Accord 125 - Universal Marketing and management

Accord 125 Commercial Insurance Application

Submission Date

Proposed Effective Date

Business Name

Contact Name

Contact Type

Street Address

City, State, ZIP code

Email Address

Phone

Type of Company

If Other Describe

NO. of members and managers

Business Start Date

Years of experience in this industry

Full-Time Employees

Part-Time Employees

Projected annual Revenue

Projected annual Payroll

Square footage of your business

Nature Of Business

If Other Describe

PREMISES INFORMATION

STREET

CITY:

STATE:

COUNTY:

ZIP

City Limits

Other city limits

Interest

Other interest

Description of operations

1a. Is the applicant is 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?

4. Any Other Insurance in this Company?

5. Any policy or coverage declined, cancelled or non-renewed during the prior three(3) years for any premises or operations?

6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?

7. During the last 5 years (10 in RI), has any applicant been indicted for or convicted of any degree of the Crime of Fraud, Bribery, Arson or any another Arson-related crime in connection in this or any other Property?

8. Any uncorrected fire and/or safety code violations?

9. Has the applicant had a foreclosure, repossession, bankruptcy or field for bankruptcy during the last five (5) years?

10. Has the applicant had a judgement or lien during the last five (5) years?

11. Has business been placed in a trust?

12. Any foreign operation, foreign products distributed in USA, or US products sold/distributed in foreign countries?

13. Does the applicant have other business venture for which coverage is not requested?

14. Does applicant own/ lease/ operate any drones?

15. Does applicant hire others to operate drones?