ACORD 125 — Commercial Application

Producer

Producer / Agency Name

Customer ID

Address Line 1

Address Line 2

City

State

ZIP

Contact Name

Phone

Fax

Email

Producer ID (code)

Sub-Producer ID

Insurer / Underwriter

Insurer / Company Name

NAIC Code

Policy Number

Product / Program

Product Code

Underwriter

Underwriter Office

Form Date

Status of Transaction

Effective Date

Expiration Date

Effective Time

AM PM

Lines of Business & Premium

Other Lines

Other Line (A) — Description

Other Line (A) — Premium

$

Other Line (B) — Description

Other Line (B) — Premium

$

Payment Plan

Direct Bill Agency/Producer Bill

Payment Schedule

Payment Method

Audit Frequency

Deposit Amount

$

Minimum Premium

$

Estimated Total Premium

$

Named Insured (Applicant)

Full Name / Business Name

Website

Mailing Address Line 1

Mailing Address Line 2

City

State

ZIP

Primary Phone

Tax ID / FEIN

GL Code

SIC Code

NAICS Code

Legal Entity Type

LLC Member/Manager Count

Entity Other — Description

Primary Contact

Contact Name

Contact Title / Description

Primary Phone

Primary Email

Secondary Phone

Secondary Email

Premises — Location 1

Loc #

Building #

Address Line 1

Address Line 2

City

County

State

ZIP

Inside City Limits Outside City Limits Owner Tenant

Full-Time Employees

Part-Time Employees

Annual Revenue

$

Occupied Area (sq ft)

Open to Public Area (sq ft)

Total Building Area (sq ft)

Description of Operations at this Location

Premises — Location 2 (Optional)

Loc #

Building #

Address Line 1

Address Line 2

City

County

State

ZIP

Inside City Limits Outside City Limits Owner Tenant

Full-Time Employees

Part-Time Employees

Annual Revenue

$

Description of Operations at this Location

Nature of Business

Other Business Type — Description

Business Start Date

% Installation/Repair Work

% Work Off Premises

Description of Primary Operations

Additional Operations / Other Ventures

Additional Interest (Primary)

Name / Entity

Account Number

Address Line 1

Address Line 2

City

State

ZIP

Country

Phone

Email

Interest End Date

Loan Amount

$

Interest Rank

Other — Description

Certificate Required Policy Required Send Bill

General Information

1. Any subsidiaries/affiliates, parent organization, or any entity not covered?

2. Is a formal safety program in operation?

3. Any exposure to flammables, explosives, or chemicals?

If Yes, explain

4. Any other insurance with this company? (Check yes and list policies below)

5. Any policy or coverage declined, cancelled, or non-renewed in the last 3 years?

Cancel / Non-Renew Other Description

6. Past losses/claims relating to sexual abuse, discrimination, or negligent hiring?

If Yes, explain

7. In past 5 years, has applicant been indicted or convicted of fraud, bribery, or arson?

8. Uncorrected fire code violations?

9. Foreclosure, repossession, or bankruptcy within past 5 years?

10. Judgments or liens within past 5 years?

11. Does applicant own, lease, or operate drones/UAVs?

12. Does applicant hire others to operate drones/UAVs on their behalf?

Prior Carrier Information

Policy Year

General Liability

Insurer

Policy Number

Total Premium

$

Effective Date

Expiration Date

Automobile

Insurer

Policy Number

Total Premium

$

Effective Date

Expiration Date

Property

Insurer

Policy Number

Total Premium

$

Effective Date

Expiration Date

Loss History

No Prior Losses

Years of Loss Information

Total Loss Amount

$

Loss #1

Occurrence Date

Line of Business

Claim Date

Amount Paid

$

Reserved Amount

$

Status (O=Open/C=Closed)

Description of Loss

Loss #2

Occurrence Date

Line of Business

Claim Date

Amount Paid

$

Reserved Amount

$

Status (O=Open/C=Closed)

Description of Loss

Remarks & Signatures

Remarks

Producer's Name (Signature)

State Producer License #

National Producer Number

Insured Signature Date

Insured Initials

Notes (Internal Only)