Business Name/Applicant Name
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Entity type
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Sole Proprietor
Limited Liability Company (LLC)
Corporation
Partnership
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Business Phone number
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Business Start Date
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Business Website
Business Street Address
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Business Address Line 2
Business City
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Business State / Province / Region
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Alabama
Alaska
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California
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District of Columbia
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Armed Forces America
Armed Forces Europe
Armed Forces Pacific
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Business ZIP / Postal Code
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Square Feet
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Is the Mailing Address the same as the Property Address?
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Yes
No
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Business Mailing Street Address
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Business Mailing Address Line 2
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Business Mailing Address City
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Business Mailing Address State / Province / Region
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
West Virginia
Wisconsin
Wyoming
Armed Forces America
Armed Forces Europe
Armed Forces Pacific
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Business Mailing Address ZIP / Postal Code
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Business Mailing address
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First Name
Last Name
Phone
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Email
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Date of birth
Description of Operations
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Gross Revenues
Interest
*
Owner
Tenant
Other
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Any Additional Insured need to be listed?
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Yes
No
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If so, Kindly provide name and mailing address.
Any Claims or Loss in the past 5 yrs?
*
Yes
No
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If so, Date of occurrence, description of occurrence, Amount paid?
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IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
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Yes
No
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If Yes, kindly fill out below.
PARENT COMPANY NAME
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RELATIONSHIP DESCRIPTION
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% OWNED
*
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
*
Yes
No
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If Yes, kindly fill out below.
SUBSIDIARY COMPANY NAME .
*
THE RELATIONSHIP DESCRIPTION
*
THE % OWNED
*
IS A FORMAL SAFTEY PROGRAM IN OPERATIONS??
SAFETY MANUAL
SAFETY POSITION
MONTHLY MEETINGS
OSHA
OTHER
ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
*
Yes
No
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If "YES", kindly describe:
ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
Yes
No
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If Yes, kindly fill out below.
Line of Business 1
*
Policy Number 1
*
Line of Business 2
Policy Number 2
Line of Business 3
Policy Number 3
ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS?
*
NON-PAYMENT
NON-RENEWAL
AGENT NO LONGER REPRESENTS CARRIER
UNDERWRITING
CONDITION CORRECTED
OTHER
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ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
*
Yes
No
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If Yes, Please Explain?
DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ?
*
Yes
No
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If yes, kindly provide the details
ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
*
Yes
No
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If Yes, answer below:
OCCURRENCE DATE
*
EXPLANATION
*
RESOLUTION
*
RESOLUTION DATE
*
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
*
Yes
No
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If Yes, answer below:
THE OCCURRENCE DATE
*
THE EXPLANATION
*
THE RESOLUTION
*
THE RESOLUTION DATE
*
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
*
Yes
No
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If Yes, the occurrence date
*
If Yes, the explanation
*
If Yes, the resolution
*
If Yes, the resolution date
*
HAS BUSINESS BEEN PLACED IN A TRUST?
*
Yes
No
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NAME OF TRUST?
*
DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
*
Yes
No
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If Yes, kindly fill out below.
ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?
*
Yes
No
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If Yes, kindly describe them below.
DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES?
*
Yes
No
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(If "YES", describe use)
DOES APPLICANT HIRE OTHERS TO OPERATE DRONES?
*
Yes
No
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(If "YES", describe the use)
PROPOSED RETROACTIVE DATE
ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE:
Yes
No
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HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?
*
Yes
No
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If yes, Please provide details.
WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY?
*
Yes
No
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If yes, provide more details.
DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
Yes
No
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If yes, kindly provide details:
FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS?
Yes
No
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RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?
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Yes
No
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If yes, please more details:
GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
Yes
No
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Provide details below
PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
Yes
No
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Kindly provide details below:
PRODUCTS RECALLED, DISCONTINUED, CHANGED?
Yes
No
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If yes, explain please
PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?
Yes
No
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If yes, kindly explain
PRODUCTS UNDER LABEL OF OTHERS?
Yes
No
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If yes, kindly describe the details
VENDORS COVERAGE REQUIRED?
*
Yes
No
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If yes, please describe the details
DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
*
Yes
No
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If yes, please provide more information
ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?
*
Yes
No
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If yes, provide more information
*
ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?
*
Yes
No
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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)
*
Yes
No
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ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?
Yes
No
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If Yes, describe please:
*
DO YOU RENT OR LOAN EQUIPMENT TO OTHERS?
Yes
No
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Equipment
TYPE OF EQUIPMENT
INSTRUCTION GIVEN (Y/N)
Yes
No
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ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?
*
Yes
No
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ANY PARKING FACILITIES OWNED/RENTED?
*
Yes
No
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IS A FEE CHARGED FOR PARKING?
*
Yes
No
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RECREATION FACILITIES PROVIDED?
*
Yes
No
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ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS?
*
Yes
No
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If "YES", answer the following
# APTS
*
TOTAL APT AREA
*
DESCRIBE OTHER LODGING OPERATIONS
*
IS THERE A SWIMMING POOL ON PREMISES?
Yes
No
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If Yes, Check All that applies:
APPROVED FENCE
LIMITED ACCESS
DIVING BOARD
SLIDE
ABOVE GROUND
IN GROUND
LIFE GUARD
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ARE SOCIAL EVENTS SPONSORED?
*
Yes
No
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If yes, describe the details below
ARE ATHLETIC TEAMS SPONSORED?
*
Yes
No
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If Yes, Kindly answer below:
TYPE OF SPORT
CONTACT SPORT (Y/N)
Yes
No
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AGE GROUP
ANY STRUCTURAL ALTERATIONS CONTEMPLATED?
*
Yes
No
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If yes, kindly provide information
ANY DEMOLITION EXPOSURE CONTEMPLATED?
*
Yes
No
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If yes, kindly provide more information
HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?
*
Yes
No
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If yes, provide information below
DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
*
Yes
No
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IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?
*
Yes
No
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ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
*
Yes
No
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HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?
*
Yes
No
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IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?
*
Yes
No
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If yes, kindly provide more information below
DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?
*
Yes
No
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If yes, please provide more information below
Have you had any losses in the past 5 years, whether or not paid by the insurance?
*
Yes
No
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If yes, please state Loss date, Description of loss, Amount paid?
Consent: 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.
*
I agree to the privacy policy.
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