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Home My WebLink AboutAcord copy signed04/04/2024 Nicholson & Associates Ins LLC1802 Black Lake Blvd SW #301Olympia, WA 98512 (360)352-8444(360)943-9712cindy@nichinsure.com 00128670 <Prospect> X X 04/12/2024 04/12/2025 Go Feasibility & Permitting LLCPO Box 1176Sumner, WA 98390 X Printed by NCC on April 11, 2024 at 04:17PM DATE (MM/DD/YYYY) NAIC CODEAGENCY COMPANY POLICY OR PROGRAM NAME PROGRAM CODE POLICY NUMBER UNDERWRITER UNDERWRITER OFFICECONTACTNAME:PHONE(A/C, No, Ext):FAX(A/C, No):STATUS OF TRANSACTIONE-MAILADDRESS: DATE TIMECODE:SUBCODE: AGENCY CUSTOMER ID: INDICATE LINES OF BUSINESS PREMIUM PREMIUM PREMIUM $$$ $$$ $$$ $$$ $$$ $$$ $$$ PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMUM POLICY PREMIUMPREMIUM NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS QUOTE ISSUE POLICY RENEW BOUND (Give Date and/or Attach Copy): CHANGE AM CANCEL PM BOILER & MACHINERY CYBER AND PRIVACY YACHT BUSINESS AUTO FIDUCIARY LIABILITY BUSINESS OWNERS GARAGE AND DEALERS COMMERCIAL GENERAL LIABILITY LIQUOR LIABILITY COMMERCIAL INLAND MARINE MOTOR CARRIER COMMERCIAL PROPERTY TRUCKERS CRIME UMBRELLA ACCOUNTS RECEIVABLE / VALUABLE PAPERS GLASS AND SIGN SECTION STATEMENT / SCHEDULE OF VALUES ADDITIONAL INTEREST SCHEDULE HOTEL / MOTEL SUPPLEMENT STATE SUPPLEMENT (If applicable) ADDITIONAL PREMISES INFORMATION SCHEDULE INSTALLATION / BUILDERS RISK SECTION VACANT BUILDING SUPPLEMENT APARTMENT BUILDING SUPPLEMENT INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE CONDO ASSN BYLAWS (for D&O Coverage only)INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT CONTRACTORS SUPPLEMENT LOSS SUMMARY COVERAGES SCHEDULE OPEN CARGO SECTION DEALERS SECTION PREMIUM PAYMENT SUPPLEMENT DRIVER INFORMATION SCHEDULE PROFESSIONAL LIABILITY SUPPLEMENT ELECTRONIC DATA PROCESSING SECTION RESTAURANT / TAVERN SUPPLEMENT DIRECT AGENCY CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS: CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS: CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS: $$$ CARRIER LINES OF BUSINESS ATTACHMENTS POLICY INFORMATION APPLICANT INFORMATION Page 1 of 4ACORD 125 (2016/03)© 1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD APPLICANT INFORMATION SECTION COMMERCIAL INSURANCE APPLICATION 00128670 Main ContactRachel KleinX(253)250-7522 contracts@gofeasibility.com 2222 Meridian Ave EEdgewoodPierce WA98371 1 500,000 11-01-2017 Excavation, painting, floor covering, septic installation Printed by NCC on April 11, 2024 at 04:17PM LENDER'S LOSS PAYABLE CONTACT TYPE:CONTACT TYPE: CONTACT NAME:CONTACT NAME: PRIMARY SECONDARY PRIMARY SECONDARYPHONE #PHONE #PHONE #PHONE # PRIMARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS:SECONDARY E-MAIL ADDRESS: DATE BUSINESSSTARTED (MM/DD/YYYY) DESCRIPTION OF PRIMARY OPERATIONS INSTALLATION, SERVICE OR REPAIR WORK OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS INTEREST NAME AND ADDRESS RANK:EVIDENCE:CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LIENHOLDER LOCATION:BUILDING:INSUREDBREACH OF LOSS PAYEE VEHICLE:BOAT:WARRANTY CO-OWNER MORTGAGEE AIRPORT:AIRCRAFT: EMPLOYEE OWNER ITEM ITEM:AS LESSOR CLASS:LEASEBACK REGISTRANT ITEM DESCRIPTIONOWNER TRUSTEE REFERENCE / LOAN #:INTEREST END DATE: LIEN AMOUNT:PHONE (A/C, No, Ext):FAX (A/C, No): REASON FOR INTEREST:E-MAIL ADDRESS: INSIDE OWNER SQ FT OUTSIDE TENANT SQ FT SQ FT INSIDE OWNER SQ FT OUTSIDE TENANT SQ FT SQ FT INSIDE OWNER SQ FT OUTSIDE TENANT SQ FT SQ FT INSIDE OWNER SQ FT OUTSIDE TENANT SQ FT SQ FT APARTMENTS CONTRACTOR MANUFACTURING RESTAURANT SERVICE CONDOMINIUMS INSTITUTIONAL OFFICE RETAIL WHOLESALE HOME BUS CELL HOME BUS CELL HOME BUS CELL HOME BUS CELL LOC #STREET CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES:$ OCCUPIED AREA: BLD #CITY:STATE:# PART TIME EMPL OPEN TO PUBLIC AREA: COUNTY:ZIP:TOTAL BUILDING AREA: DESCRIPTION OF OPERATIONS:ANY AREA LEASED TO OTHERS? Y / N LOC #STREET CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES:$ OCCUPIED AREA: BLD #CITY:STATE:# PART TIME EMPL OPEN TO PUBLIC AREA: COUNTY:ZIP:TOTAL BUILDING AREA: DESCRIPTION OF OPERATIONS:ANY AREA LEASED TO OTHERS? Y / N LOC #STREET CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES:$ OCCUPIED AREA: BLD #CITY:STATE:# PART TIME EMPL OPEN TO PUBLIC AREA: COUNTY:ZIP:TOTAL BUILDING AREA: DESCRIPTION OF OPERATIONS:ANY AREA LEASED TO OTHERS? Y / N LOC #STREET CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES:$ OCCUPIED AREA: BLD #CITY:STATE:# PART TIME EMPL OPEN TO PUBLIC AREA: COUNTY:ZIP:TOTAL BUILDING AREA: DESCRIPTION OF OPERATIONS:ANY AREA LEASED TO OTHERS? Y / N %% AGENCY CUSTOMER ID:CONTACT INFORMATION PREMISES INFORMATION (Attach ACORD 823 for Additional Premises) NATURE OF BUSINESS ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests Page 2 of 4ACORD 125 (2016/03) 00128670 N N N N N N N N N N N NN N N N Printed by NCC on April 11, 2024 at 04:17PM EXPLAIN ALL "YES" RESPONSES Y / N CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM EFFECTIVE DATE EXPIRATION DATE PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED SAFETY MANUAL SAFETY POSITION MONTHLY MEETINGS OSHA LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER NON-PAYMENT AGENT NO LONGER REPRESENTS CARRIER NON-RENEWAL UNDERWRITING CONDITION CORRECTED (Describe): OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE NAME OF TRUST: YEAR $$$$ 1a.IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? 1b.DOES THE APPLICANT HAVE ANY SUBSIDIARIES? 2.IS A FORMAL SAFETY PROGRAM IN OPERATION? 3.ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? 5.ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OROPERATIONS? (Missouri Applicants - Do not answer this question) 6.ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 7.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 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). 8.ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? 9.HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?10. HAS BUSINESS BEEN PLACED IN A TRUST?11. 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) 13.DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? 14.DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use) 15.DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES", describe use) 4.ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) AGENCY CUSTOMER ID: REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GENERAL INFORMATION PRIOR CARRIER INFORMATION Page 3 of 4ACORD 125 (2016/03) NCC 00128670 NEW X NCC Printed by NCC on April 11, 2024 at 04:17PM CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: SUBRO-GATION Y / N CLAIMOPEN Y / N DATE OF OCCURRENCE LINE DATE OF CLAIM AMOUNT PAID AMOUNT RESERVEDTYPE / DESCRIPTION OF OCCURRENCE OR CLAIM PRODUCER'S SIGNATURE PRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NO(Required in Florida) APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER CARRIER POLICY NUMBER PREMIUM EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM EFFECTIVE DATE EXPIRATION DATE ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS YEAR $$$$ $$$$ TOTAL LOSSES: $ (Applicant's Initials): Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONSOTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL ASOTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST INWRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.) THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY 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. AGENCY CUSTOMER ID: Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: 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)*. *Applies in FL Only. Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. PRIOR CARRIER INFORMATION (continued) LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information) SIGNATURE Page 4 of 4ACORD 125 (2016/03) 00128670 04/04/2024 Nicholson & Associates Ins LLC <Prospect> Go Feasibility & Permitting LLC X X x 1,000 2,000,000 2,000,0001,000,0001,000,000100,0005,000 Stop Gap 1,000,000 Additional Insured Blanket, Waiver of Subrogation, Primary Non-Contributory 1 1 S 500,000 Annual Revenue - all operations 1 2 P 80,000 1 Employee @ $80,000 1 3 C 235,000 Sub costs - $235,000 Printed by NCC on April 11, 2024 at 04:17PM PER CLAIMPEROCCURRENCE DATE (MM/DD/YYYY) AGENCY NAIC CODE POLICY NUMBER EFFECTIVE DATE APPLICANT / FIRST NAMED INSURED COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE $PREMIUMS LIMIT APPLIES PER:PREMISES/OPERATIONS OWNER'S & CONTRACTOR'S PROTECTIVE PRODUCTSPRODUCTS & COMPLETED OPERATIONS AGGREGATE $ DEDUCTIBLES PERSONAL & ADVERTISING INJURY $ OTHEREACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (each occurrence)$ TOTALMEDICAL EXPENSE (Any one person)$ EMPLOYEE BENEFITS $ $ OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY: 1. UM / UIM COVERAGE IS IS NOT AVAILABLE.2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE. CLASSCODE PREMIUMBASIS RATE PREMIUMLOC #HAZ #EXPOSURE TERR PREM / OPS PRODUCTS PREM / OPS PRODUCTS CLASSIFICATION DESCRIPTION CLASS CODE PREMIUM BASIS RATE PREMIUMLOC #HAZ #EXPOSURE TERR PREM / OPS PRODUCTS PREM / OPS PRODUCTS CLASSIFICATION DESCRIPTION CLASSCODE PREMIUMBASIS RATE PREMIUMLOC #HAZ #EXPOSURE TERR PREM / OPS PRODUCTS PREM / OPS PRODUCTS CLASSIFICATION DESCRIPTION RATING AND PREMIUM BASIS EXPLAIN ALL "YES" RESPONSES Y / N POLICY LOCATIONCLAIMS MADE OCCURRENCE PROJECT OTHER: PROPERTY DAMAGE $ BODILY INJURY $ $ (P) PAYROLL - PER $1,000/PAY (C) TOTAL COST - PER $1,000/COST (U) UNIT - PER UNIT (S) GROSS SALES - PER $1,000/SALES (A) AREA - PER 1,000/SQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:1. DEDUCTIBLE PER CLAIM:$ 2. NUMBER OF EMPLOYEES:4. RETROACTIVE DATE: AGENCY CUSTOMER ID: CARRIER IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully. COVERAGES LIMITS SCHEDULE OF HAZARDS (ACORD 211, Schedule of Hazards, may be attached if more space is required) CLAIMS MADE (Explain all "Yes" responses) EMPLOYEE BENEFITS LIABILITY Attach to ACORD 125ACORD 126 (2016/09)© 1993-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY SECTION 00128670 N N N N N N N N N N N N N N N N Printed by NCC on April 11, 2024 at 04:17PM EXPLAIN ALL "YES" RESPONSES (For all past or present operations)Y / N DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUB-% OF WORK # FULL-# PART-CONTRACTORS:SUBCONTRACTED:TIME STAFF:TIME STAFF: TIME IN EXPECTEDPRODUCTSANNUAL GROSS SALES # OF UNITS INTENDED USE PRINCIPAL COMPONENTSMARKETLIFE EXPLAIN ALL "YES" RESPONSES (For all past or present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC.Y / N 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, UNDERGROUND WORK OR EARTH MOVING? 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815) 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? 7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL? 8. PRODUCTS UNDER LABEL OF OTHERS? 9. VENDORS COVERAGE REQUIRED? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? AGENCY CUSTOMER ID:CONTRACTORS PRODUCTS / COMPLETED OPERATIONS Page 2 of 4ACORD 126 (2016/09) 00128670 N N N N N N N N N N N N N N N Printed by NCC on April 11, 2024 at 04:17PM INTEREST NAME AND ADDRESS RANK:EVIDENCE:CERTIFICATE INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION:BUILDING: EMPLOYEE AS LESSOR ITEM ITEM:CLASS: LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER LOSS PAYEE MORTGAGEE REFERENCE / LOAN #: EXPLAIN ALL "YES" RESPONSES (For all past or present operations)Y / N SMALL TOOLS LARGE EQUIPMENT SMALL TOOLS LARGE EQUIPMENT APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD 13 - 18 13 - 18 12 & UNDER OVER 18 12 & UNDER OVER 18 EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (Y/N) # APTS TOTAL APT AREA DESCRIBE OTHER LODGING OPERATIONS Sq. Ft. TYPE OF SPORT CONTACT SPORT (Y/N)AGE GROUP TYPE OF SPORT CONTACT SPORT (Y/N)AGE GROUP EXTENT OF SPONSORSHIP:EXTENT OF SPONSORSHIP: 5.DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? 11.IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) 13.ARE ATHLETIC TEAMS SPONSORED? 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 3.DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? 7. ANY PARKING FACILITIES OWNED/RENTED? 8. IS A FEE CHARGED FOR PARKING? 9. RECREATION FACILITIES PROVIDED? 10.ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES", answer the following): 12.ARE SOCIAL EVENTS SPONSORED? 14.ANY STRUCTURAL ALTERATIONS CONTEMPLATED? 15.ANY DEMOLITION EXPOSURE CONTEMPLATED? AGENCY CUSTOMER ID: ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names GENERAL INFORMATION Page 3 of 4ACORD 126 (2016/09) NCC 00128670 N N N N N N N NCC Printed by NCC on April 11, 2024 at 04:17PM EXPLAIN ALL "YES" RESPONSES (For all past or present operations)Y / N PRODUCER'S SIGNATURE PRODUCER'S NAME (Please Print)STATE PRODUCER LICENSE NO(Required in Florida) APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER WORKERS COMPENSATION COVERAGE CARRIED (Y/N) WORKERS COMPENSATION COVERAGE CARRIED (Y/N)LEASE TO LEASE FROM 17.DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY 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. 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? 18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? 21. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? 22. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? AGENCY CUSTOMER ID: Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: 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)*. *Applies in FL Only. Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any factmaterial thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. GENERAL INFORMATION (continued) REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SIGNATURE Page 4 of 4ACORD 126 (2016/09)