2/2/2004 E5AB5DB1-B17C-444D-BB55-226D84015DF4 3.25.0 Times New Roman 10 plain 0

on

application/vnd.xfdl application/vnd.xfdl 126.xfd PureEdge ACORD Customer Service: Telephone: (845) 620-1700 ex. 506 Address: New York Office (World Headquarters) Two Blue Hill Plaza 3rd Floor PO Box 1529 Pearl River, NY 10965-8529 USA 1 T-2DQ8-A99S-9ZC6-Z9TJ-VCUC off off off off off off off off off off off off off off off off ACORD 126 (2007/01) off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off off [custom:DEFAULT_MAP][custom:PAGE1][custom:DATE] PAGE1.DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PHONE] PAGE1.PHONE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD19] PAGE1.FIELD19.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AGENCY] PAGE1.AGENCY.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF1] PAGE1.EF1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EFFECTIVE_DATE] PAGE1.EFFECTIVE_DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EXPIRATION_DATE] PAGE1.EXPIRATION_DATE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PAYMENT_PLAN] PAGE1.PAYMENT_PLAN.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AUDIT] PAGE1.AUDIT.value [custom:DEFAULT_MAP][custom:PAGE1][custom:AGENCY_CUSTOMER_ID] PAGE1.AGENCY_CUSTOMER_ID.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD3] PAGE1.FIELD3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD4] PAGE1.FIELD4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD1] PAGE1.FIELD1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD2] PAGE1.FIELD2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PREMISES_OPERATIONS] PAGE1.PREMISES_OPERATIONS.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PRODUCTS] PAGE1.PRODUCTS.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF7] PAGE1.EF7.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD7] 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[custom:DEFAULT_MAP][custom:PAGE1][custom:EF15] PAGE1.EF15.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF16] PAGE1.EF16.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF17] PAGE1.EF17.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF18] PAGE1.EF18.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF19] PAGE1.EF19.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF20] PAGE1.EF20.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF21] PAGE1.EF21.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF22] PAGE1.EF22.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF23] PAGE1.EF23.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF24] PAGE1.EF24.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF25] PAGE1.EF25.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF26] PAGE1.EF26.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF27] PAGE1.EF27.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF28] PAGE1.EF28.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF29] PAGE1.EF29.value 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[custom:DEFAULT_MAP][custom:PAGE1][custom:EF45] PAGE1.EF45.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF46] PAGE1.EF46.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF47] PAGE1.EF47.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF48] PAGE1.EF48.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF49] PAGE1.EF49.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF50] PAGE1.EF50.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF51] PAGE1.EF51.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF52] PAGE1.EF52.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF53] PAGE1.EF53.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF54] PAGE1.EF54.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF55] PAGE1.EF55.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF56] PAGE1.EF56.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF57] PAGE1.EF57.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF58] PAGE1.EF58.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF59] PAGE1.EF59.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF60] PAGE1.EF60.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF61] PAGE1.EF61.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF62] PAGE1.EF62.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF63] PAGE1.EF63.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF64] PAGE1.EF64.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF65] PAGE1.EF65.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF66] PAGE1.EF66.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF67] PAGE1.EF67.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF68] PAGE1.EF68.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF69] PAGE1.EF69.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF70] PAGE1.EF70.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF71] PAGE1.EF71.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF72] PAGE1.EF72.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF73] PAGE1.EF73.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF74] PAGE1.EF74.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF75] PAGE1.EF75.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF76] PAGE1.EF76.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF77] PAGE1.EF77.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF78] PAGE1.EF78.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF79] PAGE1.EF79.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF80] PAGE1.EF80.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF81] PAGE1.EF81.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF82] PAGE1.EF82.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF83] PAGE1.EF83.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF84] PAGE1.EF84.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF85] PAGE1.EF85.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF86] PAGE1.EF86.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF87] PAGE1.EF87.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF88] PAGE1.EF88.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF89] PAGE1.EF89.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF90] PAGE1.EF90.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF91] PAGE1.EF91.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF92] PAGE1.EF92.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF93] PAGE1.EF93.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF94] PAGE1.EF94.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF95] PAGE1.EF95.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF96] PAGE1.EF96.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF97] PAGE1.EF97.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF98] PAGE1.EF98.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF99] PAGE1.EF99.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF100] PAGE1.EF100.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF101] PAGE1.EF101.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF102] PAGE1.EF102.value [custom:DEFAULT_MAP][custom:PAGE1][custom:EF107] PAGE1.EF107.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD14] PAGE1.FIELD14.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD16] PAGE1.FIELD16.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD17] PAGE1.FIELD17.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD18] PAGE1.FIELD18.value [custom:DEFAULT_MAP][custom:PAGE1][custom:FIELD15] PAGE1.FIELD15.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REMARKS] PAGE1.REMARKS.value [custom:DEFAULT_MAP][custom:PAGE1][custom:REMARKS2] PAGE1.REMARKS2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB1] PAGE1.CB1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB2] PAGE1.CB2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:OCCURRENCE] PAGE1.OCCURRENCE.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK8] PAGE1.CHECK8.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK9] PAGE1.CHECK9.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK1] PAGE1.CHECK1.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK3] PAGE1.CHECK3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK4] PAGE1.CHECK4.value [custom:DEFAULT_MAP][custom:PAGE1][custom:PER_CLAIM] PAGE1.PER_CLAIM.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CB3] PAGE1.CB3.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK5] PAGE1.CHECK5.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK2] PAGE1.CHECK2.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK6] PAGE1.CHECK6.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK7] PAGE1.CHECK7.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK10] PAGE1.CHECK10.value [custom:DEFAULT_MAP][custom:PAGE1][custom:CHECK11] PAGE1.CHECK11.value [custom:DEFAULT_MAP][custom:PAGE1][custom:changeVerFIELD] PAGE1.changeVerFIELD.value [custom:DEFAULT_MAP][custom:PAGE2][custom:PAID_TO_SUB_CONTRACTORS] PAGE2.PAID_TO_SUB_CONTRACTORS.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FULL_TIME_STAFF] PAGE2.FULL_TIME_STAFF.value [custom:DEFAULT_MAP][custom:PAGE2][custom:PART_TIME_STAFF] PAGE2.PART_TIME_STAFF.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD1] PAGE2.FIELD1.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF120] PAGE2.EF120.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF121] PAGE2.EF121.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF122] PAGE2.EF122.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF123] PAGE2.EF123.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF124] PAGE2.EF124.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF125] PAGE2.EF125.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF126] PAGE2.EF126.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF127] PAGE2.EF127.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF128] PAGE2.EF128.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF129] PAGE2.EF129.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF130] PAGE2.EF130.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF131] PAGE2.EF131.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF132] PAGE2.EF132.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF133] PAGE2.EF133.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF134] PAGE2.EF134.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF135] PAGE2.EF135.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF136] PAGE2.EF136.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF137] PAGE2.EF137.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF138] PAGE2.EF138.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF139] PAGE2.EF139.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF140] PAGE2.EF140.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF141] PAGE2.EF141.value [custom:DEFAULT_MAP][custom:PAGE2][custom:PLEASE_ATTACH_LITERATURE_BROCH] PAGE2.PLEASE_ATTACH_LITERATURE_BROCH.value [custom:DEFAULT_MAP][custom:PAGE2][custom:EF165] PAGE2.EF165.value [custom:DEFAULT_MAP][custom:PAGE2][custom:NAME_AND_ADDRESS] PAGE2.NAME_AND_ADDRESS.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD2] PAGE2.FIELD2.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD3] PAGE2.FIELD3.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD4] PAGE2.FIELD4.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD7] PAGE2.FIELD7.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD8] PAGE2.FIELD8.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD5] PAGE2.FIELD5.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD6] PAGE2.FIELD6.value [custom:DEFAULT_MAP][custom:PAGE2][custom:FIELD9] PAGE2.FIELD9.value [custom:DEFAULT_MAP][custom:PAGE2][custom:OTHER2] PAGE2.OTHER2.value [custom:DEFAULT_MAP][custom:PAGE2][custom:REMARKS3] PAGE2.REMARKS3.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK10] PAGE2.CHECK10.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK11] PAGE2.CHECK11.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK1] PAGE2.CHECK1.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK2] PAGE2.CHECK2.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK3] PAGE2.CHECK3.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK4] PAGE2.CHECK4.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK5] PAGE2.CHECK5.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK6] PAGE2.CHECK6.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK7] PAGE2.CHECK7.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK8] PAGE2.CHECK8.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK9] PAGE2.CHECK9.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK12] PAGE2.CHECK12.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK13] PAGE2.CHECK13.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK14] PAGE2.CHECK14.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK15] PAGE2.CHECK15.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK16] PAGE2.CHECK16.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK17] PAGE2.CHECK17.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK18] PAGE2.CHECK18.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK19] PAGE2.CHECK19.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK20] PAGE2.CHECK20.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK21] PAGE2.CHECK21.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK33] PAGE2.CHECK33.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK35] PAGE2.CHECK35.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK36] PAGE2.CHECK36.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK37] PAGE2.CHECK37.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK38] PAGE2.CHECK38.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK39] PAGE2.CHECK39.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK40] PAGE2.CHECK40.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK34] PAGE2.CHECK34.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK22] PAGE2.CHECK22.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK23] PAGE2.CHECK23.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK24] PAGE2.CHECK24.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK25] PAGE2.CHECK25.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK26] PAGE2.CHECK26.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK27] PAGE2.CHECK27.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK28] PAGE2.CHECK28.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK29] PAGE2.CHECK29.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK30] PAGE2.CHECK30.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK31] PAGE2.CHECK31.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK32] PAGE2.CHECK32.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK41] PAGE2.CHECK41.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK42] PAGE2.CHECK42.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK43] PAGE2.CHECK43.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK44] PAGE2.CHECK44.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK45] PAGE2.CHECK45.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK46] PAGE2.CHECK46.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK47] PAGE2.CHECK47.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK48] PAGE2.CHECK48.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK49] PAGE2.CHECK49.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK50] PAGE2.CHECK50.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK51] PAGE2.CHECK51.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK52] PAGE2.CHECK52.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK53] PAGE2.CHECK53.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK54] PAGE2.CHECK54.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK55] PAGE2.CHECK55.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK56] PAGE2.CHECK56.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK57] PAGE2.CHECK57.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK58] PAGE2.CHECK58.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK59] PAGE2.CHECK59.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK60] PAGE2.CHECK60.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK61] PAGE2.CHECK61.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK62] PAGE2.CHECK62.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK63] PAGE2.CHECK63.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK64] PAGE2.CHECK64.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK65] PAGE2.CHECK65.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK66] PAGE2.CHECK66.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK67] PAGE2.CHECK67.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK68] PAGE2.CHECK68.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK69] PAGE2.CHECK69.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK70] PAGE2.CHECK70.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK71] PAGE2.CHECK71.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK72] PAGE2.CHECK72.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK73] PAGE2.CHECK73.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK74] PAGE2.CHECK74.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK75] PAGE2.CHECK75.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK76] PAGE2.CHECK76.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK77] PAGE2.CHECK77.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK78] PAGE2.CHECK78.