Accord 160 BOP Accord 160 BOP Submission DateProposed Effective DateBusiness NameContact NameContact TypeStreet AddressCity, State, ZIP codeEmail AddressPhoneGeneral Information1. Do/ Have past, present or discountinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?YesNo2. Are athletic teams sponsored?YesNo3. Do you obtain and verify certificates of insurance obtained from subcontractors, manufacturers and/or suppliers?YesNo4. Do you lease employees to or from other employers?YesNo5. Do you own or operate any other business?YesNo6. In addition to your primary nature of business are you also involved in the manufacture, relabeling or repackaging of others products?YesNo7. In addition to your primary nature of business, are you also involved in the mixing of others products?YesNo8. Do you rent or loan equipment to others?YesNo9. Does the operation have hours after 9:00 P.M and/ or 24 hour operations?YesNoPremisesCheck if primary premises *Location numberBulding numberBuilding descriptionDescription of all occupancies at this premisesSurrounding exposures & other occupanciesRight exponsureLeft exponsureFront exponsureRear exponsureDistanceDistanceDistanceDistanceAnnual sales or receiptsAnnual payrollDistance to:HydrantFire stationFire districtFire district numberPropertyBLDGBLKT #Limit% CoinsValuationINFL %DED TypeDEDCodePremiumPROPPERSBLKT #Limit% CoinsValuationINFL %DED TypeDEDCodePremiumYear builtConstruction typeStories #SPRNK %Basement present ?YesNoIs it finished ?YesNoWind ClassResistiveSemi-resistiveOtherBuilding improvementsWiring yearRoofing yearPlumbing yearHeating yearRoof yearBLDG Code GradeInspected?YesNoGrande developed forCommunitySpecific propertyTax CodePremises general inforamation1. Does applicant have a heating or processing boiler?YesNo2. Any specialized equipment, such as medical equipment or other, valued over $100,000 ?YesNo3. Is all equipment inspected annually and well maintained ?YesNo4. Is there a swimming pool on premises?YesNo5. Is there building under construction?YesNoApartments and condominiums1. Is there a playground on premises?YesNo2. Is aluminum wire used?YesNo3. Is developer or contractor a board member?YesNo4. Is a property manager employed?YesNoSubmit