Form Acord 125 - Retail Program Acord Supplement

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(Required for all OnePac policies written in the Retail Program – Submit with ACORD 125, 126 & 140)
(If any information varies by building or premises, please use the “Notes” section to provide details)
Applicant’s Name:
Agency Name:
General Eligibility Questions – All Applicants
Is the applicant in full compliance with all life safety requirements and applicable building ordinances and laws?
Yes
No
Are there any buildings containing a habitational units? If yes,
Yes
No
do all such units have hard wired smoke detectors?
Yes
No
Is security provided at any building? If yes, check all that apply:
Yes
No
Security Guard
Guard Dog
Other
(describe type in “Notes” section)
General Underwriting Information – All Applicants
Does applicant own premises or conduct operations not described in this application? If yes, give details in “Notes” section.
Yes
No
Is any building located less than one mile from the coast (ocean, gulf or bay)?
Yes
No
Has the applicant ever been fined by any federal, state or local governmental agency or entity related to any past or current business operations?
Yes
No
Is there a restaurant or cooking operation in this building?
Yes
No
Eligibility Questions – All Retail Businesses
Do any buildings contain any of the following occupancies: lounges, bars or taverns?
Yes
No
Does the applicant’s operations include the installation, service or repair any products or the rental of any equipment?
Yes
No If yes, do the receipts from such
operations exceed 15% of the total receipts (excluding the rental of formal wear and videos)?
Yes
No
Eligibility Questions – Specific Retail Classifications
Appliance Stores—Household Type; Army and Navy Stores; Automobile Parts and Supplies; Bicycles; Carpet and Floor Coverings;
Equipment and Supplies Stores; Furniture Stores; General Stores; Gardening and Light Farming Supplies; Hardware Stores; Kitchen
Accessories; Nursery—Garden; Paint, Wallpaper and Wall Coverings; Painting, Pictures or Frame Stores; Plumbing Fixtures and Supplies;
Sewing Machines and Vacuum Cleaners; Sporting Goods or Athletic Equipment; Televisions, Stereos and Electronics - Does the applicant’s
operations include the rental of any products or equipment?
Yes
No
Automobile Parts and Supplies; Cameras and Photographic Equipment; Clothing—Children and Infants Wear; Clothing—Ladies and Men’s;
Computer Stores; Leather Products or Hides; Liquor Stores; Sporting Goods or Athletic Equipment; Televisions, Stereos and Electronics;
Video Stores -- Does the applicant have a Central Station or Police Station Connected Burglar Alarm?
Yes
No
Appliance Stores—Household; Convenience Food Stores—With or Without Gas; Equipment and Supplies—Other than Mobile Construction
and Industrial, Farm, Yard or Garden Equipment; ; General Stores; Grocery Stores and Supermarkets; Hardware Stores; Gardening and Light
Farming Supplies -- Does the applicant fill or service LPG tanks?
Yes
No
Drug Stores; Equipment and Supplies—Other than Mobile Construction and Industrial, Farm, Yard or Garden Equipment -- Does the applicant
sell medical, hospital or surgical equipment?
Yes
No
Bakeries ; Convenience Food Store-With or without Gas; Liquor Stores; Variety Stores - Is any location open more that 18 hours a day?
Yes
No
Cosmetic, Hair and Skin Preparation Stores; Drug Stores; Equipment and Supplies Stores; General Stores; Gift, Novelty and Souvenir Stores;
Hardware Stores; Liquor Stores; Toy Stores - Does the applicant manufacture, mix, re-label or repackage products (excluding ice cream and candy)
Yes
No
Underwriting Information – All Retail Businesses
Is this business conducted from an owned condominium unit?
Yes
No
Does the applicant sell over the internet?
Yes
No
Underwriting Information – Specific Retail Classifications
Equipment and Supplies—Other than Mobile Construction and Industrial, Farm, Yard or Garden Equipment; ; Gardening and Light Farming
Supplies; General Stores; Hardware Stores ; Nursery—Garden – Does the applicant manufacture, mix or apply chemicals, pesticides or fertilizers?
Yes
No
Army and Navy Stores; Convenience Food Stores—With Gas; General Stores; Variety Stores – Does the applicant sell weapons or ammunition?
Yes
No
Convenience Food Stores—With or Without Gas; Drug Stores ; General Stores; Grocery Stores and Supermarkets; Meat, Fish, Poultry or
Seafood Stores -- Is any cooking done on the premises with other than a microwave?
Yes
No
General Stores; Grocery Stores and Supermarkets; Hardware Stores – Does the applicant have gasoline pumps?
Yes
No
Convenience Food Stores—With Gas; Drug Stores; Grocery Stores and Supermarkets; Novelty Stores; Office Machines and Appliances;
Office Supplies; Paper, Paper Products and Party Goods; Variety Stores - Does the applicant’s operations include the rental of any products or
equipment?
Yes
No
Army and Navy Stores; China, Glassware and Pottery Stores; Clothing Stores; Collectible and Memorabilia Stores; Cosmetic, Hair and Skin
Preparation Stores; Drug Stores; Equipment and Supplies Stores; General Stores; Gift, Novelty and Souvenir Stores; Hardware Stores;
Hobby, Crafts or Artists Supply Stores; Kitchen Accessories; Lamps and Lighting Fixture Stores; Novelty Stores; Sporting Goods or Athletic
Equipment; Toy Stores; Variety Stores - Does the applicant directly import foreign made products from manufacturers with no legal presence in the
US?
Yes
No
Continued on Reverse
G15904 07 04

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