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK79] PAGE2.CHECK79.value [custom:DEFAULT_MAP][custom:PAGE2][custom:CHECK80] PAGE2.CHECK80.value etb TRADITIONAL letter 120 8.5;11.0 2CCEA536-7EDF-4297-988A-82F825F74924 239 239 239 255 255 255 DATE absolute 7 18 GRAYLOGODATA 1 GRAYLOGODATA absolute 819 50 extent 140 25 0 Field DATE Arial 10 plain wordwrap fixed center date optional MM/DD/YYYY HELP2 DATE EF1 absolute 155 75 extent 222 21 0 Field PHONE Arial 8 plain wordwrap fixed HELP4 EF1 FIELD19 absolute 155 96 extent 222 21 0 Field PHONE Arial 8 plain wordwrap fixed HELP124 PHONE FIELD1 absolute 82 93 extent 83 26 FAX (A/C, No): -4 Helvetica 6 bold absolute 444 75 extent 515 61 0 Field AGENCY wordwrap fixed Arial 10 plain HELP8 AGENCY_CUSTOMER_ID EFFECTIVE_DATE absolute 443 177 extent 515 58 0 Field AGENCY wordwrap fixed Arial 10 plain AUDIT CHECK1 absolute 3 118 extent 374 77 0 Field EF1 wordwrap fixed Arial 10 plain HELP3 DATE PHONE absolute 381 151 extent 105 25 0 Field EFFECTIVE_DATE Arial 10 plain wordwrap fixed center date optional MM/DD/YYYY HELP9 AGENCY EXPIRATION_DATE absolute 488 151 extent 106 25 0 Field EXPIRATION_DATE Arial 10 plain wordwrap fixed center date optional MM/DD/YYYY HELP10 EFFECTIVE_DATE CB1 absolute 704 151 extent 190 25 0 Field PAYMENT_PLAN Arial 10 plain wordwrap fixed HELP13 CB2 AUDIT absolute 896 151 extent 63 25 0 Field AUDIT Arial 10 plain wordwrap fixed HELP14 PAYMENT_PLAN FIELD29 absolute 83 215 extent 294 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP7 FIELD2 AGENCY absolute 34 315 extent 321 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP19 off CHECK4 CHECK2 absolute 34 395 extent 121 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed off CHECK7 FIELD6 absolute 41 195 extent 146 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP5 FIELD19 FIELD2 absolute 251 195 extent 126 21 0 Field AGENCY_CUSTOMER_ID Arial 8 plain wordwrap fixed HELP6 FIELD1 AGENCY_CUSTOMER_ID absolute 804 291 extent 157 25 0 Field PREMISES_OPERATIONS Arial 10 plain wordwrap fixed FIELD13 PRODUCTS dollar comma_delimit add_ds optional absolute 804 331 extent 157 25 0 Field PRODUCTS Arial 10 plain wordwrap fixed PREMISES_OPERATIONS OTHER dollar comma_delimit add_ds optional absolute 179 355 extent 91 21 0 Field EF7 wordwrap fixed Arial 8 plain CHECK2 CHECK6 off string optional absolute 651 255 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain CB3 FIELD8 right string optional absolute 651 275 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD7 FIELD9 right string optional absolute 651 295 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD8 FIELD10 right string optional absolute 651 315 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD9 FIELD11 right string optional absolute 651 335 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD10 FIELD12 right string optional absolute 651 355 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD11 FIELD13 right string optional absolute 651 375 extent 149 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD12 PREMISES_OPERATIONS right string optional absolute 179 375 extent 91 21 0 Field EF7 wordwrap fixed Arial 8 plain CHECK6 CHECK7 off string optional absolute 179 395 extent 91 21 0 Field EF7 wordwrap fixed Arial 8 plain FIELD4 PER_CLAIM off string optional absolute 804 371 extent 157 25 0 Field OTHER Arial 10 plain wordwrap fixed PRODUCTS TOTAL dollar comma_delimit add_ds optional absolute 804 410 extent 157 25 0 Field TOTAL Arial 10 plain wordwrap fixed OTHER OTHER_COVERAGES_RESTRICTIONS_A dollar comma_delimit add_ds optional absolute 3 444 extent 956 101 0 Field OTHER_COVERAGES_RESTRICTIONS_A wordwrap fixed Arial 10 plain HELP23 TOTAL EF13 absolute 3 622 extent 31 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP25 OTHER_COVERAGES_RESTRICTIONS_A FIELD20 absolute 36 622 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF13 EF14 absolute 36 662 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF23 EF24 absolute 36 702 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF33 EF34 absolute 36 742 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF43 EF44 absolute 36 782 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF53 EF54 absolute 36 822 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF63 EF64 absolute 36 862 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF73 EF74 absolute 36 902 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF83 EF84 absolute 36 942 extent 44 25 0 Field EF13 wordwrap fixed Arial 10 plain HELP125 EF93 EF94 absolute 81 622 extent 189 25 0 Field EF14 wordwrap fixed Arial 10 plain HELP34 FIELD20 EF15 absolute 272 622 extent 82 25 0 Field EF15 wordwrap fixed Arial 10 plain HELP43 EF14 EF16 absolute 356 622 extent 81 25 0 Field EF16 wordwrap fixed Arial 10 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plain HELP72 EF37 EF39 absolute 632 702 extent 70 25 0 Field EF39 wordwrap fixed Arial 10 plain HELP83 EF38 EF40 absolute 704 702 extent 70 25 0 Field EF40 wordwrap fixed Arial 10 plain HELP84 EF39 EF41 absolute 776 702 extent 94 25 0 Field EF41 wordwrap fixed Arial 10 plain HELP101 EF40 EF42 absolute 872 702 extent 87 25 0 Field EF42 wordwrap fixed Arial 10 plain HELP102 EF41 EF43 absolute 3 742 extent 31 25 0 Field EF43 wordwrap fixed Arial 10 plain HELP28 EF42 FIELD23 absolute 81 742 extent 189 25 0 Field EF44 wordwrap fixed Arial 10 plain HELP37 FIELD23 EF45 absolute 272 742 extent 82 25 0 Field EF45 wordwrap fixed Arial 10 plain HELP46 EF44 EF46 absolute 356 742 extent 81 25 0 Field EF46 wordwrap fixed Arial 10 plain HELP55 EF45 EF47 absolute 440 742 extent 142 25 0 Field EF47 wordwrap fixed Arial 10 plain HELP64 EF46 EF48 absolute 584 742 extent 46 25 0 Field EF48 wordwrap fixed Arial 10 plain HELP73 EF47 EF49 absolute 632 742 extent 70 25 0 Field EF49 wordwrap fixed Arial 10 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plain HELP110 EF81 EF83 absolute 3 902 extent 31 25 0 Field EF83 wordwrap fixed Arial 10 plain HELP32 EF82 FIELD27 absolute 81 902 extent 189 25 0 Field EF84 wordwrap fixed Arial 10 plain HELP41 FIELD27 EF85 absolute 272 902 extent 82 25 0 Field EF85 wordwrap fixed Arial 10 plain HELP50 EF84 EF86 absolute 356 902 extent 81 25 0 Field EF86 wordwrap fixed Arial 10 plain HELP59 EF85 EF87 absolute 440 902 extent 142 25 0 Field EF87 wordwrap fixed Arial 10 plain HELP68 EF86 EF88 absolute 584 902 extent 46 25 0 Field EF88 wordwrap fixed Arial 10 plain HELP77 EF87 EF89 absolute 632 902 extent 70 25 0 Field EF89 wordwrap fixed Arial 10 plain HELP93 EF88 EF90 absolute 704 902 extent 70 25 0 Field EF90 wordwrap fixed Arial 10 plain HELP94 EF89 EF91 absolute 776 902 extent 94 25 0 Field EF91 wordwrap fixed Arial 10 plain HELP111 EF90 EF92 absolute 872 902 extent 87 25 0 Field EF92 wordwrap fixed Arial 10 plain HELP112 EF91 EF93 absolute 3 942 extent 31 25 0 Field EF93 wordwrap fixed Arial 10 plain HELP33 EF92 FIELD28 absolute 81 942 extent 189 25 0 Field EF94 wordwrap fixed Arial 10 plain HELP42 FIELD28 EF95 absolute 272 942 extent 82 25 0 Field EF95 wordwrap fixed Arial 10 plain HELP51 EF94 EF96 absolute 356 942 extent 81 25 0 Field EF96 wordwrap fixed Arial 10 plain HELP60 EF95 EF97 absolute 440 942 extent 142 25 0 Field EF97 wordwrap fixed Arial 10 plain HELP69 EF96 EF98 absolute 584 942 extent 46 25 0 Field EF98 wordwrap fixed Arial 10 plain HELP78 EF97 EF99 absolute 632 942 extent 70 25 0 Field EF99 wordwrap fixed Arial 10 plain HELP95 EF98 EF100 absolute 704 942 extent 70 25 0 Field EF100 wordwrap fixed Arial 10 plain HELP96 EF99 EF101 absolute 776 942 extent 94 25 0 Field EF101 wordwrap fixed Arial 10 plain HELP113 EF100 EF102 absolute 872 942 extent 87 25 0 Field EF102 wordwrap fixed Arial 10 plain HELP114 EF101 FIELD18 absolute 660 1035 extent 299 21 0 Field EF107 wordwrap fixed Arial 8 plain dollar comma_delimit optional REMARKS FIELD14 absolute 633 1055 extent 326 21 0 Field EF107 wordwrap fixed Arial 8 plain EF107 FIELD15 absolute 604 1095 extent 355 21 0 Field EF107 wordwrap fixed Arial 8 plain center date optional MM/DD/YYYY FIELD15 REMARKS2 absolute 348 1055 extent 113 21 0 Field EF107 wordwrap fixed Arial 8 plain center date optional MM/DD/YYYY HELP116 FIELD18 CHECK8 absolute 214 1035 extent 247 21 0 Field EF107 wordwrap fixed Arial 8 plain center date optional MM/DD/YYYY HELP115 EF102 FIELD17 absolute 883 1075 extent 76 21 0 Field EF107 wordwrap fixed Arial 8 plain FIELD14 FIELD16 absolute 3 1173 extent 458 57 0 Field REMARKS wordwrap fixed Arial 10 plain CHECK11 EF107 absolute 465 1173 extent 494 57 0 Field REMARKS2 wordwrap fixed Arial 10 plain FIELD16 next_button absolute 5 1232 extent 160 22 ACORD 126 (2007/01) Helvetica 8 bold absolute 572 1232 extent 384 22 © ACORD CORPORATION 1993-2007. All rights reserved. Helvetica 8 bold right absolute 389 1232 extent 181 22 Page 1 of 2 Helvetica 8 bold center absolute 238 1251 extent 482 22 The ACORD name and logo are registered marks of ACORD Helvetica 8 bold center absolute 837 35 extent 117 18 DATE (MM/DD/YYYY) Helvetica 6 bold absolute 166 32 extent 627 40 COMMERCIAL GENERAL LIABILITY SECTION Helvetica 17 bold HELP1 absolute 82 72 extent 83 26 PHONE (A/C, No, Ext): -4 Helvetica 6 bold absolute 4 75 extent 59 18 AGENCY Helvetica 6 bold absolute 382 75 extent 62 60 APPLICANT (First Named Insured) -1 Helvetica 6 bold absolute 388 135 extent 100 18 EFFECTIVE DATE Helvetica 6 bold absolute 493 135 extent 106 18 EXPIRATION DATE Helvetica 6 bold absolute 757 135 extent 95 18 PAYMENT PLAN Helvetica 6 bold absolute 910 135 extent 45 18 AUDIT Helvetica 6 bold absolute 622 139 extent 79 19 DIRECT BILL Helvetica 6 plain absolute 622 159 extent 84 19 AGENCY BILL Helvetica 6 plain absolute 382 175 extent 68 36 FOR COMPANY USE ONLY -3 Helvetica 6 bold absolute 4 199 extent 48 18 CODE: Helvetica 6 bold absolute 190 199 extent 72 18 SUB CODE: Helvetica 6 bold absolute 4 212 extent 89 26 AGENCY CUSTOMER ID: -4 Helvetica 6 bold absolute 4 236 extent 97 22 COVERAGES Helvetica 8 bold absolute 358 236 extent 60 22 LIMITS Helvetica 8 bold HELP121 absolute 34 259 extent 188 18 COMMERCIAL GENERAL LIABILITY Helvetica 6 bold HELP15 absolute 358 259 extent 132 18 GENERAL AGGREGATE Helvetica 6 bold absolute 640 259 extent 22 18 $ Helvetica 6 bold absolute 847 259 extent 72 18 PREMIUMS Helvetica 6 bold HELP24 absolute 806 275 extent 139 18 PREMISES/OPERATIONS Helvetica 6 bold absolute 358 279 extent 283 18 PRODUCTS & COMPLETED OPERATIONS AGGREGATE Helvetica 6 bold absolute 640 279 extent 22 18 $ Helvetica 6 bold absolute 58 279 extent 88 19 CLAIMS MADE Helvetica 6 plain HELP16 absolute 202 279 extent 87 19 OCCURRENCE Helvetica 6 plain HELP17 absolute 34 299 extent 219 18 OWNER'S & CONTRACTOR'S PROTECTIVE Helvetica 6 bold HELP18 absolute 358 299 extent 193 18 PERSONAL & ADVERTISING INJURY Helvetica 6 bold absolute 640 299 extent 22 18 $ Helvetica 6 bold absolute 806 314 extent 71 18 PRODUCTS Helvetica 6 bold absolute 358 319 extent 118 18 EACH OCCURRENCE Helvetica 6 bold absolute 640 319 extent 22 18 $ Helvetica 6 bold absolute 4 339 extent 86 18 DEDUCTIBLES Helvetica 6 bold HELP20 absolute 358 339 extent 269 18 DAMAGE TO RENTED PREMISES (each occurrence) Helvetica 6 bold absolute 640 339 extent 22 18 $ Helvetica 6 bold absolute 806 354 extent 50 18 OTHER Helvetica 6 bold absolute 358 359 extent 199 18 MEDICAL EXPENSE (Any one person) Helvetica 6 bold absolute 640 359 extent 22 18 $ Helvetica 6 bold absolute 34 359 extent 121 19 PROPERTY DAMAGE Helvetica 6 plain absolute 169 359 extent 22 19 $ Helvetica 6 plain absolute 311 374 extent 28 24 center PER CLAIM -2 Helvetica 4 plain absolute 358 379 extent 126 18 EMPLOYEE BENEFITS Helvetica 6 bold absolute 640 379 extent 22 18 $ Helvetica 6 bold absolute 34 379 extent 93 19 BODILY INJURY Helvetica 6 plain absolute 169 379 extent 22 19 $ Helvetica 6 plain absolute 296 394 extent 56 24 center PER OCCURRENCE -2 Helvetica 4 plain absolute 806 394 extent 47 18 TOTAL Helvetica 6 bold absolute 169 399 extent 22 19 $ Helvetica 6 plain absolute -1 414 extent 812 19 OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) Helvetica 6 plain absolute 4 556 extent 172 22 SCHEDULE OF HAZARDS Helvetica 8 bold absolute 686 579 extent 42 18 RATE Helvetica 6 bold absolute 841 579 extent 65 18 PREMIUM Helvetica 6 bold absolute 367 581 extent 61 32 center PREMIUM BASIS -3 Helvetica 6 bold absolute 4 584 extent 30 18 LOC Helvetica 6 bold center absolute 293 584 extent 40 29 center CLASS CODE -3 Helvetica 6 bold absolute 91 585 extent 170 18 CLASSIFICATION Helvetica 6 bold center absolute 590 585 extent 42 18 TERR Helvetica 6 bold absolute 480 585 extent 73 18 EXPOSURE Helvetica 6 bold absolute 5 594 extent 29 18 # Helvetica 6 bold center absolute 638 599 extent 71 18 PREM/OPS Helvetica 6 bold absolute 708 599 extent 71 18 PRODUCTS Helvetica 6 bold absolute 794 599 extent 71 18 PREM/OPS Helvetica 6 bold absolute 885 599 extent 71 18 PRODUCTS Helvetica 6 bold absolute 4 979 extent 163 18 RATING AND PREMIUM BASIS Helvetica 6 bold absolute 244 982 extent 170 19 (P) PAYROLL - 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PROPOSED RETROACTIVE DATE: Helvetica 7 plain absolute 466 1037 extent 175 21 1. DEDUCTIBLE PER CLAIM: Helvetica 7 plain absolute 646 1037 extent 23 21 $ Helvetica 7 plain absolute 4 1057 extent 354 21 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV: Helvetica 7 plain absolute 466 1057 extent 178 21 2. NUMBER OF EMPLOYEES: Helvetica 7 plain absolute 4 1074 extent 26 21 3. Helvetica 7 plain HELP118 absolute 17 1074 extent 326 45 HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? -3 Helvetica 7 plain HELP117 absolute 414 1079 extent 37 18 YES Helvetica 6 bold absolute 440 1079 extent 31 18 NO Helvetica 6 bold absolute 466 1077 extent 428 21 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: Helvetica 7 plain absolute 466 1097 extent 149 21 4. RETROACTIVE DATE: Helvetica 7 plain absolute 4 1119 extent 26 21 4. 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1128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK9 CHECK11 absolute 443 1128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK10 REMARKS Commercial General Liability is a form of insurance designed to protect owners and operators of businesses from a wide variety of liability exposures. These exposures include liability for accidents resulting from the insured's operations or premises, products sold or operations completed by the insured, and contractual liability. The Coverage and Limits Section of the ACORD 126 was designed to follow the ISO Policy Simplification Program first initiated in 1986. The ACORD 126 was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125). Much of the information for the Identification Section should match that found within the Applicant Information Section of ACORD 125. Even so, it is still important to complete this section. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. Month/day/year (MM/DD/YYYY) on which the form is completed. Agency's name and address. Producer's telephone number. Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. If the agency uses a subcode identification system with the company, enter the appropriate code. Customer's identification number assigned by the agency. First Named Insured as it appears on the ACORD 125. Month/day/year on which the terms and conditions of the policy will commence. Month/day/year on which the terms and conditions of the policy will terminate unless renewed. Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Plan used to pay the company for the policy. Use the company's specific designation for the plan where possible, (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). The term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other Indicate if commercial general liability coverage is required. Check to request that the Commercial General Liability policy be issued on a claims made basis. For Claims Made policies, be sure to complete the Claims Made section of the application. Check to request the Commercial General Liability policy be issued on an occurrence basis. Check only when separate Owner's & Contractors Protective Liability coverage is being requested. * Use the blank area to request other coverage forms such as Railroad Protective Liability, Liquor Liability, Pollution Liability, or a separate Products/Completed Operations Liability Only policy. Check only when separate Owner's & Contractors Protective Liability coverage is being requested. * Use the blank area to request other coverage forms such as Railroad Protective Liability, Liquor Liability, Pollution Liability, or a separate Products/Completed Operations Liability Only policy. If a deductible is requested, indicate the amount and type of deductible, and whether it is to apply per claim or per occurrence. Use the blank line to indicate options other than Property Damage or Bodily Injury Deductible. A per claim deductible applies to individual claims even if the claims are all related to the same occurrence or event. A per occurrence deductible applies once to each occurrence no matter how many individual claims result from the occurrence or event. Use this area to request any other coverages, endorsements, or special conditions. Examples: *Include the Vendors Endorsement *Exclude Damage To Rented Premises coverage *Exclude Medical Expense coverage *Exclude Personal and Advertising Injury coverage Not all companies require that the producer rate the policy prior to submission of the application. If you have done so, enter the coverage premiums here. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Provide the general liability class code that corresponds to the class description shown in the previous field. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (e.g., "S456,500" means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is $456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated sales. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. Enter Exposure information as required. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. For each described exposure, enter the rating territory code based on location from the appropriate state exception page. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products manual rates applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products premiums applicable to each classification. The Retroactive Date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could "trigger" coverage under a Claims Made policy. The retroactive date shown on the applicant's first Claims Made policy. If this is the first such policy, the date will be the same as the proposed retroactive date shown on the preceding field. If this is a renewal, it is the effective date of the first policy issued in the sequence of uninterrupted Claims Made policies. For yes responses, describe the situations of the above occurrences in the Comment section. For yes responses, describe the situations of the above occurrences in the Comment section. For yes responses, describe terms and limits of tail coverage purchased under any previous policy. Tail coverage extends the reporting period on a Claims Made policy to cover claims arising from occurrences that were not known by the date the policy was cancelled, non-renewed or replaced. For yes responses, describe terms and limits of tail coverage purchased under any previous policy. Tail coverage extends the reporting period on a Claims Made policy to cover claims arising from occurrences that were not known by the date the policy was cancelled, non-renewed or replaced. Enter the policy limits as they are to appear on the policy declarations page. Available limits following the ISO Policy Simplification Program are: (All limits are in whole dollars.) *General Aggregate *Each Occurrence *Products & Completed Operations Aggregate *Damage to Rented Premises (each occurrence) *Personal & Advertising Injury *Medical Expense (Any One Person) *Employee Benefits If a Claims Made coverage is requested, this section needs to be completed. Use this section to explain the status of previous Claims Made coverage. Because a Claims Made policy uses a different coverage ""triggering"" mechanism, this additional information is needed to properly process the application. * It is very important that the information in this section be accurate to ensure uninterrupted general liability coverage for the applicant. Use the Comments area to provide additional information. 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Arial 8 plain wordwrap fixed HELP16 FIELD1 PART_TIME_STAFF absolute 892 195 extent 67 21 0 Field PART_TIME_STAFF Arial 8 plain wordwrap fixed HELP17 FULL_TIME_STAFF EF121 absolute 621 195 extent 58 21 0 Field PART_TIME_STAFF Arial 8 plain wordwrap fixed HELP15 PAID_TO_SUB_CONTRACTORS FULL_TIME_STAFF absolute 3 221 extent 956 67 0 Field EF120 wordwrap fixed Arial 10 plain HELP13 CHECK12 PAID_TO_SUB_CONTRACTORS absolute 3 342 extent 171 25 0 Field EF121 wordwrap fixed Arial 10 plain HELP18 PART_TIME_STAFF EF122 absolute 176 342 extent 130 25 0 Field EF122 wordwrap fixed Arial 10 plain HELP21 EF121 EF123 dollar comma_delimit add_ds optional absolute 308 342 extent 129 25 0 Field EF123 wordwrap fixed Arial 10 plain HELP24 EF122 EF124 absolute 440 342 extent 58 25 0 Field EF124 wordwrap fixed Arial 10 plain HELP27 EF123 EF125 absolute 500 342 extent 58 25 0 Field EF125 wordwrap fixed Arial 10 plain HELP30 EF124 EF126 absolute 560 342 extent 202 25 0 Field EF126 wordwrap fixed Arial 10 plain HELP33 EF125 EF127 absolute 764 342 extent 195 25 0 Field EF127 wordwrap fixed Arial 10 plain HELP36 EF126 EF128 absolute 3 382 extent 171 25 0 Field EF128 wordwrap fixed Arial 10 plain HELP19 EF127 EF129 absolute 176 382 extent 130 25 0 Field EF129 wordwrap fixed Arial 10 plain HELP22 EF128 EF130 dollar comma_delimit add_ds optional absolute 308 382 extent 129 25 0 Field EF130 wordwrap fixed Arial 10 plain HELP25 EF129 EF131 absolute 440 382 extent 58 25 0 Field EF131 wordwrap fixed Arial 10 plain HELP28 EF130 EF132 absolute 500 382 extent 58 25 0 Field EF132 wordwrap fixed Arial 10 plain HELP31 EF131 EF133 absolute 560 382 extent 202 25 0 Field EF133 wordwrap fixed Arial 10 plain HELP34 EF132 EF134 absolute 764 382 extent 195 25 0 Field EF134 wordwrap fixed Arial 10 plain HELP37 EF133 EF135 absolute 3 422 extent 171 25 0 Field EF135 wordwrap fixed Arial 10 plain HELP20 EF134 EF136 absolute 176 422 extent 130 25 0 Field EF136 wordwrap fixed Arial 10 plain HELP23 EF135 EF137 dollar comma_delimit add_ds optional absolute 308 422 extent 129 25 0 Field EF137 wordwrap fixed Arial 10 plain HELP26 EF136 EF138 absolute 440 422 extent 58 25 0 Field EF138 wordwrap fixed Arial 10 plain HELP29 EF137 EF139 absolute 500 422 extent 58 25 0 Field EF139 wordwrap fixed Arial 10 plain HELP32 EF138 EF140 absolute 560 422 extent 202 25 0 Field EF140 wordwrap fixed Arial 10 plain HELP35 EF139 EF141 absolute 764 422 extent 195 25 0 Field EF141 wordwrap fixed Arial 10 plain HELP38 EF140 CHECK13 absolute 3 610 extent 956 44 0 Field PLEASE_ATTACH_LITERATURE_BROCH wordwrap fixed Arial 10 plain CHECK32 CHECK33 absolute 176 701 extent 545 83 0 Field EF165 wordwrap fixed Arial 10 plain HELP53 NAME_AND_ADDRESS FIELD2 absolute 136 675 extent 39 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain HELP52 FIELD8 EF165 absolute 384 675 extent 176 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain HELP54 EF165 CHECK34 absolute 783 695 extent 58 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain CHECK34 FIELD5 absolute 776 715 extent 65 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain FIELD5 FIELD6 absolute 281 795 extent 678 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain HELP57 OTHER2 CHECK41 absolute 34 795 extent 141 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain off CHECK40 NAME_AND_ADDRESS absolute 900 695 extent 59 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain FIELD3 FIELD4 absolute 879 715 extent 80 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain FIELD4 FIELD9 absolute 869 735 extent 90 21 0 Field NAME_AND_ADDRESS wordwrap fixed Arial 8 plain FIELD6 OTHER2 absolute 722 771 extent 237 25 0 Field OTHER2 Arial 10 plain wordwrap fixed FIELD9 FIELD7 absolute 3 1171 extent 956 25 0 Field REMARKS3 Arial 10 plain wordwrap fixed HELP86 CHECK80 Save_BUTTON absolute 4 36 extent 115 22 CONTRACTORS Helvetica 8 bold HELP87 absolute 4 59 extent 340 18 EXPLAIN ALL "YES" RESPONSES (For past or present operations) Helvetica 6 bold absolute 438 59 extent 37 18 YES Helvetica 6 bold absolute 465 59 extent 31 18 NO Helvetica 6 bold absolute 490 59 extent 340 18 EXPLAIN ALL "YES" RESPONSES (For past or present operations) Helvetica 6 bold absolute 906 59 extent 37 18 YES Helvetica 6 bold absolute 935 59 extent 31 18 NO Helvetica 6 bold absolute 4 80 extent 26 21 1. Helvetica 7 plain HELP2 absolute 17 80 extent 384 33 DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? -3 Helvetica 7 plain HELP1 absolute 490 80 extent 26 21 4. Helvetica 7 plain HELP8 absolute 503 80 extent 373 33 DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? -3 Helvetica 7 plain HELP7 absolute 4 120 extent 26 21 2. Helvetica 7 plain HELP3 absolute 17 120 extent 391 33 DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? -3 Helvetica 7 plain HELP4 absolute 490 120 extent 26 21 5. Helvetica 7 plain HELP9 absolute 503 120 extent 338 33 ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? -3 Helvetica 7 plain HELP10 absolute 4 160 extent 26 21 3. Helvetica 7 plain HELP5 absolute 17 160 extent 352 33 DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? -3 Helvetica 7 plain HELP6 absolute 490 160 extent 26 21 6. Helvetica 7 plain HELP11 absolute 503 160 extent 358 33 DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? -3 Helvetica 7 plain HELP12 absolute 322 192 extent 94 28 $ PAID TO SUB- CONTRACTORS: -4 Helvetica 6 bold absolute 526 192 extent 107 28 % OF WORK SUBCONTRACTED: -4 Helvetica 6 bold absolute 682 192 extent 77 28 # FULL- TIME STAFF: -4 Helvetica 6 bold absolute 826 192 extent 77 28 # PART- TIME STAFF: -4 Helvetica 6 bold absolute 4 195 extent 315 18 REMARKS/DESCRIBE THE TYPE OF WORK SUBCONTRACTED Helvetica 6 bold absolute 4 296 extent 261 22 PRODUCTS/COMPLETED OPERATIONS Helvetica 8 bold HELP88 absolute 448 312 extent 53 18 TIME IN Helvetica 6 bold absolute 499 312 extent 70 18 EXPECTED Helvetica 6 bold absolute 57 319 extent 71 18 PRODUCTS Helvetica 6 bold absolute 180 319 extent 134 18 ANNUAL GROSS SALES Helvetica 6 bold absolute 343 319 extent 71 18 # OF UNITS Helvetica 6 bold absolute 622 319 extent 90 18 INTENDED USE Helvetica 6 bold absolute 796 319 extent 145 18 PRINCIPAL COMPONENTS Helvetica 6 bold absolute 445 321 extent 58 18 MARKET Helvetica 6 bold absolute 515 321 extent 38 18 LIFE Helvetica 6 bold absolute 4 459 extent 407 18 EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) Helvetica 6 bold absolute 438 459 extent 37 18 YES Helvetica 6 bold absolute 465 459 extent 31 18 NO Helvetica 6 bold absolute 490 459 extent 407 18 EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation) Helvetica 6 bold absolute 906 459 extent 37 18 YES Helvetica 6 bold absolute 936 459 extent 31 18 NO Helvetica 6 bold absolute 4 477 extent 432 21 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? Helvetica 7 plain HELP39 absolute 496 477 extent 335 21 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? Helvetica 7 plain HELP45 absolute 4 494 extent 429 21 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? Helvetica 7 plain HELP40 absolute 19 507 extent 385 21 (If "YES", attach ACORD 815) Helvetica 7 plain HELP40 absolute 496 500 extent 26 21 7. Helvetica 7 plain HELP46 absolute 510 500 extent 349 33 PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL? -3 Helvetica 7 plain HELP47 absolute 4 526 extent 26 21 3. Helvetica 7 plain HELP42 absolute 17 525 extent 336 34 RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? -2 Helvetica 7 plain HELP41 absolute 496 537 extent 263 21 8. PRODUCTS UNDER LABEL OF OTHERS? Helvetica 7 plain HELP48 absolute 4 557 extent 394 21 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? Helvetica 7 plain HELP43 absolute 496 557 extent 231 21 9. VENDORS COVERAGE REQUIRED? Helvetica 7 plain HELP49 absolute 4 577 extent 349 21 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? Helvetica 7 plain HELP44 absolute 490 577 extent 414 21 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? Helvetica 7 plain HELP50 absolute 4 594 extent 364 18 PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC Helvetica 6 bold absolute 4 656 extent 330 22 ADDITIONAL INTEREST/CERTIFICATE RECIPIENT Helvetica 8 bold HELP89 absolute 406 656 extent 274 22 ACORD 45 attached for additional names Helvetica 8 bold absolute 4 679 extent 64 18 INTEREST Helvetica 6 bold HELP51 absolute 100 679 extent 47 18 RANK: Helvetica 6 bold absolute 178 679 extent 122 18 NAME AND ADDRESS Helvetica 6 bold absolute 304 679 extent 90 18 REFERENCE #: Helvetica 6 bold absolute 586 679 extent 136 18 CERTIFICATE REQUIRED Helvetica 6 bold absolute 772 679 extent 151 18 INTEREST IN ITEM NUMBER Helvetica 6 bold HELP56 absolute 34 699 extent 124 18 ADDITIONAL INSURED Helvetica 6 bold absolute 724 699 extent 70 18 LOCATION: Helvetica 6 bold absolute 844 699 extent 67 18 BUILDING: Helvetica 6 bold absolute 34 719 extent 82 18 LOSS PAYEE Helvetica 6 bold absolute 724 719 extent 63 18 VEHICLE: Helvetica 6 bold absolute 844 719 extent 46 18 BOAT: Helvetica 6 bold absolute 34 739 extent 82 18 MORTGAGEE Helvetica 6 bold absolute 724 739 extent 155 18 SCHEDULED ITEM NUMBER: Helvetica 6 bold absolute 724 754 extent 50 18 OTHER Helvetica 6 bold absolute 34 759 extent 81 18 LIENHOLDER Helvetica 6 bold absolute 34 779 extent 136 18 EMPLOYEE AS LESSOR Helvetica 6 bold absolute 178 799 extent 114 18 ITEM DESCRIPTION: Helvetica 6 bold absolute 4 816 extent 172 22 GENERAL INFORMATION Helvetica 8 bold HELP90 absolute 4 839 extent 355 18 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Helvetica 6 bold absolute 438 839 extent 37 18 YES Helvetica 6 bold absolute 465 839 extent 31 18 NO Helvetica 6 bold absolute 490 839 extent 355 18 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Helvetica 6 bold absolute 906 839 extent 37 18 YES Helvetica 6 bold absolute 935 839 extent 31 18 NO Helvetica 6 bold absolute 490 857 extent 334 21 12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? Helvetica 7 plain HELP72 absolute 10 860 extent 26 21 1. Helvetica 7 plain HELP59 absolute 24 860 extent 403 33 ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? -3 Helvetica 7 plain HELP58 absolute 490 877 extent 311 21 13. ANY DEMOLITION EXPOSURE CONTEMPLATED? Helvetica 7 plain HELP73 absolute 10 897 extent 357 21 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? Helvetica 7 plain HELP60 absolute 490 900 extent 33 21 14. Helvetica 7 plain HELP75 absolute 510 900 extent 374 33 HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? -3 Helvetica 7 plain HELP74 absolute 10 915 extent 26 21 3. Helvetica 7 plain HELP61 absolute 24 915 extent 366 63 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) -1 Helvetica 7 plain HELP62 absolute 490 937 extent 403 21 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? Helvetica 7 plain HELP76 absolute 490 960 extent 33 21 16. Helvetica 7 plain HELP78 absolute 510 960 extent 382 33 IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? -3 Helvetica 7 plain HELP77 absolute 10 980 extent 26 21 4. Helvetica 7 plain HELP63 absolute 24 980 extent 358 33 ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST 5 YEARS? -3 Helvetica 7 plain HELP64 absolute 490 997 extent 369 21 17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? Helvetica 7 plain HELP79 absolute 10 1017 extent 398 21 5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS? Helvetica 7 plain HELP65 absolute 490 1020 extent 33 21 18. Helvetica 7 plain HELP80 absolute 510 1020 extent 347 33 HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE YEARS? -3 Helvetica 7 plain HELP81 absolute 10 1037 extent 407 21 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? Helvetica 7 plain HELP66 absolute 10 1057 extent 282 21 7. ANY PARKING FACILITIES OWNED/RENTED? Helvetica 7 plain HELP67 absolute 490 1060 extent 33 21 19. Helvetica 7 plain HELP82 absolute 510 1060 extent 330 33 IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? -3 Helvetica 7 plain HELP83 absolute 10 1077 extent 230 21 8. IS A FEE CHARGED FOR PARKING? Helvetica 7 plain HELP68 absolute 10 1097 extent 244 21 9. RECREATION FACILITIES PROVIDED? Helvetica 7 plain HELP69 absolute 490 1104 extent 33 21 20. Helvetica 7 plain HELP84 absolute 510 1104 extent 360 47 DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? -2 Helvetica 7 plain HELP85 absolute 4 1117 extent 320 21 10. IS THERE A SWIMMING POOL ON THE PREMISES? Helvetica 7 plain HELP70 absolute 4 1137 extent 302 21 11. SPORTING OR SOCIAL EVENTS SPONSORED? Helvetica 7 plain HELP71 absolute 4 1154 extent 67 18 REMARKS Helvetica 6 bold absolute 4 1194 extent 963 63 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, VA and WA, insurance benefits may also be denied). -1 Helvetica 7 plain absolute 311 1254 extent 324 22 ATTACH TO ACORD 125 Helvetica 8 bold center absolute 4 1254 extent 145 22 ACORD 126 (2007/01) Helvetica 8 bold absolute 444 88 extent 16 16 Check box OCCURRENCE off Arial 10 plain prev_button CHECK11 absolute 468 88 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK10 CHECK1 absolute 444 128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK11 CHECK2 absolute 468 128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK1 CHECK3 absolute 444 168 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK2 CHECK4 absolute 468 168 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK3 CHECK5 absolute 912 88 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK4 CHECK6 absolute 938 88 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK5 CHECK7 absolute 912 128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK6 CHECK8 absolute 938 128 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK7 CHECK9 absolute 912 168 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK8 CHECK12 absolute 938 168 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK9 EF120 absolute 444 478 extent 16 16 Check box OCCURRENCE off Arial 10 plain EF141 CHECK14 absolute 468 478 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK13 CHECK15 absolute 444 504 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK14 CHECK16 absolute 468 504 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK15 CHECK17 absolute 444 533 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK16 CHECK18 absolute 468 533 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK17 CHECK19 absolute 444 558 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK18 CHECK20 absolute 468 558 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK19 CHECK21 absolute 444 578 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK20 CHECK22 absolute 383 654 extent 21 21 Check box OCCURRENCE off Arial 18 plain PLEASE_ATTACH_LITERATURE_BROCH CHECK35 absolute 1 695 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK33 CHECK36 absolute 1 715 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK35 CHECK37 absolute 1 735 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK36 CHECK38 absolute 1 755 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK37 CHECK39 absolute 1 775 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK38 CHECK40 absolute 1 795 extent 21 21 Check box OCCURRENCE off Arial 18 plain CHECK39 FIELD8 absolute 563 675 extent 21 21 Check box OCCURRENCE off Arial 18 plain HELP55 FIELD2 FIELD3 absolute 468 578 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK21 CHECK23 absolute 912 478 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK22 CHECK24 absolute 939 478 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK23 CHECK25 absolute 912 508 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK24 CHECK26 absolute 939 508 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK25 CHECK27 absolute 912 538 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK26 CHECK28 absolute 939 538 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK27 CHECK29 absolute 912 558 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK28 CHECK30 absolute 939 558 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK29 CHECK31 absolute 912 578 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK30 CHECK32 absolute 939 578 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK31 PLEASE_ATTACH_LITERATURE_BROCH absolute 444 868 extent 16 16 Check box OCCURRENCE off Arial 10 plain FIELD7 CHECK42 absolute 468 868 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK41 CHECK43 absolute 444 898 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK42 CHECK44 absolute 468 898 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK43 CHECK45 absolute 444 938 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK44 CHECK46 absolute 468 938 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK45 CHECK47 absolute 444 988 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK46 CHECK48 absolute 468 988 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK47 CHECK49 absolute 444 1018 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK48 CHECK50 absolute 468 1018 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK49 CHECK51 absolute 444 1038 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK50 CHECK52 absolute 468 1038 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK51 CHECK53 absolute 444 1058 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK52 CHECK54 absolute 468 1058 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK53 CHECK55 absolute 444 1078 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK54 CHECK56 absolute 468 1078 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK55 CHECK57 absolute 444 1098 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK56 CHECK58 absolute 468 1098 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK57 CHECK59 absolute 444 1118 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK58 CHECK60 absolute 468 1118 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK59 CHECK61 absolute 444 1138 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK60 CHECK62 absolute 468 1138 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK61 CHECK63 absolute 912 858 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK62 CHECK64 absolute 939 858 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK63 CHECK65 absolute 912 878 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK64 CHECK66 absolute 939 878 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK65 CHECK67 absolute 912 908 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK66 CHECK68 absolute 939 908 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK67 CHECK69 absolute 912 938 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK68 CHECK70 absolute 939 938 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK69 CHECK71 absolute 912 968 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK70 CHECK72 absolute 939 968 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK71 CHECK73 absolute 912 998 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK72 CHECK74 absolute 939 998 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK73 CHECK75 absolute 912 1028 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK74 CHECK76 absolute 939 1028 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK75 CHECK77 absolute 912 1068 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK76 CHECK78 absolute 939 1068 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK77 CHECK79 absolute 912 1118 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK78 CHECK80 absolute 939 1118 extent 16 16 Check box OCCURRENCE off Arial 10 plain CHECK79 REMARKS3 absolute 0 0 extent 960 1260 If the applicant draws plans, designs or specifications, explain. Indicate whether qualified professionals are employed by the applicant for preparation. If the applicant draws plans, designs or specifications, explain. Indicate whether qualified professionals are employed by the applicant for preparation. Describe any operation that includes any of these activities. Describe any operation that includes any of these activities. Describe any operation that requires any of these activities and the safety measures taken. Describe any operation that requires any of these activities and the safety measures taken. State the limits of coverages carried by subcontractors if less than the applicant's. Identify the subcontractors and the amount of coverage. State the limits of coverages carried by subcontractors if less than the applicant's. Identify the subcontractors and the amount of coverage. Explain why certificates are not requested from subcontractors. Explain why certificates are not requested from subcontractors. If applicant leases equipment describe the type of equipment, number of operators, frequency, and lease arrangement. If applicant leases equipment describe the type of equipment, number of operators, frequency, and lease arrangement. Describe in detail the type of work the applicant subcontracts. Also include leased equipment activities. (e.g., An excavation contractor may subcontract the blasting required. This may account for 10% of the contracts it undertakes.) List any other remarks that may be pertinent to the contractors work. Show the total annual dollars paid. List the total percentage of work that the contractor subcontracts. Indicate the total number of full time staff. Indicate the total number of part time staff. Use this field to describe the products for which product liability coverage is being requested. The description should be detailed enough so that the underwriter can fully understand the nature of each product. If there are too many products to describe individually, those which share certain characteristics should be grouped under a single generic description and the characteristics of each group should be described. Attach any literature or brochures available. (E.g., All of the furniture manufacturer's office desks can be described as "office desks", because each one is very similar to the other, even though there are several sizes and shapes and they are designed for home or office use. On the other hand, dining tables and medical office patient examination tables should not be grouped as "tables" because they are dissimilar in design and function.) Use this field to describe the products for which product liability coverage is being requested. The description should be detailed enough so that the underwriter can fully understand the nature of each product. If there are too many products to describe individually, those which share certain characteristics should be grouped under a single generic description and the characteristics of each group should be described. Attach any literature or brochures available. (E.g., All of the furniture manufacturer's office desks can be described as "office desks", because each one is very similar to the other, even though there are several sizes and shapes and they are designed for home or office use. On the other hand, dining tables and medical office patient examination tables should not be grouped as "tables" because they are dissimilar in design and function.) Use this field to describe the products for which product liability coverage is being requested. The description should be detailed enough so that the underwriter can fully understand the nature of each product. If there are too many products to describe individually, those which share certain characteristics should be grouped under a single generic description and the characteristics of each group should be described. Attach any literature or brochures available. (E.g., All of the furniture manufacturer's office desks can be described as "office desks", because each one is very similar to the other, even though there are several sizes and shapes and they are designed for home or office use. On the other hand, dining tables and medical office patient examination tables should not be grouped as "tables" because they are dissimilar in design and function.) Estimated dollar amount the applicant expects to sell in the coming year for each product or product group described. Remember the application is for the next policy year, not the current or past policy year. An amount should be shown for each product or product group described. This breakdown of sales is primarily needed to figure the premium, especially when there are two or more products and each one is subject to a different rating classification. Estimated dollar amount the applicant expects to sell in the coming year for each product or product group described. Remember the application is for the next policy year, not the current or past policy year. An amount should be shown for each product or product group described. This breakdown of sales is primarily needed to figure the premium, especially when there are two or more products and each one is subject to a different rating classification. Estimated dollar amount the applicant expects to sell in the coming year for each product or product group described. Remember the application is for the next policy year, not the current or past policy year. An amount should be shown for each product or product group described. This breakdown of sales is primarily needed to figure the premium, especially when there are two or more products and each one is subject to a different rating classification. Number of units the applicant expects to sell and/or manufacture in the coming year. An amount should be shown for each product or product group described. The breakdown of units is primarily needed to estimate the product's claims frequency potential. Number of units the applicant expects to sell and/or manufacture in the coming year. An amount should be shown for each product or product group described. The breakdown of units is primarily needed to estimate the product's claims frequency potential. Number of units the applicant expects to sell and/or manufacture in the coming year. An amount should be shown for each product or product group described. The breakdown of units is primarily needed to estimate the product's claims frequency potential. Number of years or months that each described product or product group has been sold by the applicant. Number of years or months that each described product or product group has been sold by the applicant. Number of years or months that each described product or product group has been sold by the applicant. Average length of time, (days, weeks, months, or years) that the applicant expects each described product or group of products to last until it is worn out, used up, or consumed. This may be the shelf life for products consumed or useful life for other products. Average length of time, (days, weeks, months, or years) that the applicant expects each described product or group of products to last until it is worn out, used up, or consumed. This may be the shelf life for products consumed or useful life for other products. Average length of time, (days, weeks, months, or years) that the applicant expects each described product or group of products to last until it is worn out, used up, or consumed. This may be the shelf life for products consumed or useful life for other products. Describe the use or uses of each product or product group contemplated by the applicant. The following information should be provided: *What the product is designed to be or do *How the product is designed to work or function *How, when and where the product is designed to be used or consumed Example: If the product is food, its use is apparent. If it is a chemical or a machine part, there may be a variety of uses. In these instances, the specific use becomes an important consideration for both coverage and pricing. This information is necessary for the underwriter to identify and evaluate the hazards associated with the use or potential misuse of a product. Describe the use or uses of each product or product group contemplated by the applicant. The following information should be provided: *What the product is designed to be or do *How the product is designed to work or function *How, when and where the product is designed to be used or consumed Example: If the product is food, its use is apparent. If it is a chemical or a machine part, there may be a variety of uses. In these instances, the specific use becomes an important consideration for both coverage and pricing. This information is necessary for the underwriter to identify and evaluate the hazards associated with the use or potential misuse of a product. Describe the use or uses of each product or product group contemplated by the applicant. The following information should be provided: *What the product is designed to be or do *How the product is designed to work or function *How, when and where the product is designed to be used or consumed Example: If the product is food, its use is apparent. If it is a chemical or a machine part, there may be a variety of uses. In these instances, the specific use becomes an important consideration for both coverage and pricing. This information is necessary for the underwriter to identify and evaluate the hazards associated with the use or potential misuse of a product. Major components of the product. If additional space is needed to complete the information required for a particular product, attach a separate sheet. Use the Remarks section or a separate sheet of paper to explain any "Yes" responses to the following questions, for any past or present operation or product. Major components of the product. If additional space is needed to complete the information required for a particular product, attach a separate sheet. Use the Remarks section or a separate sheet of paper to explain any "Yes" responses to the following questions, for any past or present operation or product. Major components of the product. If additional space is needed to complete the information required for a particular product, attach a separate sheet. Use the Remarks section or a separate sheet of paper to explain any "Yes" responses to the following questions, for any past or present operation or product. The explanation of a "Yes" response to this question should include: *What, how and where it is done *Who does it, employees or independent contractors *Whether a maintenance or repair service is sold When the work is done by independent contractors, the explanation should also include information on the cost of the work done for the applicant by the independent contractors. If "YES", attach ACORD 815, International Liability Exposure Supplement. Describe the nature and extent of R&D work. Example: Indicate if it is solely directed at the development of new products or if some effort is directed to improving or changing existing products. Describe any new products to be marketed within the next 12 months and the potential market. Provide an estimate of anticipated sales. Describe the nature and extent of R&D work. Example: Indicate if it is solely directed at the development of new products or if some effort is directed to improving or changing existing products. Describe any new products to be marketed within the next 12 months and the potential market. Provide an estimate of anticipated sales. A guarantee is a promise made by the seller that the product can be returned for repair, replacement or a refund if the buyer is unsatisfied with it for some reason. A warranty is a positive statement that the product is as repres