Distributor/Wholesaler SUPP-APP 12/15 1 of 5

Carrier:

A Berkshire Hathaway Company

Distributor/Wholesaler Supplemental ApplicationComplete in addition to Acord Applications

NAME OF APPLICANT 

Location Address: 

Website Address: 

I. GENERAL INFORMATION

1. Applicant operates as a: (check all that apply) q Wholesaler q Distributor q Retailer

2. DoestheApplicantengageinanybusinessoperationsatanotherlocationother than those disclosed on this application? If "Yes," explain: q Yes  q No

3. Arethereanyotherpersonsororganizations,subsidiaries,affiliatesorother entitiesrelatedtotheApplicant(includingDBAs)forwhichcoverageisdesired? q Yes  q No

If"Yes,"pleaselistanddescribetherelationshiptotheApplicant:

Note: There is no coverage for any such person, organization or entities unless endorsed to the policy. The following questions relate to Applicant only.

4. HowmanyyearshasApplicantoperatedunderpresentownership?

5. HowmanyyearshasApplicantoperatedattheabovelocation?

6. DoesApplicantnowhandleor,inthenexttwelve(12)months,doesApplicantexpectto handlerawmaterials,petroleum,gases,chemicalsorrelatedflammableorcombustible substancesotherthancommonhouseholdsubstances? q Yes  q No

7. DoesApplicantnowsell,distributeorstoreor,inthenexttwelve(12)monthsdoes Applicantexpecttosell,distributeorstore,fireworks,pyrotechnics,firearmsorotherweapons? q Yes  q No

8. IsApplicantafreightforwarder? q Yes  q No

9. DoesApplicantnowsellordistributeor,inthenexttwelve(12)months,does Applicantexpecttosellordistributeused,salvaged,antiqueorcollectiblemerchandise? q Yes  q No

10.DoesApplicantnowoperateor,inthenexttwelve(12)months,doesApplicantexpectto operateamerchandiseliquidationfacilityattheabovelocation? q Yes  q No

11.DoesApplicantcurrentlymaintainand,inthenexttwelve(12)months,willApplicant continuetomaintainfunctioningandoperationalsmokeand/orheatdetectorsintheabovelocation? q Yes  q No

12.Foranybuildingbuiltpriorto1978,is100percentoftheelectricconnectedto functioningandoperationalcircuitbreakersandwithoutanyaluminumorknobandtubewiring? q Yes  q No

13. Indicatewhichofthefollowingproductsyoudistributeorsell:(checkallthatapply)

q Appliances(largehousehold)

q Artsandcrafts/Artwork

q Automobilesq Automobileparts

andsuppliesq Barberorbeauty

suppliesq Bedlinensq Beverages

(alcoholic, other thanbeer)

q Beverages(non-alcoholicandbeer)

q Boats

q Books,newspapers,magazinesandperiodicals

q Candles and aromatherapy

q Canned foodq Clothing,wearing

orfootwearq Cosmetics,

fragrancesorbothq Dollarstore

inventoryq Driedfoodsq Electrical

equipment

q Fabricsq Floorcoveringsq Frozenfoodsq Fruits,vegetables

orflowersq Gardeningand

lightfarmingsupplies

q Giftbasketandgiftbasketsupplies

q Groceriesq Hardwareand

toolsq Health and

nutritionitems

q Hearingaidsandopticalgoods

q Homefurnitureq Iceq Jewelryor

gemstonesq Luggageq Marketingand

promotional itemsq Mobileequipmentq Office machines

andsuppliesq Paper and

stationeryproductsq Petsupplies

q Plumbingsuppliesandfixtures

q Printersuppliesq Seasonal and

holiday items

q Sportinggoods

q Toysandgames

q Other

Carrier:

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II. GENERAL LIABILITY

14.DoestheApplicantrequireandverifythatallmanufacturersforwhichApplicantsells, distributesorhandlesgoods:

a.Maintainproducts/completedoperationsliabilitycoverage? q Yes  q No

b. ListtheApplicantasanadditionalinsured? q Yes  q No

15.Whatpercentageofgoodsareimporteddirectlyfromforeigncountries?       %

a. Indicatetypesofproductsimported:

16.DoesApplicantmanufacture,design,alter,assemble,enhance,repackage,labelorre-labelanyproducts? q Yes  q No

17. Isthereanyinstallation,servicingorrepairofproducts? q Yes  q No

a. If"Yes,"providedetails:

