Strickland General Agency, Inc.
SECURITY GUARDS/DETECTIVE AGENCIES SUPPLEMENTAL APPLICATION
COMMERCIAL GENERAL LIABILITY
(Complete in addition to the Acord application)
1. NAME OF APPLICANT:
INDIVIDUAL
CORPORATION
PARTNERSHIP
JOINT VENTURE
OTHER (Specify)
PROPOSED POLICY PERIOD
TO
NUMBER OF YEARS IN THIS BUSINESS?
4. NUMBER OF YEARS EXPERIENCE IN THIS FIELD?
IS APPLICANT LICENSED AND/OR CERTIFIED ACCORDING TO STATE REGULATIONS?
YES
NO
IS APPLICANT OWNED BY, ASSOCIATED WITH, ENGAGED IN OR INVOLVED WITH ANY OTHER ENTERPRISE?
YES
NO
IF YES, PROVIDE DETAILS:
7. DOES THE APPLICANT USE DOGS AS PART OF THEIR OPERATION?
YES
NO
IF YES, WHO HANDLES THE TRAINING OF DOGS?
WHAT TYPES OF DOGS ARE USED?
HOW/WHERE ARE THE DOGS USED?
NUMBER THAT WORK UNATTENDED?
NUMBER OF DOGS THAT WORK WITH A GUARD?
2.
3.
5.
6.
8.
PROVIDE THE NAMES OF THE APPLICANT’S FIVE LARGEST CLIENTS AND A DESCRIPTION OF THE SERVICES
PROVIDED FOR THEM:
1)
2)
3)
4)
5)
9.
FULL TIME EMPLOYEES:
PART TIME EMPLOYEES:
PAYROLL $
PAYROLL $
# ARMED:
# ARMED:
# UNARMED:
# UNARMED:
10.
OFF DUTY POLICE: #
ARE OFF DUTY POLICE OFFICERS REQUIRED BY STATE OR LOCAL LAW TO CARRY FIREARMS?
YES
NO
11. ARE ALL ARMED PERSONNEL CERTIFIED FOR USE OF FIREARMS BY STATE AGENCY?
YES
NO
12. ARE EMPLOYEES AUTHORIZED AND TRAINED TO CARRY: MACE
PEPPER SPRAY
NIGHT STICKS OR BATONS
STUN GUNS/BATONS OR TASER GUNS
HANDCUFFS OR OTHER RESTRAINING DEVICES
?
13. DESCRIBE ANY FORMAL TRAINING/EDUCATION REQUIRED OF EMPLOYEES:
14. PLEASE DESCRIBE PRE-EMPLOYMENT SCREENING PROCEDURES:
15. DOES THE APPLICANT SUBCONTRACT WORK?
YES
NO
IF YES, WHAT TYPE?
ANNUAL COST OF SUBCONTRACTED WORK?
ARE CERTIFICATES WITH EQUAL LIMITS REQUIRED FROM ALL SUBCONTRACTORS PRIOR TO COMMENCEMENT OF
WORK?
YES
NO
ARE ALL SUBCONTRACTORS REQUIRED TO NAME THE INSURED AS ADDITIONAL INSURED?
YES
NO
16. DESCRIBE ANY CONSULTING WORK:
17. TOTAL GROSS RECEIPTS FOR ALL SERVICES $
18. REQUEST FOR ADDITIONAL INSURED(S):
NAME
SG-483 0605
ADDRESS
Page 1 of 2
19. PLEASE PROVIDE A BREAKDOWN OF OPERATIONS
ARMED
UNARMED
CATEGORY OF OPERATION
PAYROLL PAYROLL
AIRPORT SECURITY
ALARM MONITORING - MEDICAL
ALARM MONITORING –
SURVEILLANCE (IE
SHOPLIFTING)
ALARM MONITORING – OTHER
APARTMENTS
ARMORED CAR/MONEY ESCORT
SERVICES
AUTOMOBILE DEALERS
BAIL BOND OPERATIONS
BANKS
BODY GUARDS – DESCRIBE
WHO/WHEN/WHERE BELOW
BOUNCERS
BOUNTY HUNTERS
CHURCHES
COLISEUM/INDOOR ARENAS
CONCERTS (DESCRIBE
PERFORMERS, LOCATIONS AND
DUTIES BELOW. IE: CROWD
CONTROL/TRAFFIC CONTROL,
ETC)
CONSTRUCTION SITES
COURIER SERVICES
DRUG SURVEILLANCE
FUNERAL ESCORT SERVICES
GOVERNMENT FACILITIES
HOSPITALS
HOTELS/MOTELS
INSURANCE ADJUSTERS
INVESTIGATIONS – CRIMINAL
20. PRODUCER NAME:
21. PRODUCER CODE:
CATEGORY OF OPERATION
INVESTIGATIONS – DIVORCE
INVESTIGATIONS –
INSURANCE
INVESTIGATIONS – MISSING
PERSONS
ARMED
PAYROLL
UNARMED
PAYROLL
LOW INCOME HOUSING
PROJECTS
MANUFACTURING PLANTS
NIGHTCLUBS, DISCOS, BARS
NUCLEAR POWER FACILITIES
OFFICES
POLYGRAPH TESTING
RAPID TRANSIT/BUS/TRAIN
STATIONS
REPOSSESSION/COLLECTIONS
RESIDENTIAL PATROL
RESTAURANTS
RETAIL STORES (INTERIOR)
RETAIL STORES (EXTERIOR)
SCHOOLS
SHOPPING MALLS
