ACORD 126 (2016/09) Attach to ACORD 125 1993-2016 ACORD CORPORATION. All rights reserved. 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, …

ACORD 126 (2007/05) Page 3 of 4 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION …

(If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) 12. AGENCY CUSTOMER ID: ACORD 125 (2016/03) Page 3 of 4 OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use) 15.

acord 126 (2009/08) ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY

additional interest/certificate recipient acord 45 attached for additional names employee as lessor lienholder mortgagee loss payee additional insured interest rank: name and address reference #: certificate required other scheduled item number: vehicle: boat: location: building: interest in item number item description: general information

acord 126 (2011/09) page 2 of 4 agency customer id: contractors time staff: # part-time staff: # full-subcontracted: % of work contractors: describe the type of work subcontracted $ paid to sub-6. does applicant lease equipment to others with or without operators? 5. are subcontractors allowed to work without providing you with a certificate of ...

acord 126-s (1/97) please complete reverse side oc acord corporation 1993 date (mm/dd/yy) producer phone (a/c, no, ext): code: sub code: agency customer id: applicant (first named insured) effective date expiration date payment plan audit for company use only commercial general liability owner’s & contractor’s protective deductibles

OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) LOC HAZ CLASSIFICATION CLASS PREMIUM EXPOSURE TERR RATE PREMIUM ## CODE BASIS PREM/OPS PRODUCTS PREM/OPS PRODUCTS RATING AND PREMIUM BASIS YES NO …

acord 126 (2004/03) attach to applicant information section. date (mm/dd/yyyy) agency phone applicant (a/c, no, ext): fax (first ... subject of insurance amount coins % valuation causes of loss deductible(s) forms and conditions to applyguard % # additional information business income / extra expense - attach acord 810 value reporting ...

ACORD 126 (2007/05) Page 3 of 4 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION …