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:
2 of 5Distributor/Wholesaler SUPP-APP 12/15
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.
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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:
