COMMERCIAL INSURANCE APPLICATION

Transcription

1 COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION AGENCY CARRIER UNDERWRITER NAIC CODE: DATE (MM/DD/YYYY) UNDERWRITER OFF. POLICIES OR PROGRAM REQUESTED POLICY NUMBER PHONE (A/C, No, Ext): FAX (A/C, No): ADDRESS: CODE: AGENCY CUSTOMER ID: STATUS OF TRANSACTION SUB CODE: INDICATE SECTIONS ATTACHED EQUIPMENT FLOATER GARAGE AND DEALERS PROPERTY INSTALLATION/BUILDERS RISK VEHICLE SCHEDULE GLASS AND SIGN ELECTRONIC DATA PROC BOILER & MACHINERY ACCOUNTS RECEIVABLE/ VALUABLE PAPERS COMMERCIAL GENERAL LIABILITY WORKERS COMPENSATION CRIME/MISCELLANEOUS CRIME BUSINESS AUTO UMBRELLA TRANSPORTATION/ TRUCK CARGO TRUCKERS/ CARRIER QUOTE ISSUE POLICY RENEW ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES. BOUND (Give Date and/or Attach Copy): PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN AUDIT CHANGE DATE TIME AM DIRECT BILL CANCEL PM AGENCY BILL APPLICANT INFORMATION NAME (First Named Insured & Other Named Insureds) PACKAGE POLICY INFORMATION FEIN OR SOC SEC # (of First Named Insured): PHONE (A/C, No, Ext): MAILING ADDRESS INCL ZIP+4 (of First Named Insured) WEBSITE ADDRESS(ES): ADDRESS(ES): INDIVIDUAL CORPORATION SUBCHAPTER "S" LLC CR BUREAU CORPORATION NAME ID NUMBER PARTNERSHIP JOINT VENTURE NOT FOR PROFIT ORG NO. OF MEMBERS AND MANAGERS INTION CONTACT ACCOUNTING RECORDS CONTACT PHONE PHONE (A/C, No, Ext): ADDRESS: (A/C, No, Ext): ADDRESS: PREMISES INFORMATION LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT # EMPLOYEES ANNUAL REVENUES DATE BUS STARTED PART OCCUPIED INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S) GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES 1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? 8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? (In RI, this question must be answered by any applicant for property insurance. 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 4. ANY CATASTROPHE EXPOSURE? 9. ANY UNCORRECTED FIRE CODE VIOLATIONS? 5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? 10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST 5 YEARS? 6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED 11. HAS BUSINESS BEEN PLACED IN A TRUST? DURING THE PRIOR 3 YEARS? (Not applicable in MO) IF YES, NAME OF TRUST: REMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required) YES NO ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied) THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. APPLICANT S SIGNATURE DATE PRODUCER S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 125 (2004/03) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

2 PRIOR CARRIER INFORMATION LINE C O M M E R C I A L G E N E R A L L I A B I L I T Y A U L T I O A M B O I B L I I L T E Y P R O P E R T Y CATEGORY CARRIER POLICY NUMBER POLICY TYPE RETRO DATE EFF-EXP DATE GENERAL AGGREGATE PRODUCTS COMP OP AGGREGATE PERSONAL & ADV INJ EACH OCCURRENCE L I FIRE DAMAGE M I MEDICAL EXPENSE T S BODILY OCCURRENCE INJURY AGGREGATE PROPERTY OCCURRENCE DAMAGE AGGREGATE COMBINED SINGLE LIMIT MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER POLICY TYPE EFF-EXP DATE COMBINED SINGLE LIMIT BODILY EA PERSON INJURY EA ACCIDENT PROPERTY DAMAGE MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER POLICY TYPE EFF-EXP DATE BUILDING AMT PERS PROP AMT MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER POLICY TYPE EFF-EXP DATE LIMIT MODIFICATION FACTOR TOTAL PREMIUM LOSS HISTORY CLAIMS CLAIMS CLAIMS CLAIMS CLAIMS OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE OCCURRENCE MADE MADE MADE MADE MADE ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY) CHK HERE IF NONE SEE ATTACHED LOSS SUMMARY DATE OF DATE AMOUNT AMOUNT CLAIM LINE TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM OCCURRENCE OF CLAIM PAID RESERVED STATUS OPEN CLOSED OPEN REMARKS NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORY ATTACHMENTS CLOSED STATE SUPPLEMENT(S) (If applicable) COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state s requirements.) NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY 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. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. ACORD 125 (2004/03)

3 ACORD TM BUSINESS AUTO SECTION AGENCY PHONE APPLICANT (A/C, No, Ext): (First FAX (A/C, No): Named Insured) DATE (MM/DD/YYYY) CODE: AGENCY CUSTOMER ID: COVERAGES/LIMITS DRIVER INFORMATION SUB CODE: EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT AGENCY BILL FOR COMPANY USE ONLY USE ACORD 137 FOR YOUR STATE TO PROVIDE COVERAGES/LIMITS INFORMATION ACORD 163 attached for additional drivers LIST ALL DRIVERS, INCLUDING FAMILY MEMBERS THAT WILL DRIVE COMPANY VEHICLES, AND EMPLOYEES WHO DRIVE OWN VEHICLES ON COMPANY BUSINESS. DRIVER MAR YRS YEAR DRIVERS LICENSE NUMBER/ STATE DATE BROADEN. DOC USE % # NAME (Include address, if required) SEX STAT DATE OF BIRTH EXP LIC SOCIAL SECURITY NUMBER LIC HIRE NO- VEH # USE GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES YES NO 1. WITH THE EXCEPTION OF ENCUMBRANCES, ARE ANY VEHICLES NOT SOLELY 8. ANY HOLD HARMLESS AGREEMENTS? OWNED BY AND REGISTERED TO THE APPLICANT? 9. ANY VEHICLES USED BY FAMILY MEMBERS? IF SO, IDENTIFY IN REMARKS. 2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS? 10. DOES THE APPLICANT OBTAIN MVR VERIFICATIONS? 3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION? 11. DOES THE APPLICANT HAVE A IFIC DRIVER RECRUITING METHOD? 4. ARE ANY VEHICLES LEASED TO OTHERS? 12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION? 5. ARE ANY VEHICLES CUSTOMIZED, ALTERED OR HAVE IAL EQUIPMENT? 13. ANY VEHICLES OWNED BUT NOT SCHEDULED ON THIS APPLICATION? 6. ARE ICC, PUC OR OTHER FILINGS REQUIRED? 14. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS? 7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL? 15. HAS AGENT INTED VEHICLES? DESCRIPTION OF GARAGE/STORAGE LOCATIONS ADDITIONAL INTEREST/CERTIFICATE RECIPIENT ACORD 45 attached for additional names MAXIMUM DOLLAR VALUE SUBJECT TO LOSS INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER ADDITIONAL INSURED VEHICLE: LOSS PAYEE SCHEDULED ITEM NUMBER: LIENHOLDER OTHER EMPLOYEE AS LESSOR OWNER REGISTRANT REMARKS ITEM DESCRIPTION: ACORD 127 (2003/08) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

4 VEHICLE DESCRIPTION ACORD 129 attached for additional vehicles VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM L CHECK COVERAGES ADD L NO- UNDRINS F LSP RENT REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO USE COMM L CHECK WORK/SCHOOL COVERAGES ADD L NO- UNDRINS F LSP RENT REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO USE COMM L CHECK ADD L NO- UNDRINS F LSP RENT WORK/SCHOOL COVERAGES REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO USE COMM L CHECK WORK/SCHOOL COVERAGES ADD L NO- UNDRINS F LSP RENT REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO USE COMM L CHECK WORK/SCHOOL COVERAGES ADD L NO- UNDRINS F LSP RENT REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO USE COMM L CHECK ADD L NO- UNDRINS F LSP RENT WORK/SCHOOL COVERAGES REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM VEH # YEAR MAKE: BODY TYPE: VEHICLE TYPE SYM/AGE COST NEW MODEL: V.I.N.: PP COML LIC CITY, STATE, TERR GVW/GCW CLASS SIC FACTOR SEAT CP RADIUS FARTHEST TERM STATE ZIP WHERE GARAGED DRIVE TO WORK/SCHOOL USE COMM L CHECK COVERAGES ADD L NO- UNDRINS F LSP RENT REIMB DEDUCTIBLES ACV COMP < 15 MILES PLEASURE RETAIL LIAB MED PAY TOWING & LABOR FT COMP FG AA ST AMT 15 MILES + FARM SERVICE NO- UNINS FTW COLL COLL NET VEH DR/CR: TOTAL PREM ACORD 127 (2003/08)

5 COMMERCIAL GENERAL LIABILITY SECTION DATE (MM/DD/YYYY) AGENCY PHONE (A/C, No, Ext): FAX (A/C, No): APPLICANT (First Named Insured) CODE: AGENCY CUSTOMER ID: COVERAGES SUB CODE: EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT AGENCY BILL FOR COMPANY USE ONLY LIMITS COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE PREMIUMS CLAIMS MADE OCCURRENCE PRODUCTS & COMPLETED OPERATIONS AGGREGATE PREMISES/OPERATIONS OWNER S & CONTRACTOR S PROTECTIVE PERSONAL & ADVERTISING INJURY EACH OCCURRENCE PRODUCTS DEDUCTIBLES DAMAGE TO RENTED PREMISES (each occurrence) PROPERTY DAMAGE MEDICAL EXPENSE (Any one person) OTHER BODILY INJURY PER CLAIM PER OCCURRENCE EMPLOYEE BENEFITS OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) TOTAL SCHEDULE OF HAZARDS LOCATION CLASSIFICATION CLASS # CODE PREMIUM BASIS EXPOSURE TERR RATE PREMIUM PREM/OPS PRODUCTS PREM/OPS PRODUCTS RATING AND PREMIUM BASIS (P) PAYROLL - PER 1,000/PAY (C) TOTAL COST - PER 1,000/COST (U) UNIT - PER UNIT (S) GROSS SALES - PER 1,000/SALES (A) AREA - PER 1,000/SQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER CLAIMS MADE (Explain all "Yes" responses) EMPLOYEE BENEFITS LIABILITY 1. PROPOSED RETROACTIVE DATE: 1. DEDUCTIBLE PER CLAIM: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV: 2. NUMBER OF EMPLOYEES: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION YES NO 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? 4. RETROACTIVE DATE: 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? REMARKS REMARKS ACORD 126 (2004/03) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1993

6 CONTRACTORS EXPLAIN ALL "YES" RESPONSES (For past or present operations) YES NO EXPLAIN ALL "YES" RESPONSES (For past or present operations) YES NO 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR IFICATIONS 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS FOR OTHERS? LESS THAN YOURS? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT EXPLOSIVE MATERIAL? PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR UNDERGROUND WORK OR EARTH MOVING? WITHOUT OPERATORS? REMARKS/DESCRIBE THE TYPE OF WORK SUBCONTRACTED PAID TO SUB- % OF WORK # FULL- # PART- CONTRACTORS: SUBCONTRACTED: TIME STAFF: TIME STAFF: PRODUCTS/COMPLETED OPERATIONS TIME IN EXPECTED PRODUCTS ANNUAL GROSS SALES # OF UNITS MARKET LIFE INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) YES NO EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) YES NO 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? 7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW APPLICANT LABEL? PRODUCTS PLANNED? 8. PRODUCTS UNDER LABEL OF OTHERS? 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? 9. VENDORS COVERAGE REQUIRED? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC ADDITIONAL INTEREST/CERTIFICATE RECIPIENT INTEREST RANK: NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION: BUILDING: LOSS PAYEE VEHICLE: BOAT: MORTGAGEE SCHEDULED ITEM NUMBER: LIENHOLDER OTHER EMPLOYEE AS LESSOR ITEM DESCRIPTION: GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES (For all past or present operations) YES NO EXPLAIN ALL "YES" RESPONSES (For all past or present operations) YES NO 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS 12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? EMPLOYED OR CONTRACTED? 13. ANY DEMOLITION EXPOSURE CONTEMPLATED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS JOINT VENTURES? INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? (e.g. landfills, wastes, fuel tanks, etc) 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST 5 YEARS? REMARKS ACORD 45 attached for additional names 16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS? 18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? YOUR PREMISES WITHIN THE LAST THREE YEARS? 7. ANY PARKING FACILITIES OWNED/RENTED? 19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY 8. IS A FEE CHARGED FOR PARKING? POLICY IN EFFECT? 9. RECREATION FACILITIES PROVIDED? 20. DOES THE BUSINESSES PROMOTIONAL LITERATURE MAKE 10. IS THERE A SWIMMING POOL ON THE PREMISES? ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY 11. SPORTING OR SOCIAL EVENTS SPONSORED? OF THE PREMISES? ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied). ACORD 126 (2004/03) ATTACH TO APPLICANT INFORMATION SECTION

7 ACORD PRODUCER TM PHONE (A/C, No, Ext): FAX (A/C, No): WORKERS COMPENSATION APPLICATION COMPANY APPLICANT NAME UNDERWRITER INTERNET ADDRESS: DATE MAILING ADDRESS (Including ZIP code) YRS IN BUS SIC INDIVIDUAL CORPORATION LIMITED CORP CODE: AGENCY CUSTOMER ID SUB CODE: CREDIT BUREAU NAME: FEDERAL EMPLOYER ID NUMBER PARTNERSHIP NCCI ID NUMBER SUBCHAPTER "S" CORP OTHER: ID NUMBER: OTHER RATING BUREAU ID OR STATE EMPLOYER REGISTRATION NUMBER STATUS OF SUBMISSION QUOTE ISSUE POLICY BILLING/AUDIT INFORMATION BILLING PLAN PAYMENT PLAN AUDIT BOUND (Give date and/or attach copy) AGENCY BILL ANNUAL OTHER: AT EXPIRATION MONTHLY ASSIGNED RISK (Attach ACORD 133) DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL OTHER: LOCATIONS QUARTERLY % DOWN: QUARTERLY # STREET, CITY, COUNTY, STATE, ZIP CODE POLICY INFORMATION PROPOSED EFF DATE PART 1 - WORKERS COMPENSATION (States) DIVIDEND PLAN/SAFETY GROUP PROPOSED EXP DATE PART 2 - EMPLOYER S LIABILITY EACH ACCIDENT DISEASE-POLICY LIMIT DISEASE-EACH EMPLOYEE ADDITIONAL COMPANY INFORMATION NORMAL ANNIVERSARY RATING DATE PART 3 - OTHER STATES INS DEDUCTIBLES PARTICIPATING NON-PARTICIPATING AMOUNT/% RETRO PLAN OTHER COVERAGES MEDICAL U.S.L. & H. INDEMNITY VOLUNTARY COMP FOREIGN COV MANAGED CARE OPTION RATING INFORMATION # EMPLOYEES DESCR ESTIMATED STATE LOC CLASS CODE CODE CATEGORIES, DUTIES, CLASSIFICATIONS ANNUAL FULL PART RATE TIME TIME REMUNERATION ESTIMATED ANNUAL PREMIUM IFY ADDITIONAL COVERAGES/ENDORSEMENTS FACTOR TOTAL INCREASED LIMITS DEDUCTIBLE EXPERIENCE MODIFICATION LOSS CONSTANT ASSIGNED RISK SURCHARGE ARAP PREMIUM DISCOUNT EXPENSE CONSTANT MINIMUM PREMIUM DEPOSIT PREMIUM TOTAL EST ANNUAL PREMIUM FACTORED PREMIUM ACORD 130 (2000/08) PLEASE COMPLETE REVERSE SIDE ACORD CORPORATION 1980

8 INDIVIDUALS INCLUDED/EXCLUDED PRIOR CARRIER INFORMATION/LOSS HISTORY PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER & POLICY NUMBER ANNUAL PREMIUM MOD # CLAIMS AMOUNT PAID RESERVE CO: POL #: CO: POL #: CO: POL #: CO: POL #: CO: POL #: NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS, OPERATIONS AND PRODUCTS: MANUFACTURING-- RAW MATERIALS, PROCESSES, PRODUCT, EQUIPMENT. CONTRACTOR-- TYPE OF WORK, SUB-CONTRACTS. MERCANTILE--MERCHANDISE, CUSTOMERS, DELIVERIES. SERVICE--TYPE, LOCATION. FARM--ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS. GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES YES NO EXPLAIN ALL "YES" RESPONSES 1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT/WATERCRAFT? 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? 2. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) 17. ANY OTHER INSURANCE WITH THIS INSURER? STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING 18. ANY PRIOR COVERAGE DECLINED/ OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) CANCELLED/NON-RENEWED (Last 3 years)? NOT APPLICABLE IN MO 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? 4. ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIDGE OVER WATER? 20. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS/SUBSIDIARY? 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS? 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? 6. ARE SUB-CONTRACTORS USED? (IF YES, GIVE % OF WORK SUBCONTRACTED) 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INS.? 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS? 8. IS A WRITTEN SAFETY PROGRAM IN OPERATION? 9. ANY GROUP TRANSPORTATION PROVIDED? PARTNERS, OFFICERS, RELATIVES TO BE INCLUDED OR EXCLUDED. (Remuneration to be included must be part of rating information section.) TITLE/ OWNER- # NAME DATE OF BIRTH RELATIONSHIP SHIP % DUTIES INC/EXC CLASS CODE REMUNERATION 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? 11. ANY SEASONAL EMPLOYEES? 12. IS THERE ANY VOLUNTEER OR DONATED LABOR? 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? 14. DO EMPLOYEES TRAVEL OUT OF STATE? 15. ARE ATHLETIC TEAMS SPONSORED? IN- TION ACCTNG RECORD CLAIMS INFO PHONE: NAME: PHONE: NAME: PHONE: NAME: 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST 5 YEARS? 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES, EXPLAIN INCLUDING ENTITIY NAME(S) AND POLICY NUMBERS(S). CONTACT INFORMATION APPLICABLE IN TENNESSEE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO ANY PARTY TO A WORKERS COM- PENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CON- CERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, VT; IN DC, LA, ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED) REMARKS YES NO APPLICANT S SIGNATURE PRODUCER S SIGNATURE ACORD 130 (2000/08)

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17 EMPLOYEE BENEFIT LIABILITY INSURANCE APPLICATION Employee Benefit Programs which are automatically covered are: Group Life Insurance, Profit Sharing Plans, Pension Plans, Employee Stock Subscription Plans, Workers Compensation, Unemployment Insurance, Social Security and Disability Benefits Insurance. 1. Name of Applicant: # of Employees 2. Address: 3. Policy #: 4. On program permitting employees an option to enroll or not to enroll, does the applicant require a signed acceptance or rejection from each employee? Yes No Administration Qualifications 5. Is the administration of the Employee Benefits Program: a. Handled by a dedicated Human Resources Department? Yes No b. Handled by a single employee? Yes No 6. If 5.b was Yes : a. How many years has the Administrator been handling the program? Years b. Total years of experience? Years 7. Is the insured subject to ERISA? Yes No Written Requirements 8. Does the insured have any of the following in writing: a. Plan? Yes No b. Amendments to Plan? Yes No c. Acceptance/rejection? Yes No d. Changes in options? Yes No e. Clauses that specifies written plan shall govern over oral Yes No communications? 9. If this insurance had been in force during the past 10 years, would any claim have been presented? (Give details.) 10. Limits desired Each Claim Aggregate (Insured s Signature) Date (Agent s Signature) Date

18 Non-owned and Hired Automobiles Questionnaire Customer Name: Policy #: Non-owned Automobile 1. Number of employees using their own vehicles for company business (full time or occasional use). Examples might includes sales, delivery, mail pickup, bank deposits. 2. How often and for what purpose do employees drive their own vehicles for company business? 3. Does the customer require MVR checks, or other forms of verification of a driver's driving record? If yes, who does it and how often? 4. What standards does the customer have for evaluating a driver s driving record, or MVR? What is considered acceptable and what is considered unacceptable? Are these acceptability standards at least as restrictive as Zurich NA s standards? Acceptable: Unacceptable: 5. What actions are taken if an employee s driving record is considered unacceptable? 6. Submit complete driver information for all full time and occasional drivers (those employees using their own vehicles for company business). 7. For those employees who use their own vehicles for company business, either full time or occasionally, does the customer require the employee to carry Personal Auto insurance? Are certificates of insurance obtained form the employees automobile insurers? Who verifies coverage, limits, and the carriers? How will the customer know if an employee s Personal Automobile Policy lapses during the term of the Commercial Automobile Policy? Hired and Borrowed Auto Liability 1. How many vehicles (cars, vans, trucks, tractors) are hired or borrowed each year (short and long term rentals, short and long term leases)? 2. For what purpose are the hired and borrowed vehicles used? 3. What is the average length of time these vehicles are hired or borrowed? 4. What is the total annual cost for all hired and borrowed vehicles? 5. Who is providing primary automobile liability and automobile physical damage for the hired and borrowed vehicles? Are certificates of insurance obtained? Who verifies limits, coverages, policy terms, and carrier strength? 6. In which states does Zurich NA s customer hire or borrow vehicles?

19 Supplemental Business Auto Fleet Checklist Please answer all of the following questions Insured: Agency: 1. Who is responsible for the vehicle safety & maintenance programs? Name: Phone Number: 2. Does the safety program include: a. Safety meetings that specifically address driving practices? How often: b. MVRs ordered prior to hiring new drivers? c. MVRs ordered on all vehicle operators at least annually? d. Suspension of driving responsibilities for serious driving violations, including DUI, Reckless Driving, leaving the scene of an accident, committing a felony with an auto, or speeding more than 20 miles over the posted speed limit. e. MVRs ordered on all non-employee drivers? f. A policy on personal use of company vehicles by employees? How is this policy enforced? : g. Management approval on all non-employee drivers? h. Inclusion of non-employee operators on the drivers list? i. Certificates of insurance acquired from employees who use their personal vehicles on company business? j. A procedure in place for drivers to report accidents? k. A procedure for management to investigate accidents at the time of loss? l. Post accident reviews performed to identify problems? m. Random drug & alcohol tests performed for all operators of company vehicles? Yes No 3. Is there a set procedure for selecting drivers? Does the procedure include: a. Reference checks? b. Physical exams with the application? c. A driving text using vehicle to be operated prior to employment? 4. Does the insured utilize owner/operators or subcontracted drivers? 5. Is there a Formal Safety Driving program in place? Is there an incentive program? If yes, please describe: 6. Does the Fleet Maintenance Program include: Does the driver perform a visual inspection of the assigned vehicle daily? Are records kept of reported deficiencies and corrective actions Are records kept for scheduled & unscheduled maintenance on vehicles? Are there any full time maintenance personnel?