEASEDPROPERTY HAULED0-50 MI50-200 MIOWNED200 MIAPPLICANT S SIGNATUREDATEIMPORTANTREALPERSONAL# OWNEDLENGTHHORSEPOWER# STORIES# UNITS# SWIMMING POOLS# DIVING BOARDSPRIVATE PASSENGERLIGHTMEDIUMTRUCKSHEAVYEX. HEAVYHEAVYTRUCKS/TRACTORSEX. HEAVYBUSES*APPLICANT: [A] IS HELD HARMLESS IN THE LEASE, [B] HAS A WAIVER OF SUBROGATION, [C] IS A NAMED INSURED IN THE FIRE POLICY, [D] OTHER (specify)1. MEDIA USED:ANNUAL COST: $20. DO CURRENT OR PAST PRODUCTS, OR THEIR COMPONENTS,2. ARE SERVICES OF AN ADVERTISING AGENCY USED?CONTAIN HAZARDOUS MATERIALS THAT MAY REQUIRESPECIAL DISPOSAL METHODS?3. ANY COVERAGE PROVIDED UNDER AGENCY S POLICY?21. INDICATE THE COVERAGES CARRIED:4. DOES APPLICANT OWN/LEASE/OPERATE AIRCRAFT?GL WITH STANDARD ISO POLLUTION EXCLUSIONGL WITH STANDARD SUDDEN & ACCIDENTAL ONLYGL WITH POLLUTION COVERAGE ENDORSEMENT5. ARE EXPLOSIVES, CAUSTICS, FLAMMABLES OR OTHERDANGEROUS CARGO HAULED?SEPARATE POLLUTION COVERAGE6. ARE PASSENGERS CARRIED FOR A FEE?7. ANY UNITS NOT INSURED BY UNDERLYING POLICIES?22. ARE MISSILES, ENGINES, GUIDANCE SYSTEMS, FRAMES OR ANYOTHER PRODUCT USED / INSTALLED IN AIRCRAFT?8. ARE ANY VEHICLES LEASED OR RENTED TO OTHERS?9. ARE HIRED AND NON/OWNED COVERAGES PROVIDED?23. ARE FOREIGN PRODUCTS DISTRIBUTED IN ARE PRODUCTS SOLD/DISTRIB D IN FOREIGN COUNTRIES?10. IS BRIDGE, DAM, OR MARINE WORK PERFORMED?25. PRODUCT LIABILITY LOSS IN PAST 3 YEARS? (SPECIFY)11. DESCRIBE TYPICAL JOBS PERFORMED (ATTACH SEPARATE SHEETS):26. GROSS SALES FROM EACH OF LAST 3 YEARS:$$ $12. DESCRIBE AGREEMENT (ATTACH SEPARATE SHEETS):27. DESCRIBE INDEPENDENT CONTRACTORS (ATTACH SEPARATE SHEETS):13. DOES APPLICANT OWN, RENT, OR OTHERWISE USE CRANES?14. DO SUBCONTRACTORS CARRY COVERAGES OR LIMITSLESS THAN APPLICANT?28. DOES APPLICANT OWN OR LEASE WATERCRAFT?15. IS APPLICANT SELF-INSURED IN ANY STATE?16. SUBJECT TO:JONES ACTFELASTOP GAPOTHER:17. IS A HOSPITAL OR FIRST AID FACILITY MAINTAINED?18. ARE COVERAGES PROVIDED FOR DOCTORS / NURSES?19. INDICATE # OF DOCTORS:NURSES:BEDS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT 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, HI, NE, OH, OK, OR or VT. In DC, LA, ME, TN and VA insurance benefits may also be denied).APPLICABLE ONLY IN INDIANA, LOUISIANA AND VERMONT:IF THE COMPANY TO WHICH I AM APPLYING OFFERS UNINSURED MOTORISTS (UM) [AND UNDERINSURED MOTORISTS (UIM) IN INDIANA] COVERAGE IN MY STATE,I ACKNOWLEDGE THAT (UM) [AND UIM IN INDIANA] COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM OR UIM[IN] LIMITS EQUAL TO MY LIABILITY LIMITS, UM OR UIM [IN] LIMITS LOWER THAN MY LIABILITY LIMITS, OR TO REJECT UM OR UIM [IN] COVERAGE I SELECT UM LIMITS INDICATED IN THIS APPLICATION.(INITIALS)OR2. I REJECT UM COVERAGE IN ITS ENTIRETY.(INITIALS)APPLICABLE ONLY IN INDIANA:1. I SELECT UIM LIMITS INDICATED IN THIS APPLICATION.(INITIALS)OR2. I REJECT UIM COVERAGE IN ITS ENTIRETY.(INITIALS)THE STATEMENTS (ANSWERS) GIVEN ABOVE ARE TRUE AND ACCURATE. THE APPLICANT HASNOT WILLFULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCECONCERNING THIS APPLICATION. THIS APPLICATION DOES NOT CONSTITUTE A , CUSTODY, CONTROLADDITIONAL EXPOSURESREMARKSVEHICLESACORD 131 (2002/01)

Related search queries