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

    DATE:
    TIME:

    LINES OF BUSINESS

    INDICATE LINES OF BUSINESS

    PREMIUM

    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

    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 #

    ADDRESS

    ENTITY TYPE:

    BUSINESS PHONE

    WEBSITE

    CONTACT INFORMATION

    CONTACT TYPE:

    AGENCY CUSTOMER ID:

    CONTACT NAME:

    PRIMARY PHONE:

    SECONDARY PHONE:

    PRIMARY EMAIL ADDRESS:

    SECONDARY EMAIL ADDRESS:

    PREMISES INFORMATION

    (Attach ACORD 823 for Additional Premises)

    LOC #

    STREET

    CITY

    STATE

    ZIP

    COUNTY

    CITY LIMITS:

    INTEREST:

    # 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?

    DESCRIPTION OF OPERATIONS:

    NATURE OF BUSINESS

    DATE BUSINESS STARTED
    (MM/DD/YYYY)

    ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only necessary data) Attach ACORD 45 for more Additional Interests

    GENERAL INFORMATION

    AGENCY CUSTOMER ID:

    EXPLAIN ALL “YES” RESPONSES

    Y / N

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

    1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

    2. IS A FORMAL SAFETY PROGRAM IN OPERATION?

    3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?

    4. ANY OTHER INSURANCE WITH THIS COMPANY?

    LINE OF BUSINESS

    POLICY NUMBER

    LINE OF BUSINESS

    POLICY NUMBER

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

    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?

    OCCUR DATE

    EXPLANATION

    RESOLUTION

    RESOLVE DATE

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

    OCCUR DATE

    EXPLANATION

    RESOLUTION

    RESOLVE DATE

    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:

    CARRIER

    POLICY NUMBER

    PREMIUM

    $

    $

    $

    $

    EFFECTIVE DATE

    EXPIRATION DATE

    PRIOR CARRIER INFORMATION (continued)

    AGENCY CUSTOMER ID:

    YEAR

    CATEGORY

    GENERAL LIABILITY

    AUTOMOBILE

    PROPERTY

    OTHER:

    CARRIER

    POLICY NUMBER

    PREMIUM

    $

    $

    $

    $

    EFFECTIVE DATE

    EXPIRATION DATE

    CARRIER

    POLICY NUMBER

    PREMIUM

    $

    $

    $

    $

    EFFECTIVE DATE

    EXPIRATION DATE

    LOSS HISTORY

    (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

    $

    $

    SIGNATURE


    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:

    FRAUD WARNINGS & SIGNATURE


    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