Loading...
HomeMy Public PortalAbout063-2012 - Highland Lake Golf Course - Liquor Liability Policy.COMMERCIAL INSURANCE: APPLICATION A.CORQ. APPLICANT INFORMATION SECTION DATE AGENCY - RMD/Patti Insurance & Financial Services 36 South 9th Street P . 0. BOX 1167 Richmond, IN 47375 CARRIER - Burns & Wilcox Ltd. NAIC CODE �008 UNDERWRITER: UNDERWRITER OFFICE; POLICIES OR PROGRAM REQUESTED POLICY NUMBER XL50066567 INDICATE SECTIONS ATTACHED ELECTRONIC DATA PROC EOUlPMENT FLOATER GARAGE AND DEALERS GLASS AND SIGN INSTALLATION/BUILDERS RISK OPEN CARGO PROPERTY TRANSPORTATION! MOTOR TRUCK CARGO TRUCKERSfMOTOR CARRIER UMBRELLA VEHICLE SCHEDULE WORKERS COMPENSATION YACHT ° ACCOUNTS RECEIVABLEI VALUABLE PAPERS BOILER & MACHINERY BUSINESS AUTO COMMERCIAL GENERAL LIABILITY CRIMEIMISCELLANEOUS CRIME DEALERS DRIVER INFO SCHEDULE X CONTACT NAME: Julie Garrett PHONE 765.966.7531 AIC No Ext ; FAX 765.935 - 2476 A!C No): ADDRESS: julieg@rmdpatti.com CODE: SUB CODE: AGENCY CUSTOMER ID: 00004245 STATUS OF TRANSACTION PACKAGE POLICY INFORMATION QUOTE ISSUE POLICY RENEW BOUND (Give Date and/or Attach Copy): CHANGE DATE TIME AM CANCEL PM ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES. PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN AUDIT O5/21/ZO1Z 05/Z1/z073 DIRECT BILL AGENCY BILL dX PACKAGE POLICY PREMIUM: $ APPLICANT INFORMATION NAME (First Named Insured & Other Named Insureds) MAILING ADDRESS INCL ZIP+4 (of First Named Insured/ City of Richmond City Building 50 North 5th Street Richmond, IN 473.74 MIN OR SOC SEC (of.First Named Insured): 000-00-0000 PHO"£AIC No, o Ext 765.983.7244 E-MAIL WEBSITE ADDRESS ES: ADDRr ES INDIVIDUAL CORPORATION SUBCHAPTER "S" CORPORATION LLC AND MANAGERS CR BUREAU NAME: DATE BUS STARTED PARTNERSHIP JOINTVENTURE PROFITOORG X Other ID NUMBER: INSPECTION CONTACT: ACCOUNTING RECORDS CONTACT: WONT— E-MAIL A1C No, Ext : ADDRESS: ONE AIC, No, Ext : I ADDRESS: PREMISES INFORMATION I I ACORD 823 attached for additional premises LOC # BLD # STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST BUILT EMPLOYEES ANNUAL REVENUES OCCUPIED •• fi}'T 2 h 4�j1:1, ZyQ, t ILI INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT INSIDE OUTSIDE OWNER TENANT immiu r- Vr Vr Vrr_r[Fi11VI4J DT r-mawi10ElAt Contract No. 63-2012 Page 7 of 3 ©1993-2007 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD City of Richmond _ Applicant Information Supplemental Schedules RMD/Patti Insurance & Financial Services Named Insureds Named Insured Entity Type Insured Type City of Richmond Other First Named Insured N i., P1 N ) L. G L } P , Ynvt-,? PA-y-K -0�-(JT AGENCY CUSTOMER ID: 00004245 A rHr.srn wi \I r^nww w T1^&l EXPLAIN ALL "YES" RESPONSES YIN la. IS THE -APPLICANT A SUBSIDIARY OF ANOTHER ENTITY?n 1b, DOES THE APPLICANT HAVE ANY SUBSIDIARIES? 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? 4. ANY CATASTROPHE EXPOSURE? 5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? ��, p I 6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON -RENEWED DURING THE PRIOR THREE (3) YEARS? (Not applicable in MO) IR 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY IA'� N] OTHER ARSON -RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 9. ANY UNCORRECTED FIRE CODE VIOLATIONS? l� 10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST FIVE (5) YEARS? 11. HAS BUSINESS BEEN PLACED IN A TRUST? IF "YES", NAME OF TRUST: — 12. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) REMARKSIPROCESSING INSTRUCTIONS (Attach additional sheets If more space is required) COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your states requirements.) NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. 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 FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND ]NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE PRODUCER'S NAME (Please Print) LIGEN5E NO (Required in Florida) APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER ACORD 125 (2007110) - rage z of a DGIRID P_ADDIRD IMGf1D1UlATInM AGENCY CUSTOMER ID: 00004245 LINE- CATEGORY CARRIER 1 POLICY NUMBER POLICYTYPE ADE / MADE 7 OCCURRENCEE M CLAIMS OCCURRENCEE C-MS OCCURRENCEE CLAIMS OCCURRENCEE CLAIMS OCCURRENCE RETRO DATE G E EFF-EXP DATE N GENERAL AGGREGATE C E p PRODUCTS COMP OP AGGREGATE A M L PERSONAL & ADV INJ M E EACH OCCURRENCE R L C L I FIRE DAMAGE A AM M MEDICAL EXPENSE L L I T S BODILY OCCURRING I INJURY AGGREGATE T Y PROPERTY OCCURRENC DAMAGE AGGREGATE COMBINED SINGLE LIMIT MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER POLICYTYPE A L T I EFF-EXP DATE A M B COMBINED SINGLE LIMIT o I L EA PERSON B T BODILY INJURY EAACCIDENT E Y PROPERTY DAMAGE MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER R POLICY TYPE EFF-EXP DATE P E BUILDING AMT R T PERS PROP AMT Y MODIFICATION FACTOR TOTAL PREMIUM CARRIER POLICY NUMBER POLICY TYPE EFF-EXP DATE LIMIT MODIFICATION FACTOR TOTAL PREMIUM 1 r%Q* 141QTADV ENTER ALL CLAIMS OR LOSSES FOR THE PRIOR (REGARDLESS 5 YEARS 3 YEARS F FAULT AND ETHER OR NOT INSURED) ROCCURRENCESTHATGIVE RISE TO CLAIMSCHK IN & HERE IF NONE SEE ATTA HED LOSS SUMMARY DATE OF OCCURRENCE LINE TYPEIDESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED CLAIM STATUS OPEN CLSD REMARKS NOTE: FIDELITY REOUIRES A FIVE YEAR LOSS HISTORY ATTACHMENTS STATE SUPPLEMENT(S) (If applicable) ACORD 125 (2007/10) Page 3 of 3 ACO R D® AGENCY CUSTOMER ID- 00004245 UMBRELLA 1 EXCESS SECTION HATE(MMlDOlYYYY) AGENCY APPLICANT {First Named Insured} RMD/Patti Insurance & Financial Services City of Richmond POLICY NUMBER CARRIER NAIC CODE XLS0066567 Burns & Wilcox Ltd. P008 EFFECTIVE DATE EXPIRATION DATE DIRECT BILL PAYMENT PLAN AUDIT FOR COMPANY USE ONLY 05/21/2012 05/21/2013 NOAGENCY BILL POLICY INFORMATION - TRANSACTION TYPE LIMIT OF LIABILITY RETAINED LIMIT X NEW RENEWAL UMBRELLA EXCESS OCCURRENCE CLAIMS MADE RETROACTIVE DATE $ 4,000,000 EA OCC $ 4,000,000 Aggregate $ $ PROPOSED CURRENT EXPIRING POL #: FIRST DOLLAR DEFENSE {Y!N] L EMPLOYEE BENEFITS LIABILITY LIMIT OF INSURANCE (Ea Employee) AGGREGATE LIMIT FOR EBL RETAINED LIMIT FOR EBL RETROACTIVE DATE FOR EBL $ $ $ NAME OF BENEFIT PROGRAM PRIMARY LOCATION P. SIIBSInIARIFS (ACORI] 4.21;1 # NAME AND LOCATION OF PRIMARY AND ALL SUBSIDIARY COMPANIES (Describe Operations) ANNUAL PAYROLL ANN GROSS SALES FOREIGN GROSS SALES # EMPL NAME: See Attached' 125 LOCATION. DESCRIPTION: NAME: LOCATION: - DESCRIPTION: NAME: LOCATION: - DESCRIPTION, NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: NAME: LOCATION: DESCRIPTION: �U►1N�;�AII►[H1�6Y�1;7_1�Ly� LIST ALL LIABILITYICOMPENSATION POLICIES IN FORCE TO APPLY AS UNDERLYING INSURANCE + - TYPE CARRIERIPOLICY NUMBER POLICY EFF DATE POLICY EXP DATE LIMITS ANNUAL RENEWAL PREMIUM RATING MOD AUTOMOBILE LIABILITY CSL EA. ACC. $ $ BI EA. ACC. $ $ BI EA. PER. $ $ PD EA. ACC. $ $ GENERAL LIABILITY POLICY TYPE OCCUR CLAIMS MADE ' JjAze5 1-I" ii4-I`j Buis if '?s�Cr J t L +� 0 tZ L• P �i uYY a '/I I '�� % EACH OCCURRENCE $ f,Cfel!7 CC& PREMIOPS GENERAL AGGR $a. oo PROD & COMP OPS AGGREGATE $ PRODUCTS $ PERSONAL & ADV INJURY $ D RENTED PREMISES $ OTHER $ MEDICAL EXPENSE $ EMPLOYERS LIABILITY EACH ACCIDENT $ $ EACH EMPLOYEE $ POLICY LIMIT $ ATTACH TO ACORD 125 AND ACORD 126 AGOKD 131 (ZUU71UU) Page 1 of 5 V 1991-2007 ACORD CORPORATION. All rights reserved. The ACORD name and Pogo are registered marks of ACORD t mK=ol vmrt IAICE ioAmr m lnnn4ln moll AGENCY CUSTOMER ID: 00004245 UNDERLYING GENERAL LIABILITY INFORMATION (Explain all "YES" responses) _ 1. ARE DEFENSE COSTS: I I WITHIN AGGREGATE LIMITS? A SEPARATE LIMIT? UNLIMITED? 2. INDICATE THE EDITION DATE OF THE ISO FORM OR SIMILAR FILING FOR THE UNDERLYING COVERAGE: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF INSURED FROM ANY PREVIOUS COVERAGE? (YIN) 4. FOR CLAIMS MADE, INDICATE RETROACTIVE DATE OF CURRENT UNDERLYING POLICY: 5. FOR CLAIMS MADE, INDICATE ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 6. FOR CLAIMS MADE, WAS "TAIL" COVERAGE PURCHASED FOR ANY PREVIOUS PRIMARY OR EXCESS POLICY? (YIN) EFF. DATE: CHECK ALL COVERAGES IN UNDERLYING POLICIES. ALSO CHECK IF ANY EXPOSURES ARE PRESENT FOR EACH COVERAGE, PROVIDE AN EXPLANATION. EXPLAIN IF DIFFERENT LIMITS, EXTENSIONS, OR EXCLUSIONS, EXPLAIN ANY SPECIAL COVERAGES BEYOND STANDARD FORMS. EXPLAIN ALL EXPOSURES. CHECK IF APPROPRIATE COVERAGE EXPOSURE I COVERAGE EXPOSURE ANY AUTO (SYMBOL 1) CGL - CLAIMS MADE CGL-OCCURRENCE CARE, CUSTODY, CONTROL EMPLOYEE BENEFIT LIABILITY FOREIGN LIABILITY/TRAVEL GARAGEKEEPERS LIABILITY INCIDENTAL MEDICAL MALPRACTICE LIQUOR LIABILITY POLLUTION LIABILITY PROFESSIONAL LIABILITY (E&O) VENDORS LIABILITY WATERCRAFT LIABILITY COVERAGE EXPOSURE rRCFTLIABILITY TPASSENGER LIABILITY AL INTERESTS UNDERLYING INSURANCE COVERAGE INFORMATION (INCLUDE ALL RESTRICTIONS; E.G. LASER ENDORSEMENTS, DISCRIMINATION, SUBROGATION WAIVERS, OR EXTENSIONS OF COVERAGE - ATTACH SEPARATE SHEET IF NECESSARY) ONtl PREVIOUS EXPERIENCE: (GIVE DETAILS OF ALL LIABILITY CLAIMS EXCEEDING $10,000 OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS, DURING THE PAST 5 YEARS, WHETHER INSURED OR NOT. SPECIFY DATE, COVERAGE, DESCRIPTION, AMOUNT PAID, AMOUNT OUTSTANDING -ATTACH SEPARATE SHEET IF NECESSARY) 1-1 NO SUCH CLAIMS nwo= ^"ovf%nv riAL170A1 �i LOC PROPERTY TYPE VALUE A B' C' D' SO FT OF BLDG OCC REAL PERSONAL OCCUPANCY 1 DESCRIPTION OF PERSONAL PROPERTY APPLICANT: [A] IS HELD HARMLESS IN THE LEASE, [B] HAS A WAIVER OF SUBROGATION, [C] IS A NAMED INSURED IN THE FIRE POLICY, [D] OTHER (specify) TYPE N OWNED OWNED LEASED PROPERTY HAULED 0-So MI SO-200 MI 200 MI PRIVATE PASSENGER LIGHT MEDIUM TRUCKS HEAVY EX. HEAVY TRUCKS/ HEAVY TRACTORS EX HEAVY BUSES ACORD 131 (2007/09) rage z or o AGENCY CUSTOMER ID: 00004245 EXPLAIN ALL "YES' RESPONSES, PROVIDE OTHER INFORMATION REQUIRED YIN ADVERTISERS LIABILITY 1. MEDIA USED: ANNUAL COST: $ 2. ARE SERVICES OF AN ADVERTISING AGENCY USED? 3, ANY COVERAGE PROVIDED UNDER AGENCY'S POLICY? AIRCRAFT LIABILITY 4. DOES APPLICANT OWNILEASEIOPERATE AIRCRAFT? AUTO LIABILITY 5. ARE EXPLOSIVES, CAUSTICS, FLAMMABLES OR OTHER DANGEROUS CARGO HAULED? 6. ARE PASSENGERS CARRIED FOR A FEE? El 7. ANY UNITS NOT INSURED BY UNDERLYING POLICIES? 71 8. ARE ANY VEHICLES LEASED OR RENTED TO OTHERS? 9. ARE HIRED AND NONIOWNED COVERAGES PROVIDED? CONTRACTORS LIABILITY 10. IS BRIDGE, DAM, OR MARINE WORK PERFORMED? El 11. DESCRIBE TYPICAL JOBS PERFORMED (Attach additional sheets if more space is required) 12. DESCRIBE AGREEMENT (Attach additional sheets if more space is required) 13. DOES APPLICANT OWN, RENT, OR OTHERWISE USE CRANES? 14. DO SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN APPLICANT? EMPLOYERS LIABILITY 15. IS APPLICANT SELF -INSURED IN ANY STATE? 16. SUBJECT TO: JONES ACT FELA STOPGAP OTHER: INCIDENTAL MALPRACTICE LIABILITY 17. IS A HOSPITAL OR FIRST AID FACILITY MAINTAINED? 18. ARE COVERAGES PROVIDED FOR DOCTORS I NURSES? IS. INDICATE #OF DOCTORS: NURSES: BEDS: ACORD 131 (2007109) rage 0 01 0 . -- V. ,-1 AGENCY CUSTOMER ID: 00004245 EXPLAIN ALL "YES" RESPONSES, PROVIDE OTHER INFORMATION REQUIRED YIN EPA #; POLLUTION LIABILITY 20. DO CURRENT OR PAST PRODUCTS, OR THEIR COMPONENTS, CONTAIN HAZARDOUS MATERIALS THAT MAY REQUIRE SPECIAL DISPOSAL METHODS? 21. INDICATE THE COVERAGES CARRIED: GL WITH STANDARD ISO POLLUTION EXCLUSION GL WITH POLLUTION COVERAGE ENDORSEMENT GL WITH STANDARD SUDDEN & ACCIDENTAL ONLY FISEPARATE POLLUTION COVERAGE PRODUCT LIABILITY 22. ARE MISSILES, ENGINES, GUIDANCE SYSTEMS, FRAMES OR ANY OTHER PRODUCT USED / INSTALLED IN AIRCRAFT? 23. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN THE USA OR US PRODUCTS SOLD ! DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES", Attach ACORD 815) 24. PRODUCT LIABILITY LOSS IN PAST THREE (3) YEARS? (SPECIFY) 25. GROSS SALES FROM EACH OF LAST THREE (3) YEARS: $ $ $ PROTECTIVE LIABILITY 26, DESCRIBE INDEPENDENT CONTRACTORS (Attach additional sheets if more space is required) WATERCRAFT LIABILITY 27. DOES APPLICANT OWN OR LEASE WATERCRAFT? Des C : LENGTH HORSEPOWER #OWNED LENGTH HORSEPOWER !!! APARTMENTS I CONDOMINIUMS I HOTELS I MOTELS # STORIES # UNITS # SWIMMING POOLS I # DIVING BOARDS #STORIES # UNITS # SWIMMING POOLS # DIt7:!5 REMARKS (Attach additional sheets it more space Is requlrea) ACORD 131 (2007/09) Page 4 of 5 ncsenn�c AGENCY CUSTOMER ID: 00004245 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 FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied) IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, 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 FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IF THE COMPANY TO WHICH I AM APPLYING OFFERS UNINSURED MOTORISTS (UM) AND/OR UNDERINSURED MOTORISTS (UIM) COVERAGE IN MY STATE: w 0- UNDERINSURED MOTORISTS (UIM) COVERAGE: $ e-- UNINSURED MOTORISTS (UM) COVERAGE: $ IF APPLICABLE IN YOUR STATE APPLICABLE ONLY IN GEORGIA, LOUISIANA NEW HAMPSHIRE VERMONT AND WISCONSIN APPLICABLE ONLY IN GEORGIA AND LOUISIANA: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS, UM LIMITS LOWER THAN MY LIABILITY LIMITS, OR TO REJECT UM COVERAGE ENTIRELY. 1. 1 SELECT UM LIMITS INDICATED IN THIS APPLICATION. OR 2. 1 REJECT UM COVERAGE IN ITS ENTIRETY. (INITIALS) (INITIALS) APPLICABLE ONLY IN NEW HAMPSHIRE: I ACKNOWLEDGE THAT UM COVERAGE HAS BEEN EXPLAINED TO ME, AND I HAVE BEEN OFFERED THE OPTION OF SELECTING UM LIMITS EQUAL TO MY LIABILITY LIMITS OR TO REJECT UM COVERAGE ENTIRELY. 1. 1 SELECT UM LIMITS INDICATED 1N THIS APPLICATION. OR 2. 1 REJECT UM COVERAGE IN ITS ENTIRETY. {INITIALS) {INITIALS) APPLICABLE ONLY IN VERMONT, I ACKNOWLEDGE THAT I HAVE BEEN OFFERED UM COVERAGE EQUAL TO MY LIABILITY LIMITS. I HAVE SELECTED THE LIMITS INDICATED IN THIS APPLICATION. APPLICABLE ONLY IN WISCONSIN: UM COVERAGE: ❑ IS AVAILABLE IS NOT AVAILABLE UIM COVERAGE: ❑ IS AVAILABLE ❑ IS NOT AVAILABLE IMPORTANT - THE STATEMENTS (ANSWERS) GIVEN ABOVE ARE TRUE AND ACCURATE. THE APPLICANT HAS NOT WILLFULLY CONCEALED OR MISREPRESENTED ANY MATERIAL FACT OR CIRCUMSTANCE CONCERNING THIS APPLICATION. THIS APPLICATION DOES NOT CONSTITUTE A BINDER. APP ANT$ GNATURJ_LE _____[ DATE '] % j! O` ` ACORD 131 (2007/09) 1 Rage 6 or 5 SCOTTSLIALE IlrTSZJRANCE CO1NiPANX° POLI BOLD RIDISCYYYURE TFRRL1Ri8M RISK OWURANCEACr I. Under the Tumcbm Risk hwumm Ant of 2M as ameadad pursmrtt to theTtualsmPft Mm== PwN mRcn*=t&= Act of M, a"w Taavary► I.2M tha "Acts, 34u hava a light to � � co�wersgo ibr tames addng ant of ads of Leu[miem, as defind n Secular 102(i) tf meAct: fire tent "wed WU of terrorism° i4te = any act tint is certified by the Socrelery . of the Musm" con mem wilh thr: Secretary offtle, and U*Attaumry t3mard aims United Statw4o be an ex offenrimtr to be a vid t act or an ad drat is dangeratm io h— M, propar A or inGastt CM% to ban resulted in &amp within me Uaad States, at uWWe McUdtod Staks in dw can of oertaira air cemim or vessels or me pmnbas era thtlted $No r Ww, to have been aommitoad by an individual our individuals as past man afAut so ooetce civilian pogula6oa adf the United States or tolmOusaw dis galley oraffhet iha cond+metof the tJ,Qited Slates Oavt by . You sb wM fnsaw 6atwham cwmpis pwvidod by pd* for kwes rows g from "cut6d acts of twomse r& loam may be put* nimWrmed by the Ud6ed States Gov: mt uaft a formula established by federal law. HowvmeA your policy may .110 other amhulm vM& m4ht of ct your cwnsW such as in mckman for a mkor w=ts. Under me formula, tha United &AWS Gmunoast genes ft reimbumea SM of oovamd tmmism losses exceodfpg &e statulorfiy c9MMW dedttctibla paid by eve . umm OQMM pwdft the eavem9L Ths pmhn charged 1br dib covemp is provided below and does not inciuda any dqp far theporkm of Joss 69 may be wvrs+md by the FWeW Oavamawat under UwAct. Yon WwWd also iomwv Mat rbaA a. as ammdad, comWw a Sloe million Cep dw Hauls United States Oosaemasmt raitobtmmaoet as wdl as harmer-L%bitiW !br !oases soublug fbam °ce Med acts of knvr:emlm when the amount of such lames in ate► ems cala der year cmeeds $100 billion. If ttre s to im,t�ed losxeat he all inslttem aluceed S itfil biiiim your c wmmpe may be t�ttad, CINIDI'l!7ONALTEMRW COWBAGE The hdud 7owdsm ift Iasareace Pi+ograat Remfibubafm Act of 2007 b edmkoed to. seaninde at firs and of Dmmber 31, 2614, uNess tmaar4 aftW cc cewMn continued by the ibdecai gmamnem. Should you sated Tarorim C valor fire Act mad to Act is ten�eri December 3L, 2#14. may► teaarism rouge as defied by lira Act podded die pdUey wM also tamdaata. 1NACCORDAN CE Wy'FiI'1'IiIH.AGT, YOU MW CHOOSE TD SSIACT OR REJECT COVERAGE FOR I%IMM D ACI"S'OFTERROIROW BELOW. > el�aiaos�eQteenptmea�m�gafisesprastma afi�34. !� Afrtc tleenmeee �n xdt of =ber�3l,�K sha:tMawlaaoar ary aavaov farewmtm ��s • ?tamed tqkzxdIFtmi 6u-c, 'R a br✓,r�a,n taxerm nat�rr>e,rr�fr a! I� MMIOL v fr.tM fN1a vt, 14