ACORD 125

COMMERCIAL INSURANCE APPLICATION

LINES OF BUSINESS

ATTACHMENTS

Untitled(Required)

POLICY INFORMATION

MM slash DD slash YYYY
MM slash DD slash YYYY

APPLICANT INFORMATION

CONTACT INFORMATION

PRIMARY PRIMARY#
SECONDARYPRIMARY#
PRIMARY PRIMARY#
SECONDARYPRIMARY#

NATURE OF BUSINESS

Address
CITY LIMITS
INTEREST
ANY AREA LEASED TO OTHERS?
Address
CITY LIMITS
INTEREST
ANY AREA LEASED TO OTHERS?
Address
CITY LIMITS
INTEREST
ANY AREA LEASED TO OTHERS?
Address
CITY LIMITS
INTEREST
ANY AREA LEASED TO OTHERS?

PREMISES INFORMATION

Untitled(Required)
MM slash DD slash YYYY

ADDITIONAL INTEREST

INTEREST

INTEREST IN ITEM NUMBER

GENERAL INFORMATION

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

1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

2. IS A FORMAL SAFETY PROGRAM IN OPERATION?

Untitled

3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?

4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)

5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri Applicants - Do not answer this question)

Untitled

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).

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

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

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

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?

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

14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES?

15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES?

PRIOR CARRIER INFORMATION

LOSS HISTORY

Clear Signature