AGENCY

DATE (MM/DD/YYYY)

CARRIER

NAIC CODE

COMPANY POLICY OR PROGRAM NAME

PROGRAM CODE

POLICY NUMBER

CONTACT NAME

UNDERWRITER

PHONE (A/C, No, Ext)

FAX (A/C, No)

UNDERWRITER OFFICE

EMAIL

ADDRESS

CODE

SUBCODE

AGENCY CUSTOMER ID

STATUS OF TRANSACTION

QUOTEISSUE POLICYRENEWBOUNDCHANGECANCEL

DATE:
TIME:
AMPM

BOILER & MACHINERY

CYBER AND PRIVACY

BUSINESS AUTO

FIDUCIARY LIABILITY

BUSINESS OWNERS

GARAGE AND DEALERS

COMMERCIAL GENERAL LIABILITY

LIQUOR LIABILITY

COMMERCIAL INLAND MARINE

MOTOR CARRIER

COMMERCIAL PROPERTY

TRUCKERS

CRIME

UMBRELLA

ACCOUNTS RECEIVABLE / VALUABLE PAPERSADDITIONAL INTEREST SCHEDULEADDITIONAL PREMISES INFORMATION SCHEDULEAPARTMENT BUILDING SUPPLEMENTCONDO ASSN BYLAWSCONTRACTORS SUPPLEMENTCOVERAGES SCHEDULEDEALER SECTIONDRIVER INFORMATION SCHEDULEELECTRONIC DATA PROCESSING SECTION

GLASS AND SIGN SECTIONHOTEL / MOTEL SUPPLEMENTINSTALLATION / BUILDERS RISK SECTIONINTERNATIONAL LIABILITY EXPOSUREINTERNATIONAL PROPERTY EXPOSURELOSS SUMMARYOPEN CARGO SECTIONPREMIUM PAYMENT SUPPLEMENTPROFESSIONAL LIABILITY SUPPLEMENTRESTAURANT / TAVERN SUPPLEMENT

STATEMENT / SCHEDULE OF VALUESSTATE SUPPLEMENT (if applicable)VACANT BUILDING SUPPLEMENTVEHICLE SCHEDULE

PROPOSED EFF DATE

PROPOSED EXP DATE

BILLING PLAN

PAYMENT PLAN

METHOD OF PAYMENT

AUDIT

DEPOSIT $

MINIMUM PREMIUM $

POLICY PREMIUM $

NAME (First Named Insured)

GL CODE

SIC

NAICS

FEIN or SOC SEC #

ADDRESS

ENTITY TYPE:

CORPORATIONJOINT VENTUREINDIVIDUALLLC (No. of Members and Managers)NOT FOR PROFIT ORGPARTNERSHIPSUBCHAPTER ‘S’ CORPORATIONTRUST

BUSINESS PHONE

WEBSITE

CONTACT TYPE:

AGENCY CUSTOMER ID:

CONTACT NAME:

PRIMARY PHONE:
HOMEBUSCELL

SECONDARY PHONE:
HOMEBUSCELL

PRIMARY EMAIL ADDRESS:

SECONDARY EMAIL ADDRESS:

LOC #

STREET

CITY

STATE

ZIP

COUNTY

CITY LIMITS:
INSIDEOUTSIDE

INTEREST:
OWNERTENANT

# FULL TIME EMPL:

# PART TIME EMPL:

ANNUAL REVENUES $:

OCCUPIED AREA:
SQ FT

OPEN TO PUBLIC:
SQ FT

TOTAL BUILDING AREA:
SQ FT

ANY AREA LEASED TO OTHERS?
YesNo

DESCRIPTION OF OPERATIONS:

APARTMENTS

CONDOMINIUMS

CONTRACTOR

INSTITUTIONAL

MANUFACTURING

OFFICE

RESTAURANT

RETAIL

DESCRIPTION OF PRIMARY OPERATIONS

RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:

INSTALLATION, SERVICE OR REPAIR WORK

OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK

DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS

INTEREST
ADDITIONAL INSUREDLIENHOLDERLOSS PAYEEMORTGAGEEOWNERTRUSTEEEMPLOYEECO-OWNERLESSORLOSS PAYABLELEASEBACKREGISTRANT

NAME AND ADDRESS

RANK

EVIDENCE:
CERTIFICATEPOLICY

SEND BILL

REFERENCE / LOAN #:

INTEREST END DATE:

LIEN AMOUNT:

REASON FOR INTEREST:

E-MAIL ADDRESS:

PHONE:

FAX:

LOCATION:

BUILDING:

VEHICLE:

BOAT:

AIRPORT:

AIRCRAFT:

ITEM CLASS:

ITEM:

ITEM DESCRIPTION:

1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY?

YesNo

PARENT COMPANY NAME

RELATIONSHIP DESCRIPTION

% OWNED

1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

YesNo

SUBSIDIARY COMPANY NAME

RELATIONSHIP DESCRIPTION

% OWNED

2. IS A FORMAL SAFETY PROGRAM IN OPERATION?

SAFETY MANUALSAFETY POSITIONMONTHLY MEETINGSOSHA

YesNo

3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?

YesNo

4. ANY OTHER INSURANCE WITH THIS COMPANY?

YesNo

5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS?

NON-PAYMENTNON-RENEWALAGENT NO LONGER REPRESENTS CARRIERUNDERWRITING

CONDITION CORRECTED (Describe):

YesNo

6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

YesNo

7. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?

(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)

YesNo

8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?

YesNo

9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?

YesNo

10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?

YesNo

11. HAS BUSINESS BEEN PLACED IN A TRUST?
NAME OF TRUST:

YesNo

12. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?

(If “YES”, attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure)

YesNo

13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?

YesNo

14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If “YES”, describe use)

YesNo

15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If “YES”, describe use)

YesNo

CARRIER

POLICY NUMBER

PREMIUM

$

$

$

$

EFFECTIVE DATE

EXPIRATION DATE

CARRIER

POLICY NUMBER

PREMIUM

$

$

$

$

EFFECTIVE DATE

EXPIRATION DATE

CARRIER

POLICY NUMBER

PREMIUM

$

$

$

$

EFFECTIVE DATE

EXPIRATION DATE

Check if none (Attach Loss Summary for Additional Loss Information)

ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS

TOTAL LOSSES: $

$

$

YesNo

YesNo

PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT,
MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND
SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED
INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES
WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR
ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION
WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR
FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT
WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.
THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS
MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION
OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.

(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)

Applicant's Initials: