Accord 131 form excess liability 131 accord form Excess Liability Submission DateProposed Effective DateBusiness NameContact NameContact TypeAddressEmail AddressPhoneDescription of businessAnnual payrollAnnual gross salesForeign gross salesNumber of EmployeeGeneral Liability SectionPolicy TypeOccurenceClaims MadCarrierPolicy NumberPolicy Effective DatePolicy Expirate DateLimitsEach OccurenceGeneral AggregateProducts and Completed Operations AggregatePersonal and Advertising InjuryDamage to Rented PremisesMedical ExpenseInformationAre defense costs:---Select---Whithin aggregate limits?A separate limit?Unlimited?Date of the ISO form or similar filing for the Underlying CoverageHas any product, work, accident or location been excluded, uninsured or self-insured from any previous coverage?YesNoAdditional Exposures 1. Media usedAnnual cost2. Are services of an adverstising agency used?YesNo3. Any coverage provided under agency's policy?YesNo4. Does applicant own/lease/operate aircraft?YesNo5. Are explosives, caustics, flammables or other dangerous cargo hauled?YesNo6. Are passengers carried for a fee?YesNo7. Any units not insured by underlying policies?YesNo8. Are any vehicles leased or rented to others?YesNo9. Are hired and non-owned coverages provided?YesNo10. Is bridge, dam, or marine work performed?YesNo11. Describe typical jobs performed12. Describe agreement13. Does applicant own, rent, or otherwise use cranes?YesNo14. Do subcontractors carry coverages or limits less than applicant?YesNo15. Is applicant self-insured in any state?YesNo16. Subject to:Jones actFelaStop gapOtherIf Other Describe17. Is a hopital or first aid facility maintained?YesNo18. Are coverages provided for doctors / nurses?YesNo19. Indicate number ofDoctorsNursesBeds20. Do current or past products, or their components, contain hazardous materials that may require special dosposal methods?YesNo21. Indicate the coverages carriedGL with standard iso pollution exlcusionGL with standard sudden and accidental onlyGL with pollution coverage endorsementSeparate pollution coverage22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft?YesNo23. Any foreign operations, foreign products disturbed in the USA or us products sold/distributed in foreign countries?YesNo24. Product liability loss in past three(3) years?YesNo25. Gross sales from each of the last three(3) years?26. Describe independent contractors27. Does applicant own or lease watercraft?YesNo28. Apartements / Condominums/ Hotels/ MotelsNumber StoriesNumber UnitsNumber Swimming poolsNumber Diving boardsSubmit
