Commercial Package (ACORD 125 )

COMMERCIAL INSURANCE APPLICATION

APPLICANT INFORMATION SECTION

AGENCY

CONTACT NAME:

PHONE (A/C, No, Ext):

FAX (A/C, No):

E-MAIL ADDRESS:

CODE:

POLICY INFORMATION

PROPOSED EFF DATE

PROPOSED EXP DATE

APPLICANT INFORMATION

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

BUSINESS PHONE #:

WEBSITE 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

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

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

AMOUNT PAID

AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

DATE OF OCCURRENCE

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

AMOUNT PAID

AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

DATE OF OCCURRENCE

LINE

TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

DATE OF CLAIM

AMOUNT PAID

AMOUNT RESERVED

SUBRO- GATION Y / N

CLAIM OPEN Y / N

COMMERCIAL INSURANCE APPLICATION

LINES OF BUSINESS

POLICY INFORMATION

APPLICANT INFORMATION

CONTACT INFORMATION

PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)

NATURE OF BUSINESS

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

INTEREST IN ITEM NUMBER

PRIOR CARRIER INFORMATION

PRIOR CARRIER INFORMATION 2

LOSS HISTORY