ACORD 125

COMMERCIAL INSURANCE APPLICATION

This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
This field is hidden when viewing the form
MM slash DD slash YYYY
This field is hidden when viewing the form
Time
:

LINES OF BUSINESS

Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.
Please enter a number from 0 to 10.

ATTACHMENTS

Untitled(Required)

POLICY INFORMATION

MM slash DD slash YYYY
MM slash DD slash YYYY

APPLICANT INFORMATION

Not sure what your GL Code is? Click here to look it up.
Don't know your SIC Code? Click here to look it up.
Need help finding your NAICS Code? Click here to look it up.
Not sure what your GL Code is? Click here to look it up.
Don't know your SIC Code? Click here to look it up.
Need help finding your NAICS Code? Click here to look it up.
Not sure what your GL Code is? Click here to look it up.
Don't know your SIC Code? Click here to look it up.
Need help finding your NAICS Code? Click here to look it up.

CONTACT INFORMATION

PRIMARY PHONE#
SECONDARY PHONE#
PRIMARY PHONE#
SECONDARY PHONE#

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

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?

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?

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
Clear Signature
MM slash DD slash YYYY