18.DoesApplicantcurrentlyengageinretailoperationsordoesApplicantexpecttoengage insuchoperationsinthenexttwelve(12)months? q Yes  q No

a. If"Yes,"providetype(s)ofproductsandtotalannualsalesbyproducttype: $      

19.Arecustomerspermittedinanywarehouse/storageareas? q Yes  q No

20.DoesApplicantuseforkliftsorothermobileequipmenttohandlegoodsattheabove locationoratcustomers’locations?If"Yes": q Yes  q No

a.Howmanyforklifts? #      

b.Areallemployeesandotherswhooperatetheequipmentfullytrainedtodoso? q Yes  q No

c. Arecustomersandnon-employeesprohibitedfromareaswheresuchequipmentisoperated? q Yes  q No

d. Isallsuchequipmentequippedwithback-upalarmsorsimilardevices? q Yes  q No

21.DoesApplicantmakeoff-sitedeliveries?If"Yes": q Yes  q No

a.DoestheApplicantstockshelvesorsetupanymerchandisedisplaysoncustomerpremises? q Yes  q No

b.Aredeliveriesgenerallymadethroughthesameentranceusedbycustomers? q Yes  q No

22.DoesApplicantrentanyequipmenttoothers? q Yes  q No

23. IsApplicantresponsibleforbuildingmaintenance? q Yes  q No

a. If"Yes,"whoisthemaintenanceperformedby? q Employees  q Subcontractors

(ifcheckingemployees,skipquestionb.)

b. Ifsubcontractors:

i. Iswrittencontractinplaceforservices? q Yes  q No

ii. IsApplicantnamedasanadditionalinsuredonthesubcontractor'spolicy? q Yes  q No

iii.Doessubcontractorcarrygeneralliabilitylimitsofatleast$1,000,000? q Yes  q No

iv.Arecertificatesofinsuranceobtainedfromallsubcontractors? q Yes  q No

24. IstheApplicantresponsibleforsnowandiceremoval? q Yes  q No

a. If"Yes,"whoisthemaintenanceperformedby? q Employees  q Subcontractors

(ifcheckingemployees,skipquestionb.)

b. Ifsubcontractors:

i. Iswrittencontractinplaceforservices? q Yes  q No

ii. IsApplicantnamedasanadditionalinsuredonthesubcontractor'spolicy? q Yes  q No

iii.Doessubcontractorcarrygeneralliabilitylimitsofatleast$1,000,000? q Yes  q No

iv.Arecertificatesofinsuranceobtainedfromallsubcontractors? q Yes  q No

25.DoesApplicantnowuse,orinthenexttwelve(12)months,doesApplicantexpect tousearmedsecurityattheabovelocation? q Yes  q No(If "Yes," Firearms and Assault or Battery exclusions will apply)

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Complete below for all applicable products:

ApplianceDistributor  q N/A

26.DoesApplicantdisposeoforrecycleoldappliancesorelectronicequipmentin accordancewithapplicablestatutes,regulationsorordinances? q Yes  q No

Clothing,Wearing,ApparelorFootwear  q N/A

27. Isthereanysaleofchildren'sclothing? q Yes  q No

28.DoesApplicantsellorstorefursorcostumes? q Yes  q No

Fruits,VegetablesorFlowers  q N/A

29. IsApplicantinvolvedinfarming,harvestingortreatingfruitsorvegetablesinanyway? q Yes  q No

GardeningandLightFarmingSupplies  q N/A

30.Arethereanynurseryoperations? q Yes  q No

Seasonal and Holiday  q N/A

31.Arethereanysalesorstorageoffursorcostumes? q Yes  q No

III. BUILDING INFORMATION (IF APPLICABLE)

32.DoestheApplicantownthebuilding?If"Yes": q Yes  q No

a.Whatisthetotalsquarefootageofthebuilding?       sq.ft.

b. Isanyportionofthebuildingvacant?If"Yes,"providesquarefootage: q Yes  q No

      sq.ft.  q Unknown

c. Is any portion leased to others? If "Yes": q Yes  q No

i. Providealistoftenantsandsquarefootageoccupiedbyeach.

       sq.ft.          sq.ft.

       sq.ft.          sq.ft.

ii. Istherealeaseagreementinplacewithalltenants? q Yes  q No

iii.Doestheleaserequireallcommercialtenantstomaintaingeneral liabilitycoveragewithlimitsofatleast$1,000,000? q Yes  q No

iv.AretenantsrequiredtonameApplicantasanadditionalinsured? q Yes  q No

v. DoesapplicantobtaincertificatesofInsurancefromallcommercialtenants? q Yes  q No

vi.Aretenantspermittedtosubleasetoothers? q Yes  q No

d. Isthereanyexistingdamagetothebuilding? q Yes  q No

33.Whattypeofplumbingiswithinthebuilding?(checkallthatapply)

q Copper q Galvanized q Iron q Lead q PVC q Other

34. Istheentirebuildingattheabovelocationequippedwithafunctioningand operationalsprinklerorfiresuppressantsystem?If"Yes": q Yes  q No

a.Whattypeofsprinklersystem? q Wetsystem q Drysystem q Other q Unknown

b.Wasthesprinklersystemdesignedforthecurrenttypeofoccupant? q Yes  q No

c. Isacertifiedcontractorresponsibleforthesprinklersysteminspection,testingandmaintenance? q Yes  q No

d.Howoftenisthesprinklersystemmaintenanceandinspectionperformed?

q Monthly q Quarterly q Semi-Annual q Annual q Unknown

e. Is the sprinkler system tied to a central station alarm? q Yes  q No  q Unknown

35.Whattypeofsecurityiswithinthebuilding?(checkallthatapply)

q Local alarm q Centralstationburglaralarm q Centralstationfirealarm q 24-hoursecurity

q Smoke detection q Fireextinguisher(s) q Other q Unknown

36.Whatisthesmokingpolicyforthepremise?

37.DoesApplicantuseanyportionoftheabovelocationforwarehousingorstorageofgoods?If"Yes": q Yes  q No

a.Whatisthemaximumheightofstorage?        ft.

b.Arestoragerackspositionedsothatthegoodsstoredatthehighestlevelsareatleast 18inchesbelowanyoverheadsprinklers? q N/A  q Yes  q No

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c. Issolidshelvingusedinrackstorage? q Yes q No

d. Isthereanycoldstoragewarehousing?If"Yes": q Yes q No

i. Totalsquarefootageofcoldstoragewarehouse: sq.ft.

ii. Arethetemperaturecontrolvalvestiedtoacentralstationalarm? q Yes q No

iii. DoestheApplicantuseammonia-basedrefrigerants? q Yes q No

1) If "Yes," is there an ammonia detection system? q Yes q No

iv. DoestheApplicanthavebackupgeneratorstoprovideacontinuouspowersourceforrefrigerationandfreezerequipmentintheeventofapowerfailure? q Yes q No

