ACORD 126 (2014/04) - COMMERCIAL GENERAL LIABILITY SECTION

ACORD 126 (2014/04) - COMMERCIAL GENERAL LIABILITY SECTION
ACORD 126, Commercial General Liability Section, is a form of insurance designed to protect owners and operators of businesses from a wide
variety of liability exposures. These exposures include liability for accidents resulting from the insured's operations or premises, products sold or
operations completed by the insured, and contractual liability.
The Coverage and Limits Section of the ACORD 126 was designed to follow the ISO Policy Simplification Program first initiated in 1986.
ACORD 126 was designed to be used in conjunction with the Commercial Insurance Application - Applicant Information Section (ACORD 125).
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant / First Named
Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
COVERAGES
Commercial General
Liability
Check the box (if applicable): Indicates the claims made or occurrence option applies for the
general liability policy.
COVERAGES
Claims Made
Check the box (if applicable): Indicates the claims made option applies on the general liability
policy.
COVERAGES
Occurrence
Check the box (if applicable): Indicates the general liability policy, occurrence basis applies.
COVERAGES
Owner's & Contractors
Protective
Check the box (if applicable): Indicates the owners and contractors protective option applies for
the general liability policy.
ACORD 126 (2014/04) rev. 10-31-2013
Page 1 of 20
COVERAGES
Other checkbox
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGES
Other Field
Enter text: The description of other coverage (not the limit) on the general liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Deductibles-Property
Damage checkbox
Check the box (if applicable): Indicates if a property damage deductible is requested.
COVERAGES
Property Damage
Enter amount: The deductible applicable to the Property Damage coverage.
COVERAGES
Bodily Injury checkbox
Check the box (if applicable): Indicates if a bodily injury deductible is requested.
COVERAGES
Bodily Injury
Enter amount: The deductible applicable to the Bodily Injury coverage.
COVERAGES
Other checkbox
Check the box (if applicable): Indicates that a deductible is requested on the coverage other
than Property Damage or Bodily Injury.
COVERAGES
Other Field
Enter text: The type of deductible being requested other than property damage and bodily injury.
COVERAGES
Other
Enter amount: The deductible applicable to the Other Coverage.
COVERAGES
Per Claim checkbox
Check the box (if applicable): Indicates that a per claim deductible applies to individual claims
even if the claims are all related to the same occurrence or event.
COVERAGES
Per Occurrence checkbox
Check the box (if applicable): Indicates that a per occurrence deductible applies once to each
occurrence no matter how many individual claims result from the occurrence or event.
LIMITS
General Aggregate
Enter limit: The general liability, general aggregate limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
LIMITS
Limit Applies per Policy
(check box)
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies per policy.
LIMITS
Project (check box)
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies per project.
LIMITS
Location (check box)
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies per location.
LIMITS
Other: (check box)
Check the box (if applicable): Indicates the general liability policy, general aggregate limit
applies to option is other than those listed on the form.
LIMITS
Other Description
Enter text: The description of the other option to which the general liability policy, general
aggregate limit applies.
LIMITS
Products & Completed
Operations Aggregate $
Field
Enter limit: The general liability, products and completed operations aggregate limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
ACORD 126 (2014/04)
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LIMITS
Personal & Advertising
Injury
Enter limit: The general liability, personal and advertising injury limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
LIMITS
Each Occurrence
Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate
limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
LIMITS
Damage to Rented Premises
Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
LIMITS
Medical Expense
Enter limit: The general liability, medical expense each person limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
LIMITS
Employee Benefits
Enter limit: The general liability employee benefits limit amount.
LIMITS
Other Limit Description
Enter text: The description of other coverage (not the limit) on the general liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
LIMITS
Other Limit
Enter limit: The general liability, other coverage limit amount. Any questions about appropriate
limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
LIMITS
Premiums-Premises/Operations
Enter amount: The premium for premises/operations coverage.
LIMITS
Products
Enter amount: The premium for products coverage.
LIMITS
Other
Enter amount: The premium for other general liability coverage.
LIMITS
Total
Enter amount: The total premium amount for the commercial general liability line of business.
LIMITS
Other Coverages,
Restrictions and/or
Endorsements
Enter text: The remarks associated with the general liability line of business. Use this section to
provide any additional information required for underwriting or rating. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required.
LIMITS
UM / UIM Coverage is
available
Check the box (if applicable): Indicates if uninsured/underinsured motorist coverage is to be
provided under the policy.
LIMITS
UM / UIM Coverage is not
available
Check the box (if applicable): Indicates that uninsured/underinsured motorist coverage is not to
be provided under the policy.
LIMITS
Medical Payments Coverage
is available
Check the box (if applicable): Indicates that medical payment coverage is to be provided under
the policy.
LIMITS
Medical Payments Coverage
is not available
Check the box (if applicable): Indicates that medical payment coverage is not to be provided
under the policy.
ACORD 126 (2014/04)
Page 3 of 20
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
ACORD 126 (2014/04)
Page 4 of 20
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
ACORD 126 (2014/04)
Page 5 of 20
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
ACORD 126 (2014/04)
Page 6 of 20
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
ACORD 126 (2014/04)
Page 7 of 20
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
SCHEDULE OF HAZARDS
Location #
Enter number: The producer assigned identifier for the location number of the risk's location as
it appears on the Applicant Information Section of ACORD 125. All classifications should be
grouped by location number.
SCHEDULE OF HAZARDS
Hazard #
Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
SCHEDULE OF HAZARDS
Classification
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class description
from the table in this field.
SCHEDULE OF HAZARDS
Class Code
Enter code: The general liability class code that corresponds to the classification description
shown in the previous field.
SCHEDULE OF HAZARDS
Premium Basis
Enter code: An industry code designating the rating basis of the exposure amount.
SCHEDULE OF HAZARDS
Exposure
Enter amount: The amount of the exposure used for this class code in calculating the premium.
The contents of this data element depends on the rating basis used. The full amount of
exposure is contained.
SCHEDULE OF HAZARDS
Terr.
Enter code: The rating territory code based on location from the appropriate state exception
page.
SCHEDULE OF HAZARDS
Rate - Prem/Ops
Enter rate: The separate Premises Operations manual rate applicable to the classification.
SCHEDULE OF HAZARDS
Rate - Products
Enter rate: The separate Products rate applicable to the classification.
SCHEDULE OF HAZARDS
Premium - Prem/Ops
Enter amount: The premium associated with the premises operations coverage.
SCHEDULE OF HAZARDS
Premium - Products
Enter amount: The premium associated with the products coverage.
CLAIMS MADE
1. Proposed Retroactive
Date
Enter date: The retroactive date you are requesting for the policy being applied for. This is the
proposed earliest date for which an occurrence could trigger coverage under a Claims Made
policy.
CLAIMS MADE
2. Entry date into
uninterrupted claims made
coverage
Enter date: The retroactive date shown on the applicant's first Claims Made policy. If this is the
first such policy, the date will be the same as the proposed retroactive date shown on the
preceding field. If this is a renewal, it is the effective date of the first policy issued in the
sequence of uninterrupted Claims Made policies.
CLAIMS MADE
3. Has any product, work,
accident or location been
excluded, uninsured or
self-insured from any
previous coverage?
Enter Y for a Yes response. Input N for No response. The response to the question, Has any
product, work, accident or location been excluded, uninsured or self-insured from any previous
coverage?.
ACORD 126 (2014/04)
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CLAIMS MADE
Remarks
Enter text: An explanation of any work, accident or location that has been excluded, uninsured
or self-insured from any previous coverage.
CLAIMS MADE
4. Was tail coverage
purchased under any
previous policy?
Enter Y for a Yes response. Input N for No response. The response to the question, Was tail
coverage purchased under any previous policy?.
CLAIMS MADE
Remarks
Enter text: An explanation if tail was coverage purchased under any previous policy.
EMPLOYEE BENEFITS
LIABILITY
Deductible Per Claim:
Enter deductible: The deductible per claim applicable to Employee Benefits Liability coverage.
EMPLOYEE BENEFITS
LIABILITY
Number of Employees:
Enter number: The total number of employees.
EMPLOYEE BENEFITS
LIABILITY
Number of Employees
Covered By Employee
Benefits Plan:
Enter number: The total number of employees covered by employee benefits plans.
EMPLOYEE BENEFITS
LIABILITY
Retroactive Date:
Enter date: The retroactive date that is the earliest date for which an occurrence could trigger
coverage under Employee Benefits coverage.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
CONTRACTORS
1. Does applicant draw
plans, designs, or
specifications for others?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant draw plans, designs or specifications for others?.
CONTRACTORS
Remarks
Enter text: An explanation of any plans, designs or specifications drawn for others.
CONTRACTORS
2. Do any operations include
blasting or utilize or store
explosive material?
Enter Y for a Yes response. Input N for No response. The response to the question, Do any
operations include blasting or utilize, or store explosive material?.
CONTRACTORS
Remarks
Enter text: An explanation of any operations that include blasting or utilize , store explosive
material.
CONTRACTORS
3. Do any operations include
evacuation, tunneling,
underground work or earth
moving?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
any operation involve excavation, tunneling, underground work or earth moving?.
ACORD 126 (2014/04)
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CONTRACTORS
Remarks
Enter text: An explanation of any operations which include evacuation, tunneling, underground
work or earth moving.
CONTRACTORS
4. Do your subcontractors
carry coverages or limits
less than yours?
Enter Y for a Yes response. Input N for No response. The response to the question, Do
subcontractors carry coverages or limits less than applicant?.
CONTRACTORS
Remarks
Enter text: An explanation of any of your subcontractors who carry coverages or limits less than
yours.
CONTRACTORS
5. Are subcontractors
allowed to work without
providing you with
Certificates of Insurance?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
subcontractors allowed to work without providing you with a certificate of insurance?.
CONTRACTORS
Remarks
Enter text: An explanation of any subcontractors allowed to work without providing you with
Certificates of Insurance.
CONTRACTORS
6. Does applicant lease
equipment to others with or
without operators?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant lease equipment to others with or without operators?.
CONTRACTORS
Remarks
Enter text: An explanation of any applicant who leases equipment to others with or without
operators.
CONTRACTORS
$ Paid to Subcontractors
Enter amount: The total dollar amount for work that the contractor pays to subcontractors.
CONTRACTORS
% of Work Subcontracted
Enter percentage: The percentage of the work described by the applicant as subcontracted out.
CONTRACTORS
# Full Time Staff
Enter number: The number of individuals employed full time by the applicant.
CONTRACTORS
# Part Time Staff
Enter number: The number of individuals employed part time by the applicant.
CONTRACTORS
Remarks/Describe the type
of work & percentage
subcontracted
Enter text: Describe the type of work and percentage subcontracted.
PRODUCTS/COMPLETED
OPERATIONS
Products
Enter text: The name used to identify the product manufactured or sold or service provided by
the applicant.
PRODUCTS/COMPLETED
OPERATIONS
Annual Gross Sales
Enter amount: The whole dollar estimate of the annual sales receipts realized by this product or
service.
PRODUCTS/COMPLETED
OPERATIONS
# of Units
Enter number: The number of units of this product manufactured and/or sold each year.
PRODUCTS/COMPLETED
OPERATIONS
Time in Market
Enter number: The number of months the product or service has been marketed to the public.
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PRODUCTS/COMPLETED
OPERATIONS
Expected Life
Enter number: The anticipated number of months of useful life of the product or service.
PRODUCTS/COMPLETED
OPERATIONS
Intended Use
Enter text: The intended use of the product.
PRODUCTS/COMPLETED
OPERATIONS
Principal Components
Enter text: The principal components of the product.
PRODUCTS/COMPLETED
OPERATIONS
Products
Enter text: The name used to identify the product manufactured or sold or service provided by
the applicant.
PRODUCTS/COMPLETED
OPERATIONS
Annual Gross Sales
Enter amount: The whole dollar estimate of the annual sales receipts realized by this product or
service.
PRODUCTS/COMPLETED
OPERATIONS
# of Units
Enter number: The number of units of this product manufactured and/or sold each year.
PRODUCTS/COMPLETED
OPERATIONS
Time in Market
Enter number: The number of months the product or service has been marketed to the public.
PRODUCTS/COMPLETED
OPERATIONS
Expected Life
Enter number: The anticipated number of months of useful life of the product or service.
PRODUCTS/COMPLETED
OPERATIONS
Intended Use
Enter text: The intended use of the product.
PRODUCTS/COMPLETED
OPERATIONS
Principal Components
Enter text: The principal components of the product.
PRODUCTS/COMPLETED
OPERATIONS
Products
Enter text: The name used to identify the product manufactured or sold or service provided by
the applicant.
PRODUCTS/COMPLETED
OPERATIONS
Annual Gross Sales
Enter amount: The whole dollar estimate of the annual sales receipts realized by this product or
service.
PRODUCTS/COMPLETED
OPERATIONS
# of Units
Enter number: The number of units of this product manufactured and/or sold each year.
PRODUCTS/COMPLETED
OPERATIONS
Time in Market
Enter number: The number of months the product or service has been marketed to the public.
PRODUCTS/COMPLETED
OPERATIONS
Expected Life
Enter number: The anticipated number of months of useful life of the product or service.
PRODUCTS/COMPLETED
OPERATIONS
Intended Use
Enter text: The intended use of the product.
PRODUCTS/COMPLETED
OPERATIONS
Principal Components
Enter text: The principal components of the product.
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PRODUCTS/COMPLETED
OPERATIONS
1. Does applicant install,
service or demonstrate
products?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant install, service or demonstrate products?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of any installation, service or product demonstration applicant would
perform.
PRODUCTS/COMPLETED
OPERATIONS
2. Foreign products sold,
distributed, or used as
components?
Enter Y for a Yes response. Input N for No response. The response to the question, Foreign
products, sold, distributed, used as components?.
PRODUCTS/COMPLETED
OPERATIONS
3. Research and
development conducted or
new products planned?
Enter Y for a Yes response. Input N for No response. The response to the question,
Research and development conducted or new products planned?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of any research and development conducted on new products
planned.
PRODUCTS/COMPLETED
OPERATIONS
4. Guarantees, warranties,
hold harmless agreements?
Enter Y for a Yes response. Input N for No response. The response to the question,
Guarantees, warrantees, hold harmless agreements?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of any guarantees, warranties, hold harmless agreements.
PRODUCTS/COMPLETED
OPERATIONS
5. Products related to
aircraft/space industry?
Enter Y for a Yes response. Input N for No response. The response to the question,
Products related to aircraft/space industry?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation products related to aircraft/space industry.
PRODUCTS/COMPLETED
OPERATIONS
6. Products recalled,
discontinued, changed?
Enter Y for a Yes response. Input N for No response. The response to the question,
Products recalled, discontinued, changed?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation products recalled, discontinued, changed.
PRODUCTS/COMPLETED
OPERATIONS
7. Products of others sold or
repackaged under
applicant's label?
Enter Y for a Yes response. Input N for No response. The response to the question,
Products of others sold or repackaged under applicant label?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of products of others sold or repackaged under applicant's label.
PRODUCTS/COMPLETED
OPERATIONS
8. Products under label of
others?
Enter Y for a Yes response. Input N for No response. The response to the question,
Products under label of others?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of products under label of others.
ACORD 126 (2014/04)
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PRODUCTS/COMPLETED
OPERATIONS
9. Vendor's coverage
required?
Enter Y for a Yes response. Input N for No response. The response to the question,
Vendors coverage required?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation any vendor's coverage required.
PRODUCTS/COMPLETED
OPERATIONS
10. Does any named insured
sell to any other named
insured?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
any named insured sell to other named insured?.
PRODUCTS/COMPLETED
OPERATIONS
Remarks
Enter text: An explanation of any named insured who sells to any other named insured.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
ACORD 45 attached for
additional names checkbox
Check the box (if applicable): Indicates that further additional interests appear on the attached
ACORD 45.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest-Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
ACORD 126 (2014/04)
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ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the type of interest in the item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Required
Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name & Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Enter code: The additional interest's country code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Reference #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item:
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ACORD 126 (2014/04)
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ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT
Item Description
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
GENERAL INFORMATION
1. Any medical facilities
provided or medical
professionals employed or
contracted?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
medical facilities provided or medical professionals employed or contracted?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any medical facilities provided or medical professionals employed
or contracted.
GENERAL INFORMATION
2. Any exposure to
radioactive/nuclear
materials?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
exposure to radioactive/nuclear materials?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any exposure to radioactive/nuclear materials
GENERAL INFORMATION
3. Do operations involve
storing, treating,
discharging, applying,
disposing or transporting
hazardous material?
Enter Y for a Yes response. Input N for No response. The response to the question,
Do/have past, present or discontinued operations involve(d) storing, treating, discharging,
applying, disposing, or transporting of hazardous material?.
GENERAL INFORMATION
Remarks
Enter text: An explanation any operations that involve storing, treating, discharging, applying,
disposing or transporting hazardous material.
GENERAL INFORMATION
4. Any listed operations
sold, acquired, or
discontinued in the last five
(5) years?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
operations sold, acquired or discontinued in the last specified number of years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any listed operations sold, acquired, or discontinued in the last five
(5) years.
