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
LINES OF BUSINESS
INDICATE LINES OF BUSINESS
PREMIUM
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
ATTACHMENTS
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
POLICY INFORMATION
PROPOSED EFF DATE
PROPOSED EXP DATE
BILLING PLAN
PAYMENT PLAN
METHOD OF PAYMENT
AUDIT
DEPOSIT $
MINIMUM PREMIUM $
POLICY PREMIUM $
APPLICANT INFORMATION
NAME (First Named Insured)
GL CODE
SIC
NAICS
FEIN or SOC SEC #
ENTITY TYPE:
CORPORATIONJOINT VENTUREINDIVIDUALLLC (No. of Members and Managers)NOT FOR PROFIT ORGPARTNERSHIPSUBCHAPTER ‘S’ CORPORATIONTRUST
BUSINESS PHONE
WEBSITE
CONTACT INFORMATION
CONTACT TYPE:
AGENCY CUSTOMER ID:
CONTACT NAME:
PRIMARY PHONE: HOMEBUSCELL
SECONDARY PHONE: HOMEBUSCELL
PRIMARY EMAIL ADDRESS:
SECONDARY EMAIL ADDRESS:
PREMISES INFORMATION
(Attach ACORD 823 for Additional Premises)
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:
NATURE OF BUSINESS
DATE BUSINESS STARTED (MM/DD/YYYY)
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
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only necessary data) Attach ACORD 45 for more Additional Interests
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:
GENERAL INFORMATION
EXPLAIN ALL “YES” RESPONSES
Y / N
1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY?
YesNo
PARENT COMPANY NAME
RELATIONSHIP DESCRIPTION
% OWNED
1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
SUBSIDIARY COMPANY NAME
2. IS A FORMAL SAFETY PROGRAM IN OPERATION?
SAFETY MANUALSAFETY POSITIONMONTHLY MEETINGSOSHA
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
4. ANY OTHER INSURANCE WITH THIS COMPANY?
LINE OF BUSINESS
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):
6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
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.)
8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
OCCUR DATE
EXPLANATION
RESOLUTION
RESOLVE DATE
9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
11. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST:
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)
13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If “YES”, describe use)
15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If “YES”, describe use)
REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
YEAR
CATEGORY
GENERAL LIABILITY
AUTOMOBILE
PROPERTY
OTHER:
$
EFFECTIVE DATE
EXPIRATION DATE
PRIOR CARRIER INFORMATION (continued)
LOSS HISTORY
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: $
DATE OF OCCURRENCE
LINE
TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM
DATE OF CLAIM
AMOUNT PAID
AMOUNT RESERVED
SUBROGATION Y / N
CLAIM OPEN Y / N
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)
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:
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company...
Applicable in FL and OK: 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).* *Applies in FL Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented...
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application...
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company...
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
Applicable in OR: Any person who knowingly and with intent to defraud the insurer by submitting an application containing a false statement...
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application...
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
PRODUCER'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO (Required in Florida)
NATIONAL PRODUCER NUMBER
APPLICANT'S SIGNATURE
DATE