1) If"Yes,"whenwasitlastinspected/tested?   /  /

e. DoestheApplicantstoreanygoodsofothers? q Yes q No

i. If"Yes,"providetypeofgoodsstoredandtotalvalues: $

38. Isanycommercialcookingdoneattheabovelocation? q Yes q No

IV. HIRED AND NON-OWNED AUTO INFORMATION (IF COVERAGE IS DESIRED)

39. DoestheApplicanthaveacommercialautomobilepolicyinplace? q Yes q No

40. DoestheApplicantownanyautos,orleaseanyautosinexcessof30days? q Yes q No

41. DoestheApplicantregularlydelivergoodsorproducts? q Yes q No

FRAUD STATEMENTSAlabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia:Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.Colorado Fraud Statement:Itisunlawfultoknowinglyprovidefalse,incomplete,ormisleadingfactsorinformationtoaninsurancecompanyforthepurposeofdefraudingorattemptingtodefraudthecompany.Penaltiesmayincludeimprisonment,fines,denialofinsuranceandcivildamages.Anyinsurancecompanyoragentofaninsurancecompanywhoknowinglyprovidesfalse,incomplete,ormisleadingfactsorinformationtoapolicyholderorclaimantforthepurposeofdefraudingorattemptingtodefraudthepolicyholderorclaimantwithregardtoasettlementorawardpayablefrominsuranceproceedsshallbereportedtotheColoradodivisionofinsurancewithinthedepartmentofregulatoryagencies.Florida Fraud Statement:Anypersonwhoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurerfilesastatementofclaimoranapplicationcontaininganyfalse,incomplete,ormisleadinginformationisguiltyofafelonyofthethirddegree.Kansas Fraud Statement:Anypersonwho,knowinglyandwithintenttodefraud,presents,causestobepresentedorprepareswithknowledgeorbeliefthatitwillbepresent-edtoorbyaninsurer,purportedinsurer,brokeroranyagentthereof,anywrittenstatementaspartof,orinsupportof,anapplicationfortheissuanceof,ortheratingofaninsurancepolicyforpersonalorcommercialinsurance,oraclaimforpaymentorotherbenefitpursuanttoaninsurancepolicyforcommercialorpersonalinsurancewhichsuchpersonknowstocontainmateriallyfalseinformationconcerninganyfactmaterialthereto;orconceals,forthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact.Maine Fraud Statement:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepurposeofdefraudingthecompany.Penaltiesmayincludeimprisonment,finesoradenialofinsurancebenefitsMaryland Fraud Statement:Anypersonwhoknowinglyorwillfullypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorwhoknowinglyorwillfullypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.New Jersey Fraud Statement:Anypersonwhoincludesanyfalseormisleadinginformationonanapplicationforaninsurancepolicyissubjecttocriminalandcivilpenalties.New York Fraud Statement:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformation,orconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialthereto,commitsafraudulentinsuranceact,whichisacrimeandshallalsobesubjecttoacivilpenaltynottoexceedfivethousanddollarsandthestatedvalueoftheclaimforeachsuchviolation.Oklahoma Fraud Statement:WARNING:Anypersonwhoknowingly,andwithintenttoinjure,defraudordeceiveanyinsurer,makesanyclaimfortheproceedsofaninsur-ancepolicycontaininganyfalse,incompleteormisleadinginformationisguiltyofafelony.Oregon Fraud Statement:NoticetoOregonapplicants:Anypersonwho,withintenttodefraudorknowingthatheisfacilitationafraudagainstaninsurer,submitsanapplica-tionorfilesaclaimcontainingafalseordeceptivestatementmaybeguiltyofinsurancefraud.Kentucky, Pennsylvania AND Ohio Fraud Statement:Anypersonwhoknowinglyandwithintenttodefraudanyinsurancecompanyorotherpersonfilesanapplicationforinsuranceorstatementofclaimcontaininganymateriallyfalseinformationorconcealsforthepurposeofmisleading,informationconcerninganyfactmaterialtheretocommitsafraudulentinsuranceact,whichisacrimeandsubjectssuchpersontocriminalandcivilpenalties.Tennessee, Virginia and Washington Fraud Statement:Itisacrimetoknowinglyprovidefalse,incompleteormisleadinginformationtoaninsurancecompanyforthepur-poseofdefraudingthecompany.Penaltiesincludeimprisonment,finesanddenialofinsurancebenefits.Fraud Statement (All Other States):Anypersonwhoknowinglypresentsafalseorfraudulentclaimforpaymentofalossorbenefitorknowinglypresentsfalseinformationinanapplicationforinsuranceisguiltyofacrimeandmaybesubjecttofinesandconfinementinprison.

STATE NOTICESArizona Notice:Misrepresentations,omissions,concealmentoffactsandincorrectstatementsshallpreventrecoveryunderthepolicyonlyifthemisrepresentations,omissions,concealmentoffactsorincorrectstatementsare;fraudulentormaterialeithertotheacceptanceoftherisk,ortothehazardassumedbytheinsurerortheinsureringoodfaithwouldeithernothaveissuedthepolicy,orwouldnothaveissuedapolicyinaslargeanamount,orwouldnothaveprovidedcoveragewithrespecttothehazardresultingintheloss,ifthetruefactshadbeenmadeknowntotheinsurerasrequiredeitherbytheapplicationforthepolicyorotherwise.Florida Surplus Lines Notice:(Appliesonlyifpolicyisnon-admitted)Youareagreeingtoplacecoverageinthesurpluslinesmarket.Superiorcoveragemaybeavailableintheadmittedmarketandatalessercost.PersonsinsuredbysurpluslinescarriersarenotprotectedundertheFloridaInsuranceGuarantyActwithrespecttoanyrightofrecoveryfortheobligationofaninsolventunlicensedinsurer.Florida and Illinois Punitive Damage Notice:IunderstandthatthereisnocoverageforpunitivedamagesassesseddirectlyagainstaninsuredunderFloridaandIllinoislaw.However,Ialsounderstandthatpunitivedamagesthatarenotassesseddirectlyagainstaninsured,alsoknownas“vicariouslyassessedpunitivedamages”,areinsurableunderFloridaandIllinoislaw.Therefore,ifanyPolicyisissuedtotheApplicantasaresultofthisApplicationandsuchPolicyprovidescoverageforpunitivedamages,IunderstandandacknowledgethatthecoverageforClaimsbroughtintheStateofFloridaandIllinoisislimitedto“vicariouslyassessedpunitivedamages”andthatthereisnocoveragefordirectlyassessedpunitivedamages.Maine Notice:Theinsurerisnotpermittedtowithdrawanybinderonceissued,butaprospectivenoticeofcancellationmaybesentandcoveragedeniedforfraudormaterialmisrepresentationinobtainingcoverage.Apolicymaynotbeunilaterallyrescindedorvoided.