SPORTING EVENTS
STRIKE WORK
SURVEILLANCE WORK
(DESCRIBE BELOW – DETAIL
ARREST/DETENTION
AUTHORITY)
TRAFFIC CONTROL
WAREHOUSES
OTHER (DESCRIBE BELOW):
22. PRODUCER PHONE NUMBER:
23. STATE CODE:
COMMENTS:
SPECIAL NOTE:
THIS FORM IS NOT AN INSURANCE POLICY OR AN INSURANCE CONTRACT
Your agreement to these terms DOES NOT create an insurance contract or an insurance agreement. These terms MUST BE accepted
by the insurance company before there is any insurance contract or insurance coverage.
Applicant warrants and agrees that the above answers and all attachments are in all respects true and shall be deemed material and are
made to induce the Company to issue a policy, that the Company will rely on the same when issuing a policy, and that all pertinent
information has been fully disclosed. The applicant understands that submission of this information creates no obligation on the part of the
Company to provide insurance either on the basis requested or on any other basis.
DATE
SIGNATURE OF APPLICANT
SIGNATURE OF PRODUCER
SG-483 0605
Page 2 of 2
COMMERCIAL INSURANCE APPLICATION
DATE (MM/DD/YYYY)
APPLICANT INFORMATION SECTION
AGENCY
CARRIER
UNDERWRITER OFF.
UNDERWRITER
NAIC CODE:
POLICIES OR PROGRAM REQUESTED
POLICY NUMBER
EQUIPMENT FLOATER
GARAGE AND DEALERS
PROPERTY
INSTALLATION/BUILDERS RISK
VEHICLE SCHEDULE
GLASS AND SIGN
ELECTRONIC DATA PROC
BOILER & MACHINERY
ACCOUNTS RECEIVABLE/
VALUABLE PAPERS
CRIME/MISCELLANEOUS CRIME
COMMERCIAL
GENERAL LIABILITY
BUSINESS AUTO
WORKERS COMPENSATION
TRANSPORTATION/
MOTOR TRUCK CARGO
TRUCKERS/MOTOR CARRIER
INDICATE SECTIONS ATTACHED
PHONE
(A/C, No, Ext):
FAX
(A/C, No):
E-MAIL
ADDRESS:
CODE:
SUB CODE:
AGENCY CUSTOMER ID:
STATUS OF TRANSACTION
QUOTE
PACKAGE POLICY INFORMATION
ISSUE POLICY
RENEW
BOUND (Give Date and/or Attach Copy):
CHANGE
DATE
UMBRELLA
ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES.
PROPOSED EFF DATE
TIME
CANCEL
PROPOSED EXP DATE
BILLING PLAN
AM
DIRECT BILL
PM
AGENCY BILL
PAYMENT PLAN
AUDIT
APPLICANT INFORMATION
FEIN OR SOC SEC #
(of First Named Insured):
PHONE
(A/C, No, Ext):
NAME (First Named Insured & Other Named Insureds)
MAILING ADDRESS INCL ZIP+4 (of First Named Insured)
E-MAIL
ADDRESS(ES):
INDIVIDUAL
PARTNERSHIP
SUBCHAPTER "S"
CORPORATION
NOT FOR
PROFIT ORG
CORPORATION
JOINT VENTURE
CR BUREAU
NAME
LLC
WEBSITE
ADDRESS(ES):
ID NUMBER
DATE BUS
STARTED
NO. OF MEMBERS
AND MANAGERS
INSPECTION CONTACT
ACCOUNTING RECORDS CONTACT
PHONE
(A/C, No, Ext):
E-MAIL
ADDRESS:
PHONE
(A/C, No, Ext):
E-MAIL
ADDRESS:
PREMISES INFORMATION
LOC #
BLD #
STREET, CITY, COUNTY, STATE, ZIP+4
CITY LIMITS
INTEREST
INSIDE
OWNER
OUTSIDE
TENANT
INSIDE
OWNER
OUTSIDE
TENANT
YR
BUILT
#
EMPLOYEES
ANNUAL
REVENUES
PART OCCUPIED
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES
YES NO
1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
2. IS A FORMAL SAFETY PROGRAM IN OPERATION?
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
EXPLAIN ALL "YES" RESPONSES
7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR
MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT
BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON?
