Commercial Package (ACORD 125 & ACORD 126) - Simon Insurance Broker Portal

Step 1 of 13

COMMERCIAL INSURANCE APPLICATION

APPLICANT INFORMATION SECTION

AGENCY

CONTACT NAME:

PHONE (A/C, No, Ext):

FAX (A/C, No):

E-MAIL ADDRESS:

CODE:

LINES OF BUSINESS

INDICATE LINES OF BUSINESS

BOILER & MACHINERY

Y/N

$ PREMIUM

BUSINESS AUTO

Y/N

$ PREMIUM

BUSINESS OWNERS

Y/N

$ PREMIUM

COMMERCIAL GENERAL LIABILITY

Y/N

$ PREMIUM

COMMERCIAL INLAND MARINE

Y/N

$ PREMIUM

COMMERCIAL PROPERTY

Y/N

$ PREMIUM

CRIME

Y/N

$ PREMIUM

CYBER AND PRIVACY

Y/N

$ PREMIUM

FIDUCIARY LIABILITY

Y/N

$ PREMIUM

GARAGE AND DEALERS

Y/N

$ PREMIUM

LIQUOR LIABILITY

Y/N

$ PREMIUM

MOTOR CARRIER

Y/N

$ PREMIUM

TRUCKERS

Y/N

$ PREMIUM

UMBRELLA

Y/N

$ PREMIUM

YACHT

Y/N

$ PREMIUM

POLICY INFORMATION

PROPOSED EFF DATE

MM slash DD slash YYYY

PROPOSED EXP DATE

MM slash DD slash YYYY

APPLICANT INFORMATION

NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)

BUSINESS PHONE #:

WEBSITE ADDRESS

CONTACT INFORMATION

CONTACT TYPE:

CONTACT NAME:

PRIMARY PHONE #

HOME

BUS

CELL

PRIMARY PHONE #

PRIMARY E-MAIL ADDRESS:

SECONDARY PHONE #

HOME

BUS

CELL

SECONDARY PHONE #

SECONDARY E-MAIL ADDRESS:

CONTACT TYPE:

CONTACT NAME:

PRIMARY PHONE #

HOME

BUS

CELL

PRIMARY PHONE #

PRIMARY E-MAIL ADDRESS:

SECONDARY PHONE #

HOME

BUS

CELL

SECONDARY PHONE #

SECONDARY E-MAIL ADDRESS:

PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)

LOC #

STREET

BLD #

Address

City State / Province / Region ZIP / Postal Code Country

CITY LIMITS

INSIDE

OUTSIDE

INTEREST

OWNER

TENANT

# FULL TIME EMPL

# PART TIME EMPL

DESCRIPTION OF OPERATIONS:

$ ANNUAL REVENUES:

OCCUPIED AREA (SQ FT):

OPEN TO PUBLIC AREA: (SQ FT):

TOTAL BUILDING AREA: (SQ FT):

ANY AREA LEASED TO OTHERS? Yes / No

LOC #

STREET

BLD #

Address

City State / Province / Region ZIP / Postal Code Country

CITY LIMITS

INSIDE

OUTSIDE

INTEREST

OWNER

TENANT

# FULL TIME EMPL

# PART TIME EMPL

DESCRIPTION OF OPERATIONS:

$ ANNUAL REVENUES:

OCCUPIED AREA (SQ FT):

OPEN TO PUBLIC AREA: (SQ FT):

TOTAL BUILDING AREA: (SQ FT):

ANY AREA LEASED TO OTHERS? Yes / No

LOC #

STREET

BLD #

Address

City State / Province / Region ZIP / Postal Code Country

CITY LIMITS

INSIDE

OUTSIDE

INTEREST

OWNER

TENANT

# FULL TIME EMPL

# PART TIME EMPL

DESCRIPTION OF OPERATIONS:

$ ANNUAL REVENUES:

OCCUPIED AREA (SQ FT):

OPEN TO PUBLIC AREA: (SQ FT):

TOTAL BUILDING AREA: (SQ FT):

ANY AREA LEASED TO OTHERS? Yes / No

LOC #

STREET

BLD #

Address

City State / Province / Region ZIP / Postal Code Country

CITY LIMITS

INSIDE

OUTSIDE

INTEREST

OWNER

TENANT

# FULL TIME EMPL

# PART TIME EMPL

DESCRIPTION OF OPERATIONS:

$ ANNUAL REVENUES:

OCCUPIED AREA (SQ FT):

OPEN TO PUBLIC AREA: (SQ FT):

TOTAL BUILDING AREA: (SQ FT):

ANY AREA LEASED TO OTHERS? Yes / No

NATURE OF BUSINESS

APARTMENTS

CONDOMINIUMS

CONTRACTOR

INSTITUTIONAL

MANUFACTURING

OFFICE

RESTAURANT

RETAIL

SERVICE

WHOLESALE

This field is hidden when viewing the form

NATURE OF BUSINESS

DATE BUSINESS STARTED (MM/DD/YYYY)