5 of 5Distributor/Wholesaler SUPP-APP 12/15

Minnesota Notice:Authorizationoragreementtobindtheinsurancemaybewithdrawnormodifiedonlybasedonchangestotheinformationcontainedinthisapplicationpriortotheeffectivedateoftheinsuranceappliedforthatmayrenderinaccurate,untrueorincompleteanystatementmadewithaminimumof10days’noticegiventotheinsuredpriortotheeffectivedateofcancellationwhenthecontracthasbeenineffectforlessthan90daysorisbeingcanceledfornonpaymentofpremium.Ohio Representation Statement:Byacceptanceofthispolicy,theInsuredagreesthestatementsintheapplication(neworrenewal)submittedtothecompanyaretrueandcorrect.Itisunderstoodandagreedthat,totheextentpermittedbylaw,theCompanyreservestherighttorescindthispolicy,oranycoverageprovidedherein,formaterialmisrepresentationsmadebytheInsured.Itisunderstoodandagreedthatthestatementsmadeintheinsuranceapplicationsareincorporatedinto,andshallformpartof,thispolicy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CON-TRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE COMPANY THE RIGHT TO RESCIND IT.

Utah Punitive Damages Notice:IunderstandthatPunitiveDamagesarenotinsurableinthestateofUtah.TherewillbenocoverageaffordedforPunitiveDamagesforanyClaimbroughtintheStateofUtah.AnycoverageforPunitiveDamageswillonlyapplyifaClaimisfiledinastatewhichallowspunitiveorexemplarydamagestobeinsurable.ThismayapplyifaClaimisbroughtinanotherstatebyasubsidiaryoradditionallocation(s)oftheNamedInsured,outsidethestateofUtah,forwhichcoverageissoughtunderthe same policy.

IfyourstaterequiresthatwehaveinformationregardingyourAuthorizedRetailAgentorBroker,pleaseprovidebelow.

Retailagencyname:  License#:

Agent’ssignature:  Mainagencyphonenumber:

(RequiredinNewHampshire)

Agencymailingaddress:

City:  State:  Zip

ThesignerofthisapplicationacknowledgesandunderstandsthattheinformationprovidedinthisApplicationismaterialtotheInsurer’sdecisiontoprovidetherequestedin-suranceandisreliedonbytheInsurerinprovidingsuchinsurance.ThesignerofthisapplicationrepresentsthattheinformationprovidedinthisApplicationistrueandcorrectinallmatters.ThesignerofthisApplicationfurtherrepresentsthatanychangesinmattersinquiredaboutinthisApplicationoccurringpriortotheeffectivedateofcoverage,whichrendertheinformationprovidedhereinuntrue,incorrectorinaccurateinanywaywillbereportedtotheInsurerimmediatelyinwriting.TheInsurerreservestherighttomodifyorwithdrawanyquoteorbinderissuedifsuchchangesarematerialtotheinsurabilityorpremiumcharged,basedontheInsurer’sunderwritingguides.TheInsurerisherebyauthorized,butnotrequired,tomakeanyinvestigationandinquiryinconnectionwiththeinformation,statementsanddisclosuresprovidedinthisApplication.ThedecisionoftheInsurernottomakeortolimitanyinvestigationorinquiryshallnotbedeemedawaiverofanyrightsbytheInsurerandshallnotestoptheInsurerfromrelyingonanystatementinthisApplicationintheeventthePolicyisissued.ItisagreedthatthisApplicationshallbethebasisofthecontractshouldapolicybeissuedanditwillbeattachedandbecomeapartofthePolicy.

Applicant’ssignature: Title:

President,ChairpersonoftheBoard,ManagingMember,orExecutiveDirector

Date: