Form Acord 125 - Retail Program Acord Supplement (Page 2 of 2) in pdf

(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)

Underwriting Information – Specific Retail Classifications (continued)

Appliance Stores; Automobile Parts and Supplies; Bicycle Stores; Book Stores; Clothing Stores; Computer Stores; Drug Stores; Furniture

Stores; Equipment and Supplies; Gardening and Light Farming Supplies; General Stores; Gift, Novelty or Souvenir Stores; Hardware Store;

Hearing Aid Stores; Kitchen Accessories; Lamps and Lighting Fixtures; Nursery—Garden; Musical Instruments; Office Furniture; Sewing

Machine and Vacuum Cleaner Stores; Sporting Goods Toy Stores; Variety Stores – Does the applicant sell used or reconditioned parts or

equipment?

Yes

Location Information (the following information is required for each building)

Is applicant the sole building occupant?

Yes

Is applicant a member of a franchise group?

Yes

Is business in an enclosed shopping mall?

Yes

Is business closed more than 60 consecutive days each year?

Yes

Is there a restaurant or cooking operation in the building?

Yes

Building Condition:

Excellent

Good

Average

Poor

Very Poor

Quality of Construction:

Average (standard)

Economy

Superior

Basement of Building is:

Finished

Unfinished

No Basement

Optional Coverages by Building

Druggists Professional Liability – Number of Pharmacists at this location: ________; Number of Technicians at this location: ________

Hearing Aid Dealers Professional Liability– Number of Hearing Aid Practitioners at this location: ________

Liquor Liability Coverage – Receipts from liquor sales at this building: $________________

Opticians Professional Liability– Number of Opticians at this location: ________

NOTES:

G15904 07 04

Form Acord 125 - Retail Program Acord Supplement Page 2