GENERAL INFORMATION
5. Do you rent or loan
equipment to others?
Enter Y for a Yes response. Input N for No response. The response to the question, Do you
rent or loan equipment to others?.
GENERAL INFORMATION
Equipment
Enter text: An explanation of any machinery or equipment that is loaned or rented to others.
GENERAL INFORMATION
Type of Equipment - Small
Tools checkbox
Check the box (if applicable): Indicates the subclass / grouping of property into which the item
falls is small tools.
GENERAL INFORMATION
Large Tools checkbox
Check the box (if applicable): Indicates the subclass / grouping of property into which the item
falls is large equipment.
GENERAL INFORMATION
Instruction Given (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates instructions are given on how
to use the item when it is rented or loaned to others.
ACORD 126 (2014/04)
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GENERAL INFORMATION
Equipment
Enter text: An explanation of any machinery or equipment that is loaned or rented to others.
GENERAL INFORMATION
Type of Equipment - Small
Tools checkbox
Check the box (if applicable): Indicates the subclass / grouping of property into which the item
falls is small tools.
GENERAL INFORMATION
Large Tools checkbox
Check the box (if applicable): Indicates the subclass / grouping of property into which the item
falls is large equipment.
GENERAL INFORMATION
Instruction Given (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates instructions are given on how
to use the item when it is rented or loaned to others.
GENERAL INFORMATION
6. Any watercraft, docks,
floats owned, hired, or
leased?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
watercraft, docks, floats owned, hired or leased?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any watercraft, docks, floats owned, hired, or leased.
GENERAL INFORMATION
7. Any parking facilities
owned/ rented?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
parking facilities owned/rented?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any parking facilities owned/ rented.
GENERAL INFORMATION
8. Is a fee charged for
parking?
Enter Y for a Yes response. Input N for No response. The response to the question, Is a fee
charged for parking?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any fee charged for parking.
GENERAL INFORMATION
9. Are any recreational
facilities provided?
Enter Y for a Yes response. Input N for No response. The response to the question,
Recreation facilities provided?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any recreational facilities provided.
GENERAL INFORMATION
10. Are there any lodging
operations including
apartments?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any lodging operations including apartments?
GENERAL INFORMATION
# Apts
Enter number: The number of separate living units in structure.
GENERAL INFORMATION
Total Apt Area (Sq. Ft.)
Enter number: The area, in square feet, of the building used as apartments.
GENERAL INFORMATION
Describe Other Lodging
Operations
Enter text: The description of other lodging operations.
GENERAL INFORMATION
11. Is there a swimming pool
on the premises? (Check all
that apply)
Enter Y for a Yes response. Input N for No response. The response to the question, Is there
a swimming pool on the premises?.
GENERAL INFORMATION
Approved Fence (checkbox)
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an
approved height.
ACORD 126 (2014/04)
Page 16 of 20
GENERAL INFORMATION
Limited Access (checkbox)
Check the box (if applicable): Indicates there is limited access to the swimming pool.
GENERAL INFORMATION
Diving Board (checkbox)
Check the box (if applicable): Indicates the swimming pool has a diving board.
GENERAL INFORMATION
Slide (checkbox)
Check the box (if applicable): Indicates the swimming pool has a slide.
GENERAL INFORMATION
Above Ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is above ground.
GENERAL INFORMATION
In Ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is in the ground.
GENERAL INFORMATION
Lifeguard (checkbox)
Check the box (if applicable): Indicates there is life guard for the swimming pool.
GENERAL INFORMATION
12. Are social events
sponsored?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
social events sponsored?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any social events sponsored.
GENERAL INFORMATION
13. Are athletic teams
sponsored?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are athletic teams sponsored?
GENERAL INFORMATION
Type of Sport
Enter text: The description of the type of sport in which the sponsored athletic team is involved.
GENERAL INFORMATION
Contact Sport (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the sponsored athletic team
is involved in a contact sport.
GENERAL INFORMATION
Age Group 12 & Under
(checkbox)
Check the box (if applicable): Indicates the sport participants are 12 years old or under.
GENERAL INFORMATION
13 - 18 (checkbox)
Check the box (if applicable): Indicates the sport participants are 13 through 18 years old.
GENERAL INFORMATION
Over 18 (checkbox)
Check the box (if applicable): Indicates the sport participants are over 18 years old.
GENERAL INFORMATION
Extent of Sponsorship
Enter text: The description of the extent of sponsorship the named insured provides for the
athletic team.
GENERAL INFORMATION
Type of Sport
Enter text: The description of the type of sport in which the sponsored athletic team is involved.
GENERAL INFORMATION
Contact Sport (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the sponsored athletic team
is involved in a contact sport.
GENERAL INFORMATION
Age Group 12 & Under
(checkbox)
Check the box (if applicable): Indicates the sport participants are 12 years old or under.
GENERAL INFORMATION
13 - 18 (checkbox)
Check the box (if applicable): Indicates the sport participants are 13 through 18 years old.
GENERAL INFORMATION
Over 18 (checkbox)
Check the box (if applicable): Indicates the sport participants are over 18 years old.
GENERAL INFORMATION
Extent of Sponsorship
Enter text: The description of the extent of sponsorship the named insured provides for the
athletic team.
ACORD 126 (2014/04)
Page 17 of 20
GENERAL INFORMATION
14. Any structural
alterations contemplated?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
structural alterations contemplated?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any structural alterations contemplated.
GENERAL INFORMATION
15. Any demolition exposure
contemplated?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
demolition exposure contemplated?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any demolition exposure contemplated.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
GENERAL INFORMATION
16. Has applicant been
active in or is currently
active in joint ventures?
Enter Y for a Yes response. Input N for No response. The response to the question, Has
applicant been active in or is currently active in joint ventures?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any joint ventures in which the applicant may be currently active.
GENERAL INFORMATION
17. Do you lease employees
to or from others?
Enter Y for a Yes response. Input N for No response. The response to the question, Do you
lease employees to or from other employers?.
GENERAL INFORMATION
Lease To
Enter text: The additional interest's full name. As used here, this is the company to whom
employees are leased.
GENERAL INFORMATION
Workers Compensation
Coverage Carried (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is workers compensation coverage carried?.
GENERAL INFORMATION
Lease To
Enter text: The additional interest's full name. As used here, this is the company to whom
employees are leased.
GENERAL INFORMATION
Workers Compensation
Coverage Carried (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is workers compensation coverage carried?.
GENERAL INFORMATION
Lease From
Enter text: The additional interest's full name. As used here, this is the company from whom
employees are leased.
GENERAL INFORMATION
Workers Compensation
Coverage Carried (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is workers compensation coverage carried?.
GENERAL INFORMATION
Lease From
Enter text: The additional interest's full name. As used here, this is the company from whom
employees are leased.
GENERAL INFORMATION
Workers Compensation
Coverage Carried (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is workers compensation coverage carried?.
ACORD 126 (2014/04)
Page 18 of 20
GENERAL INFORMATION
18. Is there a labor
interchange with any other
business or subsidiaries?
Enter Y for a Yes response. Input N for No response. The response to the question, Is there
a labor interchange with any other business or subsidiaries?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any labor interchange with any other business or subsidiaries.
GENERAL INFORMATION
19. Are daycare facilities
operated or controlled?
Enter Y for a Yes response. Input N for No response. The response to the question, Are day
care facilities operated or controlled?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any daycare facilities operated or controlled.
GENERAL INFORMATION
20. Have any crimes
occurred or been attempted
on your premises within the
last three (3) years?
Enter Y for a Yes response. Input N for No response. The response to the question, Have
any crimes occurred or been attempted on your premises within the last specified number of
years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any crimes that occurred or been attempted on your premises
within the last three (3) years
GENERAL INFORMATION
21. Is there a formal, written
safety and security policy in
effect?
Enter Y for a Yes response. Input N for No response. The response to the question, Is there
a formal, written safety and security policy in effect?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any formal, written safety and security policy in effect.
GENERAL INFORMATION
22. Does the businesses'
promotional literature make
any representations about
the safety or security of the
premises?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
the business' promotional literature make any representation about the safety or security of the
premises?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any business promotional literature that makes any representations
about the safety or security of the premises.
GENERAL INFORMATION
REMARKS
Enter text: The remarks associated with the general liability line of business. Use this section to
provide any additional information required for underwriting or rating. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required.
SIGNATURE SECTION
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE SECTION
Producers Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE SECTION
State Producer License
Number
Enter identifier: The State License Number of the producer.
SIGNATURE SECTION
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured.
ACORD 126 (2014/04)
Page 19 of 20
SIGNATURE SECTION
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 126 (2014/04)
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