(In RI, this question must be answered by any applicant for property insurance.
Failure to disclose the existence of an arson conviction is a misdemeanor
punishable by a sentence of up to one year of imprisonment).
YES NO
9. ANY UNCORRECTED FIRE CODE VIOLATIONS?
4. ANY CATASTROPHE EXPOSURE?
5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?
6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED
DURING THE PRIOR 3 YEARS? (Not applicable in MO)
REMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)
10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT
IN THE PAST 5 YEARS?
11. HAS BUSINESS BEEN PLACED IN A TRUST?
IF YES, NAME OF TRUST:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND
[NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND CERTIFIES THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE CERTIFIES THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
APPLICANT’S SIGNATURE
ACORD 125 (2004/03)
DATE
PRODUCER’S SIGNATURE
PLEASE COMPLETE REVERSE SIDE
NATIONAL PRODUCER NUMBER
© ACORD CORPORATION 1993
PRIOR CARRIER INFORMATION
LINE
CATEGORY
CARRIER
POLICY NUMBER
CLAIMS
MADE
POLICY TYPE
OCCURRENCE
CLAIMS
MADE
OCCURRENCE
CLAIMS
MADE
OCCURRENCE
CLAIMS
MADE
OCCURRENCE
CLAIMS
MADE
OCCURRENCE
RETRO DATE
G
E
N
E
C
R
O
A
M
L
M
E
L
R
I
C
A
I
B
A
I
L
L
I
T
Y
EFF-EXP DATE
GENERAL AGGREGATE
PRODUCTS COMP OP
AGGREGATE
PERSONAL & ADV INJ
EACH OCCURRENCE
L
I FIRE DAMAGE
M
I MEDICAL EXPENSE
T
S BODILY OCCURRENCE
INJURY AGGREGATE
PROPERTY OCCURRENCE
DAMAGE AGGREGATE
COMBINED SINGLE LIMIT
MODIFICATION FACTOR
TOTAL PREMIUM
CARRIER
POLICY NUMBER
A
U
T
O
M
O
B
I
L
E
POLICY TYPE
L
I
A
B
I
L
I
T
Y
EFF-EXP DATE
COMBINED SINGLE LIMIT
BODILY
INJURY
EA PERSON
EA ACCIDENT
PROPERTY DAMAGE
MODIFICATION FACTOR
TOTAL PREMIUM
CARRIER
POLICY NUMBER
P
R
O
P
E
R
T
Y
POLICY TYPE
EFF-EXP DATE
BUILDING
AMT
PERS PROP
AMT
MODIFICATION FACTOR
TOTAL PREMIUM
CARRIER
POLICY NUMBER
POLICY TYPE
EFF-EXP DATE
LIMIT
MODIFICATION FACTOR
TOTAL PREMIUM
LOSS HISTORY
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS
FOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)
DATE OF
OCCURRENCE
LINE
TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM
DATE
OF CLAIM
AMOUNT
PAID
CHK HERE
IF NONE
AMOUNT
RESERVED
SEE ATTACHED
LOSS SUMMARY
CLAIM
STATUS
OPEN
CLOSED
OPEN
CLOSED
REMARKS
NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORY
ATTACHMENTS
STATE SUPPLEMENT(S) (If applicable)
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state’s requirements.)
NOTICE OF INSURANCE INFORMATION PRACTICES PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM
PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER
PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR
AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE
DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR
INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.
ACORD 125 (2004/03)
COMMERCIAL GENERAL LIABILITY SECTION
PHONE
(A/C, No, Ext):
FAX
(A/C, No):
AGENCY
DATE (MM/DD/YYYY)
APPLICANT
(First
Named
Insured)
EFFECTIVE DATE
EXPIRATION DATE
PAYMENT PLAN
DIRECT BILL
AUDIT
AGENCY BILL
CODE:
AGENCY
CUSTOMER ID:
FOR
COMPANY
USE ONLY
SUB CODE:
COVERAGES
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE
OCCURRENCE
OWNER’S & CONTRACTOR’S PROTECTIVE
DEDUCTIBLES
PROPERTY DAMAGE
$
BODILY INJURY
$
PER
CLAIM
$
PER
OCCURRENCE
GENERAL AGGREGATE
$
PRODUCTS & COMPLETED OPERATIONS AGGREGATE
$
PERSONAL & ADVERTISING INJURY
$
EACH OCCURRENCE
$
DAMAGE TO RENTED PREMISES (each occurrence)
$
MEDICAL EXPENSE (Any one person)
$
EMPLOYEE BENEFITS
$
PREMIUMS
PREMISES/OPERATIONS
PRODUCTS
OTHER
TOTAL
$0.00
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)
SCHEDULE OF HAZARDS
LOCATION
#
CLASSIFICATION
RATING AND PREMIUM BASIS
(S) GROSS SALES - PER $1,000/SALES
CLASS
CODE
PREMIUM
BASIS
(P) PAYROLL - PER $1,000/PAY
(A) AREA - PER 1,000/SQ FT
EXPOSURE
RATE
TERR
PREM/OPS
(C) TOTAL COST - PER $1,000/COST
(M) ADMISSIONS - PER 1,000/ADM
CLAIMS MADE (Explain all "Yes" responses)
PREMIUM
PRODUCTS
PREM/OPS
PRODUCTS
(U) UNIT - PER UNIT
(T) OTHER
EMPLOYEE BENEFITS LIABILITY
1. PROPOSED RETROACTIVE DATE:
1. DEDUCTIBLE PER CLAIM:
2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV:
3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION
BEEN EXCLUDED, UNINSURED OR SELF-INSURED
FROM ANY PREVIOUS COVERAGE?
2. NUMBER OF EMPLOYEES:
YES NO
$
3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:
4. RETROACTIVE DATE:
4. WAS TAIL COVERAGE PURCHASED UNDER ANY
PREVIOUS POLICY?
REMARKS
ACORD 126 (2004/03)
REMARKS
PLEASE COMPLETE REVERSE SIDE
© ACORD CORPORATION 1993
CONTRACTORS
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
YES NO
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
YES
1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS
FOR OTHERS?
4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS
LESS THAN YOURS?
2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE
EXPLOSIVE MATERIAL?
5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT
PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING,
UNDERGROUND WORK OR EARTH MOVING?
6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR
WITHOUT OPERATORS?
$ PAID TO SUBCONTRACTORS:
REMARKS/DESCRIBE THE TYPE OF WORK SUBCONTRACTED
% OF WORK
SUBCONTRACTED:
# FULLTIME STAFF:
NO
# PARTTIME STAFF:
PRODUCTS/COMPLETED OPERATIONS
PRODUCTS
ANNUAL GROSS SALES
TIME IN
MARKET
# OF UNITS
EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation)
YES NO
EXPECTED
LIFE
INTENDED USE
PRINCIPAL COMPONENTS
EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation)
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?
2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS?
7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER
APPLICANT LABEL?
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW
PRODUCTS PLANNED?
YES
NO
YES
NO
8. PRODUCTS UNDER LABEL OF OTHERS?
4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
9. VENDORS COVERAGE REQUIRED?
5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT
INTEREST
RANK:
NAME AND ADDRESS
ACORD 45 attached for additional names
REFERENCE #:
CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOCATION:
BUILDING:
LOSS PAYEE
VEHICLE:
BOAT:
MORTGAGEE
SCHEDULED ITEM NUMBER:
LIENHOLDER
OTHER
EMPLOYEE AS LESSOR
ITEM DESCRIPTION:
GENERAL INFORMATION
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
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 5 YEARS?
5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS?
6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?
7. ANY PARKING FACILITIES OWNED/RENTED?
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?
13. ANY DEMOLITION EXPOSURE CONTEMPLATED?
14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN
JOINT VENTURES?
15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS
OR SUBSIDIARIES?
17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON
YOUR PREMISES WITHIN THE LAST THREE YEARS?
19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY
POLICY IN EFFECT?
8. IS A FEE CHARGED FOR PARKING?
9. RECREATION FACILITIES PROVIDED?
10. IS THERE A SWIMMING POOL ON THE PREMISES?
11. SPORTING OR SOCIAL EVENTS SPONSORED?
YES NO
20. DOES THE BUSINESSES’ PROMOTIONAL LITERATURE MAKE
ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY
OF THE PREMISES?
REMARKS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL
PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied).
ACORD 126 (2004/03)
ATTACH TO APPLICANT INFORMATION SECTION