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DATE MM/DD/YYYY COMMERCIAL POLICY CHANGE REQUEST NAIC CODE CARRIER AGENCY ATTENTION POLICY NUMBER CONTACT NAME PHONE A/C No Ext FAX A/C No E-MAIL ADDRESS ACCOUNT NUMBER EFFECTIVE DATE OF CHANGE POLICY INCEPTION DATE POLICY EXPIRATION DATE SUBCODE CODE POLICY TYPE TRUCKERS MOTOR CARRIERS GENERAL LIABILITY INSURED S NAME AND MAILING ADDRESS IF CHANGED INC ZIP 4 AUTO UMBRELLA NAMED INSURED PROPERTY INLAND MARINE AGENCY CUSTOMER ID WORKERS COMP BUSINESS OWNERS THIS IS AN ACKNOWLEDGEMENT OF YOUR REQUEST. I. N. STREET Required in KY TERR SPEC COMP / SYM / AGE OTC SYM COUNTY CLASS SIC FACTOR SEAT CP RADIUS COLL SYM COML FARTHEST TERMINAL ZIP COST NEW USE PLEASURE CHECK COVERAGES RETAIL FARM FOR HIRE SERVICE DRIVE TO WORK / SCHOOL 15 MILES LIABILITY ADD L NOFAULT LIAB NOFAULT NET VEH DR/CR ST AMT C OF L UNINSURED MOTORISTS UNDERINSURED MOTORISTS AA OTC ACV DEDUCTIBLES FTW RENT REIMB FG MEDICAL PAYMENTS LSP FT F TOTAL PREM MED PAY UNINS MOTOR TOWING LABOR CITY STATE AND ZIP CODE MAR SEX STAT DATE OF BIRTH YRS EXP DRIVER INFORMATION List drivers who frequently use own vehicles DRIVER DRIVERS LICENSE NUMBER/ SOCIAL SECURITY NUMBER DATE HIRE BROADEN. DOC MARITAL STATUS / CIVIL UNION if applicable ACORD 175 2012/04 Page 1 of 2 1991-2012 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TYPE OF CLASS CODE DESCR PROPERTY / INLAND MARINE - PREMISES INFORMATION SUBJECT OF INSURANCE OF EMPLOYEES FULL PART TIME TIME CATEGORIES DUTIES CLASSIFICATIONS AMOUNT COINS PREMISES VALUATION BUILDING INFLATION GUARD CAUSES OF LOSS ESTIMATED ANNUAL REMUNERATION FORMS AND CONDITIONS TO APPLY ADDITIONAL COVERAGES OPTIONS RESTRICTIONS ENDORSEMENTS AND RATING INFORMATION Attach ACORD 101 Additional Remarks Schedule if more space is required DISTANCE TO HYDRANT FIRE STAT CONSTRUCTION TYPE BUILDING IMPROVEMENTS PLUMBING YR WIRING YR OTHER INSPECTED Y/N ROOF PROT CL STORIES BASM TS TOTAL AREA OTHER OCCUPANCIES HEATING YR ROOFING YR FIRE DISTRICT / CODE NUMBER MI BLDG CODE GRADE TAX CODE RIGHT EXPOSURE DISTANCE LEFT EXPOSURE DISTANCE BURGLAR ALARM TYPE CERTIFICATE REAR EXPOSURE DISTANCE EXPIRATION DATE EXTENT CENTRAL STATION WITH KEYS BURGLAR ALARM INSTALLED AND SERVICED BY GUARDS/WATCHMEN CLOCK HOURLY FIRE ALARM MANUFACTURER PREMISES FIRE PROTECTION Sprinklers Standpipes CO2 / Chemical Systems LOCAL GONG COINSURANCE DESCRIPTION TYPE MANUFACTURER MODEL CAPACITY ETC ID /SERIAL PURCHASED NEW/USED GENERAL AGGREGATE DAMAGE TO RENTED PREMISES PRODUCTS COMPLETED OPERATIONS AGGREGATE MEDICAL EXPENSE Any one person PERSONAL ADVERTISING INJURY EMPLOYEE BENEFITS EACH OCCURRENCE HAZ CLASSIFICATION PREMIUM BASIS EXPOSURE PREMIUM BASIS CODES S P A C M U T GROSS SALES - PER 1 000/SALES PAYROLL - PER 1 000/PAY AREA - PER 1 000/SQ FT TOTAL COST - PER 1 000/COST ADMISSIONS - PER 1 000/ADM UNIT - PER UNIT LIMIT OF LIABILITY RETAINED LIMIT DESCRIBE ADDITIONAL INTEREST ADDITIONAL INSURED AS LESSOR LIENHOLDER NAME AND ADDRESS RANK EVIDENCE INTEREST IN ITEM NUMBER MORTGAGEE LOCATION VEHICLE BOAT REGISTRANT AIRPORT LOSS PAYEE ITEM CLASS ITEM ITEM DESCRIPTION REFERENCE / LOAN SIGNATURE Any deletion or reduction in coverage requires the Insured s signature PRODUCER S SIGNATURE INSURED S SIGNATURE STATE PRODUCER LICENSE NO Required in Florida PRODUCER S NAME Please Print NATIONAL PRODUCER NUMBER.

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