COGO Insurance - Trucking Liability & Commercial Building Insurance

AGENCY		CARRIER	NAIC CODE

POLICY NUMBER	EFFECTIVE DATE	APPLICANT / FIRST NAMED INSURED

IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully.
COVERAGES		LIMITS	PREMIUMS
CLAIMS MADE OCCURRENCE OWNER'S & CONTRACTOR'S PROTECTIVE		GENERAL AGGREGATE: $ LIMIT APPLIES PER:	Premises/Operations Products Other Total: $
DEDUCTIBLES Property Damage: $ Bodily Injury: $		Products & Completed Operations Aggregate: $ Personal & Advertising Injury: $ Each Occurrence: $ Damage to Rented Premises: $ Medical Expense (any one person): $ Employee Benefits: $
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS
APPLICABLE ONLY IN WISCONSIN: 1. UM/UIM COVERAGE: ISIS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE: ISIS NOT AVAILABLE.

SCHEDULE OF HAZARDS (ACORD 211, Schedule of Hazards, may be attached if more space is required)
LOC #	HAZ #	CLASS CODE	PREMIUM BASIS	EXPOSURE	TERR	RATE (Prem / Ops & Products)	PREMIUM (Prem / Ops & Products)

Classification/Description:

Classification/Description:

Classification/Description:
RATING AND PREMIUM BASIS: (P) PAYROLL – PER $1,000/PAY, (S) GROSS SALES – PER $1,000/SALES, (A) AREA – PER 1,000/SQ FT, (C) TOTAL COST – PER $1,000/COST, (M) ADMISSIONS – PER 1,000/ADM, (U) UNIT – PER UNIT, (T) OTHER
CLAIMS MADE (Explain all "Yes" responses)
EXPLAIN ALL "YES" RESPONSES								Y / N
1. PROPOSED RETROACTIVE DATE:
2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:
3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?
4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?

EMPLOYEE BENEFITS LIABILITY
1. DEDUCTIBLE PER CLAIM: $	2. NUMBER OF EMPLOYEES:	3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:	4. RETROACTIVE DATE:

CONTRACTORS		Y / N
1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?		YesNo
2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?		YesNo
3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?		YesNo
4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?		YesNo
5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?		YesNo
6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?		YesNo

DESCRIBE THE TYPE OF WORK SUBCONTRACTED

$ PAID TO SUBCONTRACTORS	% OF WORK SUBCONTRACTED	# FULL-TIME STAFF	# PART-TIME STAFF

PRODUCTS	ANNUAL GROSS SALES	# OF UNITS	TIME IN MARKET	EXPECTED LIFE	INTENDED USE	PRINCIPAL COMPONENTS

EXPLAIN ALL "YES" RESPONSES (For all past or present products or operations)

PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC.

Question	Y / N
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?	YesNo
2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)	YesNo
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?	YesNo
4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?	YesNo
5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?	YesNo
6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?	YesNo
7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?	YesNo
8. PRODUCTS UNDER LABEL OF OTHERS?	YesNo
9. VENDORS COVERAGE REQUIRED?	YesNo
10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?	YesNo

ADDITIONAL INTEREST / CERTIFICATE RECIPIENT
INTEREST	NAME AND ADDRESS		RANK:	EVIDENCE:
CERTIFICATE:
REFERENCE / LOAN #:
LOCATION:	BUILDING:	ITEM CLASS:	ITEM:	ITEM DESCRIPTION:

GENERAL INFORMATION

EXPLAIN ALL "YES" RESPONSES (For all past or present operations)		Y / N
1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?		YesNo
2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?		YesNo
3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)		YesNo
4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?		YesNo

5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS?

EQUIPMENT

TYPE OF EQUIPMENT

Small ToolsLarge Equipment

INSTRUCTION GIVEN (Y/N)
YesNo

6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?

7. ANY PARKING FACILITIES OWNED/RENTED?

8. IS A FEE CHARGED FOR PARKING?
YesNo

9. RECREATION FACILITIES PROVIDED?

10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? YesNo
# APTS	TOTAL APT AREA (Sq. Ft.)	DESCRIBE OTHER LODGING OPERATIONS

11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply)
Approved FenceLimited AccessDiving BoardSlideAbove GroundIn GroundLifeguard

12. ARE SOCIAL EVENTS SPONSORED?
YesNo

13. ARE ATHLETIC TEAMS SPONSORED?
TYPE OF SPORT	CONTACT SPORT (Y/N) YesNo	AGE GROUP 12 & UNDER Yes	13 - 18 Yes	OVER 18 Yes
TYPE OF SPORT	CONTACT SPORT (Y/N) YesNo	AGE GROUP 12 & UNDER Yes	13 - 18 Yes	OVER 18 Yes
EXTENT OF SPONSORSHIP:
14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?		YesNo
15. ANY DEMOLITION EXPOSURE CONTEMPLATED?		YesNo

GENERAL INFORMATION (continued)		Y / N
16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?		YesNo
17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
LEASE TO	WORKERS COMPENSATION COVERAGE CARRIED (Y/N) YesNo
LEASE FROM	WORKERS COMPENSATION COVERAGE CARRIED (Y/N) YesNo
18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?		YesNo
19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?		YesNo
20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?		YesNo
21. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?		YesNo
22. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?		YesNo

REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

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...

Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge...

Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company...

Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information...

Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy...

Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer...

Applicable in PR: Any person who knowingly and with the intent to defraud presents false information in an insurance application...

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE 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)

APPLICANT'S SIGNATURE

DATE

NATIONAL PRODUCER NUMBER

GENERAL INFORMATION

SIGNATURE

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