Accord 160 BOP

Submission Date

Proposed Effective Date

Business Name

Contact Name

Contact Type

Street Address

City, State, ZIP code

Email Address

Phone

General Information

1. Do/ Have past, present or discountinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material?

2. Are athletic teams sponsored?

3. Do you obtain and verify certificates of insurance obtained from subcontractors, manufacturers and/or suppliers?

4. Do you lease employees to or from other employers?

5. Do you own or operate any other business?

6. In addition to your primary nature of business are you also involved in the manufacture, relabeling or repackaging of others products?

7. In addition to your primary nature of business, are you also involved in the mixing of others products?

8. Do you rent or loan equipment to others?

9. Does the operation have hours after 9:00 P.M and/ or 24 hour operations?

Premises

Check if primary premises *

Location number

Bulding number

Building description

Description of all occupancies at this premises

Surrounding exposures & other occupancies

Right exponsure

Left exponsure

Front exponsure

Rear exponsure

Distance

Annual sales or receipts

Annual payroll

Distance to:

Hydrant

Fire station

Fire district

Fire district number

Property

BLDG

BLKT #

Limit

% Coins

Valuation

INFL %

DED Type

DED

Code

Premium

PROPPERS

BLKT #

Limit

% Coins

Valuation

INFL %

DED Type

DED

Code

Premium

Year built

Construction type

Stories #

SPRNK %

Basement present ?

Is it finished ?

Wind Class

Building improvements

Wiring year

Roofing year

Plumbing year

Heating year

Roof year

BLDG Code Grade

Inspected?

Grande developed for

Tax Code

Premises general inforamation

1. Does applicant have a heating or processing boiler?

2. Any specialized equipment, such as medical equipment or other, valued over $100,000 ?

3. Is all equipment inspected annually and well maintained ?

4. Is there a swimming pool on premises?

5. Is there building under construction?

Apartments and condominiums

1. Is there a playground on premises?

2. Is aluminum wire used?

3. Is developer or contractor a board member?

4. Is a property manager employed?