AGENCY CUSTOMER ID:

DATE (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY SECTION
AGENCY CARRIER NAIC CODE

POLICY NUMBER EFFECTIVE DATE APPLICANT / FIRST NAMED INSURED

IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy.
Read all provisions of the policy carefully.

COVERAGES LIMITS
COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $ PREMIUMS

CLAIMS MADE OCCURRENCE LIMIT APPLIES PER: PREMISES/OPERATIONS

POLICY LOCATION
OWNER'S & CONTRACTOR'S PROTECTIVE PROJECT OTHER:
PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ PRODUCTS

DEDUCTIBLES PERSONAL & ADVERTISING INJURY $

PROPERTY DAMAGE $ EACH OCCURRENCE $ OTHER

PER
BODILY INJURY $ CLAIM DAMAGE TO RENTED PREMISES (each occurrence) $
PER
$ MEDICAL EXPENSE (Any one person) $ TOTAL
OCCURRENCE

EMPLOYEE BENEFITS $

$
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)

APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY:

1. UM / UIM COVERAGE IS IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE.

SCHEDULE OF HAZARDS
LOC HAZ PREMIUM RATE PREMIUM
CLASSIFICATION CLASS EXPOSURE TERR
# # CODE BASIS
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)

EXPLAIN ALL "YES" RESPONSES Y/N

1. PROPOSED RETROACTIVE DATE:

2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:
3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?

4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?

EMPLOYEE BENEFITS LIABILITY

1. DEDUCTIBLE PER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:
2. NUMBER OF EMPLOYEES: 4. RETROACTIVE DATE:
ACORD 126 (2016/03) Attach to ACORD 125 © 1993-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
 AGENCY CUSTOMER ID:
CONTRACTORS
EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y/N

1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?

2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?

3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?

4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?

5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?

6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?

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 all past or present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y/N

1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?

2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?

4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?

5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?

6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?

7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?

8. PRODUCTS UNDER LABEL OF OTHERS?

9. VENDORS COVERAGE REQUIRED?

10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?

ACORD 126 (2016/03) Page 2 of 4

 AGENCY CUSTOMER ID:
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names
INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER
ADDITIONAL INSURED LOCATION: BUILDING:
EMPLOYEE AS LESSOR ITEM ITEM:
CLASS:
LENDER'S LOSS PAYABLE ITEM DESCRIPTION

LIENHOLDER

LOSS PAYEE

MORTGAGEE

REFERENCE / LOAN #:

GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y/N

1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?

2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?

3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR
TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)

4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?

5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS?

EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (Y/N)
SMALL TOOLS LARGE EQUIPMENT
SMALL TOOLS LARGE EQUIPMENT

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

7. ANY PARKING FACILITIES OWNED/RENTED?

8. IS A FEE CHARGED FOR PARKING?

9. RECREATION FACILITIES PROVIDED?

10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES", answer the following):
# APTS TOTAL APT AREA DESCRIBE OTHER LODGING OPERATIONS
Sq. Ft.

11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply)

APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD

12. ARE SOCIAL EVENTS SPONSORED?

13. ARE ATHLETIC TEAMS SPONSORED?

TYPE OF SPORT CONTACT TYPE OF SPORT CONTACT
AGE GROUP 13 - 18 AGE GROUP 13 - 18
SPORT (Y/N) SPORT (Y/N)
12 & UNDER OVER 18 12 & UNDER OVER 18
EXTENT OF SPONSORSHIP: EXTENT OF SPONSORSHIP:

14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?

15. ANY DEMOLITION EXPOSURE CONTEMPLATED?

ACORD 126 (2016/03) Page 3 of 4

 AGENCY CUSTOMER ID:
GENERAL INFORMATION (continued)
EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y/N

16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?

17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?

WORKERS WORKERS
LEASE TO COMPENSATION LEASE FROM COMPENSATION
COVERAGE CARRIED (Y/N) COVERAGE CARRIED (Y/N)

18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?

19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?

20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?

21. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?

22. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?

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

SIGNATURE
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or
benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison. *Applies in MD Only.
Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be
presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance
of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for
commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties (not to exceed five thousand dollars and
the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a
false statement as to any material fact may be violating state law.
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps,
or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss,
shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty
thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2)
years.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
PRODUCER'S SIGNATURE PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO
(Required in Florida)

APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER

ACORD 126 (2016/03) Page 4 of 4