MM slash DD slash YYYY

DESCRIPTION OF PRIMARY OPERATIONS

ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests

INTEREST

ADDITIONAL INSURED

BREACH OF WARRANTY

CO-OWNER

EMPLOYEE AS LESSOR

LEASEBACK OWNER

LENDER'S LOSS PAYABLE

LIENHOLDER

LOSS PAYEE

MORTGAGEE

OWNER

REGISTRANT

TRUSTEE

NAME AND ADDRESS

This field is hidden when viewing the form

NAME AND ADDRESS (2)

RANK:

EVIDENCE:

CERTIFICATE

POLICY

SEND BILL

REFERENCE / LOAN #:

INTEREST END DATE:

MM slash DD slash YYYY

LIEN AMOUNT:

PHONE (A/C, No, Ext):

ITEM DESCRIPTION

FAX (A/C, No):

REASON FOR INTEREST:

E-MAIL ADDRESS:

INTEREST IN ITEM NUMBER

LOCATION:

VEHICLE:

AIRPORT:

ITEM CLASS:

BUILDING:

BOAT:

AIRCRAFT:

ITEM:

PRIOR CARRIER INFORMATION

YEAR

CATEGORY - CARRIER

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - POLICY NUMBER

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - PREMIUM

$ GENERAL LIABILITY

$ AUTOMOBILE

$ PROPERTY

$ OTHER:

CATEGORY - EFFECTIVE DATE

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - EXPIRATION DATE

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

PRIOR CARRIER INFORMATION 2

YEAR

CATEGORY - CARRIER

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - POLICY NUMBER

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - PREMIUM

$ GENERAL LIABILITY

$ AUTOMOBILE

$ PROPERTY

$ OTHER:

CATEGORY - EFFECTIVE DATE

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

CATEGORY - EXPIRATION DATE

GENERAL LIABILITY

AUTOMOBILE

PROPERTY

OTHER:

LOSS HISTORY

(Attach Loss Summary for Additional Loss Information)

Check if none

None

DATE OF OCCURRENCE

MM slash DD slash YYYY

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

MM slash DD slash YYYY

$ AMOUNT PAID

$ AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

DATE OF OCCURRENCE

MM slash DD slash YYYY

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

MM slash DD slash YYYY

$ AMOUNT PAID

$ AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

DATE OF OCCURRENCE

MM slash DD slash YYYY

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

MM slash DD slash YYYY

$ AMOUNT PAID

$ AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

COMMERCIAL GENERAL LIABILITY SECTION

AGENCY

CARRIER

POLICY NUMBER

APPLICANT / FIRST NAMED INSURED

LIMITS

$ GENERAL AGGREGATE

Please enter a number from 0 to 10000000.

GENERAL AGGREGATE LIMIT APPLIES PER:

POLICY

LOCATION

PROJECT

OTHER:

GENERAL AGGREGATE - OTHER:

$ PRODUCTS & COMPLETED OPERATIONS AGGREGATE

Please enter a number from 0 to 10000000.

$ PERSONAL & ADVERTISING INJURY

Please enter a number from 0 to 10000000.

$ EACH OCCURRENCE

Please enter a number from 0 to 10000000.

$ DAMAGE TO RENTED PREMISES (each occurrence)

Please enter a number from 0 to 10000000.

$ MEDICAL EXPENSE (Any one person)

Please enter a number from 0 to 10000000.

$ EMPLOYEE BENEFITS

Please enter a number from 0 to 10000000.

SCHEDULE OF HAZARDS

RATING AND PREMIUM BASIS: (S) GROSS SALES - PER $1,000/SALES (P) PAYROLL - PER $1,000/PAY (A) AREA - PER 1,000/SQ FT (C) TOTAL COST - PER $1,000/COST (M) ADMISSIONS - PER 1,000/ADM (U) UNIT - PER UNIT (T) OTHER

SCHEDULE OF HAZARDS (1) - PREMIUM BASIS A (Total)

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (2) - PREMIUM BASIS S (Total)

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (3) - PREMIUM BASIS P (Total)

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (4) - PREMIUM BASIS S

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (5) - PREMIUM BASIS P

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (6) - PREMIUM BASIS S

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (7) - PREMIUM BASIS P

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (8) - PREMIUM BASIS S

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

SCHEDULE OF HAZARDS (9) - PREMIUM BASIS P

LOC #

HAZ #

CLASSIFICATION

CLASS CODE

EXPOSURE

TERR

RATE PREM/OPS

RATE PRODUCTS

PREMIUM PREM/OPS

PREMIUM PRODUCTS

PROPERTY SECTION

NAMED INSURED(S)

PREMISES INFORMATION

STREET ADDRESS:

Street Address City State / Province / Region ZIP / Postal Code

BLDG DESCRIPTION:

SUBJECT OF INSURANCE (1)

AMOUNT