—! ACORDY COMMERCIAL INSURANCE APPLICATION ae RT Ve APPLICANT INFORMATION SECTION 40/1 9/2023 Taener CARRIER Sac ston Insurance Agony Pian svanso reup eo arose roca $95 ome Gr STE A St Gouge Ur crs. 7009 freuen SA" Resa viadon oT RR RCE Fee ey 95092000 Bs mene Jee Jessa [Jam sfliss Talcon@ painonnsgou com eon sce ove ot ncaa SECTIONS ATTACHED Gamer ——|s eromousownen: | EAE, : S0.EFaINONERT o EaIPNeT ROMER o racee eToxemaiat [9 comcrontenemunaury [3 ASTON SUBSE [3 = ‘ATTACHMENTS POLICY INFORMATION tovisao29 | taroz028 : : : Xercer| csr "RBBLICANT NF ORUATION Rafts MOMMLNOROORES aE DPG aa = ma Teo Wem Edson oseop PoROK 840787 armen nee Loe ur 2a ‘CORPERATON |_| ONTVENTURE [por rowrnortons | _[suenarrens comomnon |] nore ce grasa recreate mst ke nevaiteest 0 mA AOR aye eae = Dry Tanna eee Rk oe noreesucA 0 RALNG OURS TPE aaa = mas Fanensorsee "AGORD 125 (207303) Page oté © 1085 201SACORD CORPORATION. AllFGNs SENG ‘The ACORD name and loge are registered marks of ACORDCONTACT INFORMATION AGENCY CUSTOMER 1D: [eowacrrere, Ovnor concn eowpaczasue Wiha Eso Jaap eowartnaue. Ray Crow en Gem |S Oro Oes au [ay Crees Com [SSRI Crom Cee Oo "raset7-a26 peneryeaus snonens wil ojsicp@omal com penanv ca saoaes PREMISES INFORMATION (Afiah ACORD 823 for Addional Promo) Toe | SET ‘rvs [TEREST FAL TRE [RAL RETR oc SET eaves [ERE TAAL TRE PL [AMAL RETEWER NATURE OF BUSINESS fons |_[cawmcron [emmcnmne []eewamer [Jemven [X] Relgous Oanzaion | BERS Rams conooms [| nermrons. || orrce ners ces ‘sport Religious Organizaion/Churen ‘ADDITIONAL INTEREST (Not all fields apply to al scenarios - provide only the necessary data| Attach ACORD 45 for more Additional nteresis [LENANOUNT ‘RIONE NE, Na Et FAKE “ACORD 125 (2013100) Page? of(GENERAL INFORMATION AGENCY CUSTOMER ID: 7a. ISTHE APPLCANTA SUBSIDIARY OF ANOTHER ENT? N 7E, DOES THE APPLCANT HAVE ANY SUBSDARIES? W [2 ISAFORNAL SAFETY PROGRAM NOPERATION SAFETY MANUAL, 3X wovnieymeeravas [3 ANY EXPCSURETO FLANNAGLES, EXPLOSIVES, CHEMICALS? W a. ANY OTHER INSURANCE WHITH THIS COMPANY? (Lat pokey numbers] W [5 Ai POLIGY GF COVERAGE DECLINED, CANCELLEDOR WON RENEWED DURING THE PRIOR THREE G) YEARS FOR ANY PREMISES OR ‘GBERATICNS? (iovow Applicarta- Do notarower tis guration) NOW PAMEAT | ACENTHO LONGER REPRESENTS CARTER a oecreran —[]ecrarre [| eovcron comecreD oes [7 DURING THE LAST FIVE VEARS (TEW IR] HAS AW APPLICINT BEEN NDICTED FOR OR CONVICTED OF AN DEGREE OF THE CRNEOF FRAUD, (Rls qiasto muse ansnera y ay apocar popaly mmuanes, Penulc decose le xblenceoTana'son Cowen emistoncana punstatke by asemiaoco' tp bone yaurotmprserem), [a HAS APPLICANT HAD-AFOREGLOSURE, REPOSSESSION ANIKRUPTCV OR FILED FOR BANKRUPTCY BUFING THE LAST FUE @) YEARS? 10, HASAPPLCANT HAD A JUDGEMENT OR LEN DURING THE LAST FVE (| YEARS? "7, AY FOREIGNOPERATIONS, FORE ISN PRODUCTS OISTRIBUTEDIN USA, OR USPRODUCTS SOLDIDISTABLTED W FOREIGNCOUNTRIES? [UVES" ataeh ACORD 815 or Lnity Egon ary ACORD 816 rapa Esper TE, DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR VIKIGH GOVERAGE B NOT REQUESTED? REMARKS | PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PRIOR CARRIER INFORMATION AEORD 125 (204300) Page? offPRIOR CARRIER INFORMATION (continued) AGENCY CUSTOMER O: LOSS HISTORY )X[Checkif none _(Atlach Loss Summary for Additonal Loss Information) ‘SIGNATURE, (Copy ct renews oT rtaraton Facies (PmVa)) hs toe gveno Be appical (Nal equnedtal Sass, conan yauragotlo’ DOK Biyeu' Saws Yequraneas) ‘OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUESEGUENT ANENONENTS AND RENEWALS. SUCH NFCRMATON AS WELL AS OTHER PERSONAL AND PRVLEGED INFCRIMATON COLLECTED BY US OR OUR AGENTS NAY IN CERTAIN CIRCUMSTANCES SE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORUATION. CREDIT SCORNG INFORMATION NAY BE USED 0 HELP DETERWNE SITHER YOUR ELIGEILITY FOR MSURANCE OR THE REVIEW YOUR PERGOKAL INFCRIATION IN OUR FILES AKO REQUEST CORRECTION OF ANY RACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN HOW TO SUBMIT AREQUEST TOUS “OR A MORE D= TALEDD=SCRIPTIONO® YOUR RIOHTS AND OUR PRACTICES REGARDING PERSONAL NFORMATION (ct anatcabiein AZ.CA, DE, KS, MA, MN. ND, NY. OR VA.or WV. Specie ACORD 38s ae avalabo branolcant hese sas ) ost Wits ‘Applicable in AL, AR, DG, LA, MD, NM, Rand WV: Any person who krowinaly (or wilfully)" presents a fase or fraudulent damm for payment ofa loss or hone or knowingly [or willl presants fae information in an application for nsurance is guily of a cro and may ba sibjectto fines and corfieemant prison. “Apples fh MD Only ‘Applicable in CO: It is unawul to knowingly provide false, incomplete, oF misleading facts or infomation to an insurance company forthe purpose of Getrauding or atampting tb dafiaud the company. Penalios may indude imprisonment, fnes, denial of insurance and iil damages fn) insuranco ‘company or agent ofan insurance company who Knowingly provides false, incomplote, of misleading facts or information to a patcyholcer or claimant for tho purpose of defrauding or attemping io detraud me potcynolser or calmant wn regard io a seltement or aware payable ram insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies ‘Applicable in FL and OK: Any person whe Inowingly and with intent to injure, defauc, or deceive any insurer fies @ statement of caim or an applicaion Containing ary false, incomplete, or misleading ivoraion 's guy ofa felony (of tne tied degree). “Apples in FL Oniy. Applicable in KS: Any person who, krowinly and witnntart to defraud, prosonis, causes to bo praconted or prepares with inowlodge or batat that it willbo presented to or by an insurer, purporied insurer, broker or any agent thereef, any writen stalement as pat of, orn support of, an appicaton forthe issuance {oF the ‘ang of an insurance poly for personal or commercial surance, or a cain for payment cr her benalt pursuani 12 an surance policy for ‘commercial or personal surance which Such person knows to contain mately false information concerring any fact material herete: or conceals, for tha purpose of misleading, lxomation consoming any fast mataral thot commits Fauculbrt nauranco act ‘Applicable in KY, NY, OH and PA: Ary person who knowngly and with intent to defraud any insurance company or other person fles an application for ineurance orstatarsent of claim containing ary matarallyfalsa nformaton or enceals forthe purpose of misleading, nformaton concaming any fact atrial ‘hereto commis a Feudulont neurance act, which & a efimo and subjects auch parson to cimina’ ang cil ponaltes (acto oxc2ed five thovaand dollars and ‘ne tated value ofthe clin foreach uch violation), “Apples in NY’ Only, Applicable ia ME, TN, VA and WA: isa ermo toknowingly provide flee, incomplete o* misleading information to an insurance company forthe purpose of defrauding the company. Penalies (may) include imprisonment, [nes and denial of surance benefts, “Applies in ME Only Applicable in NJ: ‘Ary parson who incites any falsa or misleading information on an appleation for an insuranee policy i subject fo minal and chil ponltos ‘Applicable la OR: Ary person who snewingly and with intent to defraud or solo another Yo detiaud the insurer by sudmiting an application containing a {alae saioment 2s to-any material fac may be veatng sate ian. ‘Applicable In PR: Any person who knowingly and wi the hlention & Gerauding pesents fale infomation in an insurance appicaton, or presents eps, (of causes the presentation oa faudulent claim forthe payment of alossor any other beneft or orasents mere than one claim for the same damage or loss. Shal incur aatony and, upon conviction, shal ba sanctioned for each vation by 2 fhe cf nc ass than fue thousand colars (85,000) and nek moe than to ‘reusané collars ($10,000), or axed torm ofimprisenment for tee (3 years, or both penalties. Should aggravating creumiances fe] resort, tho penally ‘hus estabisned may ve increased to a maximum of ve (5) years, extenuating creumstances are present, Ii may be reduced to 2 minimum of M0 (2) “THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE O= THE APPLIGANT AND REPRESENTS THAT REASONABLE INGUIRY FAS BEEN MADE TO OBTAIN THE ANSWERS TO QLESTIONS ON THIS APPLICATION. HESHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORNECT AND COMPLETE [0 THe SEST OF HIMES FNOWLEDCE, Fproucens wATURE ‘PRODUITS AANE Pes Poa) ana Robin Walden soner2023 ‘ACORD 125 (207300) Paget off