GNCY CC NSUNC PPCN PPCN NFN SCN C NC CD: UNDW D (/DD/YYYY) UNDW FF. PCS PG QUSD PCY NUB PHN (/C, No, xt): FX (/C, No): - DDSS: CD: GNCY CUS D: SUS F NSCN QU CHNG CNC D PPCN NFN SUB CD: SSU PCY BUND (Give Date and/or ttach Copy): N (First Named nsured & ther Named nsureds) NW P NDC SCNS CHD CCUNS CVB/ VUB PPS B & CHNY BUSNSS U CC GN BY C/SCNUS C DS DV NF SCHDU PCKG PCY NFN CNC D PC QUPN F GG ND DS GSS ND SGN NSN/BUDS SK PN CG PPY NSPN/ UCK CG NG DDSS NC ZP+4 (of First Named nsured) UCKS/ C UB VHC SCHDU WKS CPNSN YCH N HS NFN WHN CN DS ND S PPY SV NS, F NN PCS. PPSD FF D PPSD XP D BNG PN PYN PN UD DC B GNCY B FN SC SC # (of First Named nsured): - DDSS(S): NDVDU PNSHP NSPCN CNC: PHN (/C, No, xt): PSS NFN C # BD # CPN JN VNU - DDSS: PHN (/C, No, xt): SUBCHP "S" CPN N F PF G C N. F BS ND NGS CCUNNG CDS CNC: PHN (/C, No, xt): CD 823 attached for additional premises S, CY, CUNY, S, ZP+4 CY S D NUB: WBS DDSS(S): C BUU NS Y BU - DDSS: # PYS NNU VNUS D BUS SD % CCUPD NSD USD WN NN NSD USD WN NN NSD USD WN NN NSD USD WN NN NU F BUSNSS/DSCPN F PNS BY PS(S) CD 125 (2006/08) Page 1 of 3 CD CPN 1993-2006. ll rights reserved. he CD name and logo are registered marks of CD
GN NFN XPN "YS" SPNSS YS N XPN "YS" SPNSS YS N 1a. S H PPCN SUBSDY F NH NY? 6. NY PCY CVG DCND, CNCD NN-NWD DUNG H P 3 YS? (Not applicable in ) 1b. DS H PPCN HV NY SUBSDS? 7. NY PS SSS CS NG SXU BUS SN GNS, DSCNN NGGN HNG? 2. S F SFY PG N PN? 8. DUNG H S FV YS (N N ), HS NY PPCN BN NDCD F CNVCD F NY DG F H C F FUD, BBY, SN NY H SN-D C N CNNCN WH HS NY H PPY? (n, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 3. NY XPSU FBS, XPSVS, CHCS? 9. NY UNCCD F CD VNS? 4. NY CSPH XPSU? 10. NY BNKUPCS, X CD NS GNS H PPCN N H PS 5 YS? 5. NY H NSUNC WH HS CPNY BNG SUBD? KS/PCSSNG NSUCNS (ttach additional sheets if more space is required) 11. HS BUSNSS BN PCD N US? 12. F YS, N F US: NY FGN PNS, FGN PDUCS DSBUD N US, US PDUCS SD/DSBUD N FGN CUNS? (f "YS", attach CD 815 for iability xposure and/or CD 816 for Property xposure) NY PSN WH KNWNGY ND WH NN DFUD NY NSUNC CPNY NH PSN FS N PPCN F NSUNC SN F C CNNNG NY Y FS NFN, CNCS F H PUPS F SDNG, NFN CNCNNG NY FC H, CS FUDUN NSUNC C, WHCH S C ND SUBJCS H PSN CN ND [NY: SUBSN] CV PNS. (Not applicable in C, H, N, H, K,, or V; in DC,,, N, V and W, insurance benefits may also be denied) H UNDSGND S N UHZD PSNV F H PPCN ND CFS H SNB NQUY HS BN BN H NSWS QUSNS N HS PPCN. H/SH CFS H H NSWS U, CC ND CP H BS F HS/H KNWDG. PPCN'S SGNU D PDUC'S SGNU NN PDUC NUB CD 125 (2006/08) Page 2 of 3
P C NFN N C C G N B Y U B B Y P P Y S C PCY NUB PCY YP D FF-XP D GN GGG PDUCS CP P GGG PSN & DV NJ CH F DG DC XPNS BDY NJUY GGG PPY DG GGG CBND SNG DFCN FC PU C PCY NUB PCY YP FF-XP D CBND SNG BDY NJUY C PCY NUB PCY YP FF-XP D C PCY NUB PCY YP FF-XP D CGY BUDNG PS PP DFCN FC PU DFCN FC PU PSN CCDN PPY DG DFCN FC PU SS HSY CS CS CS N CS SSS (GDSS F FU ND WHH N NSUD) S H Y GV S CS F H P 5 YS (3 YS N KS & NY) D F N YP/DSCPN F C D F C CS UN PD CHK H F NN UN SVD CS S CHD SS SUY C SUS PN CSD KS N: FDY QUS FV Y SS HSY CHNS S SUPPN(S) (f applicable) CPY F H NC F NFN PCCS (PVCY) HS BN GVN H PPCN. (Not applicable in all states, consult your agent or broker for your state's requirements.) NC F NSUNC NFN PCCS PSN NFN BU YU, NCUDNG NFN F CD P, Y B CCD F PSNS H HN YU N CNNCN WH HS PPCN F NSUNC ND SUBSQUN PCY NWS. SUCH NFN S W S H PSN ND PVGD NFN CCD BY US U GNS Y N CN CCUSNCS B DSCSD HD PS WHU YU UHZN. YU HV H GH VW YU PSN NFN N U FS ND CN QUS CCN F NY NCCUCS. DD DSCPN F YU GHS ND U PCCS GDNG SUCH NFN S VB UPN QUS. CNC YU GN BK F NSUCNS N HW SUB QUS US. CD 125 (2006/08) Page 3 of 3
UB / XCSS SCN D (/DD/YYYY) GNCY PHN (/C, No, xt): FX (/C, No): PPCN (First Named nsured) - DDSS: CD: GNCY CUS D: PCY NFN NW NW XPNG P #: UB XCSS SUBCD: NSCN YP PY BNFS BY CS FFCV D F CPNY US NY CV D PPSD CUN XPN D F BY DC B GNCY B CC PYN PN ND UD FS D DFNS YS N F NSUNC (a mployee) GGG F B ND F B CV D F B N F BNF PG PY CN & SUBSDS (CD 125) # N ND CN F PY ND SUBSDY CPNS (Describe perations) NNU PY NN GSS SS FGN GSS SS # P CN: DSCPN: CN: DSCPN: CN: DSCPN: CN: DSCPN: CN: DSCPN: CN: DSCPN: UNDYNG NSUNC S BY/CPNSN PCS N FC PPY S UNDYNG NSUNC YP C/PCY NUB PCY FF D PCY XP D S CS. CC. NNU NW PU + - NG D UB BY B. CC. B. P. PD. CC. GN BY PCY YP CCU CS CH GN GG PD & CP PS GGG PSN & DV NJUY DG ND PSS DC XPNS P/PS PDUCS H PYS BY CH CCDN DSS CH PY DSS PCY CD 131 (2007/03) CH CD 125 ND CD 126 Page 1 of 4 CD CPN 1991-2007. ll rights reserved. he CD name and logo are registered marks of CD
UNDYNG NSUNC (continued) UNDYNG GN BY NFN (xplain all "YS" responses) 1. DFNS CSS: WHN GGG S? SP? UND? 2. NDC H DN D F H S F S FNG F H UNDYNG CVG: 3. HS NY PDUC, WK, CCDN, CN BN XCUDD, UNNSUD SF NSUD F NY PVUS CVG? YS N 4. 5. F CS, NDC CV D F CUN UNDYNG PCY: F CS, NDC NY D N UNNUPD CS CVG: 6. F CS, WS "" CVG PUCHSD F NY PVUS PY XCSS PCY? FF. D: N YS CHCK CVGS N UNDYNG PCS. S CHCK F NY XPSUS PSN F CH CVG. PVD N XPNN. XPN F DFFN S, XNSNS, XCUSNS. XPN NY SPC CVGS BYND SNDD FS. XPN XPSUS. NY U (SYB 1) CG - CS CG - CVG CF BY DDN NSS CHCK F PPP CVG XPSU CVG XPSU CF PSSNG BY XPSU C, CUSDY, CN PY BNF BY FGN BY/V GGKPS BY NCDN DC PCC QU BY PUN BY PFSSN BY (&) VNDS BY WCF BY UNDYNG NSUNC CVG NFN (NCUD SCNS;.G. S NDSNS, DSCNN, SUBGN WVS, XNSNS F CVG - CH SP SH F NCSSY) PVUS XPNC: (GV DS F BY CS XCDNG 10,000 S H Y GV S CS, DUNG H PS 5 YS, WHH NSUD N. SPCFY D, CVG, DSCPN, UN PD, UN USNDNG - CH SP SH F NCSSY) N SUCH CS C, CUSDY, CN C PPY YP VU * B* C* D* SQ F F BDG CC PSN CCUPNCY / DSCPN F PSN PPY *PPCN: [] S HD HSS N H S, [B] HS WV F SUBGN, [C] S ND NSUD N H F PCY, [D] H (specify) VHCS PV PSSNG UCKS UCKS/ CS BUSS YP GH DU HVY X. HVY HVY X. HVY CD 131 (2007/03) # WND # NN- WND # SD Page 2 of 4 PPY HUD 0-50 50-200 V 200
DDN XPSUS XPN "YS" SPNSS, PVD H NFN QUD 1. D USD: NNU CS: 2. SVCS F N DVSNG GNCY USD? DVSS BY YS N 3. NY CVG PVDD UND GNCY'S PCY? 4. DS PPCN WN/S/P CF? CF BY 5. U BY XPSVS, CUSCS, FBS H DNGUS CG HUD? 6. PSSNGS CD F F? 7. NY UNS N NSUD BY UNDYNG PCS? 8. NY VHCS SD ND HS? 9. HD ND NN/WND CVGS PVDD? 10. S BDG, D, N WK PFD? CNCS BY 11. DSCB YPC JBS PFD (ttach additional sheets if more space is required) 12. DSCB GN (ttach additional sheets if more space is required) 13. DS PPCN WN, N, HWS US CNS? 14. D SUBCNCS CY CVGS S SS HN PPCN? 15. S PPCN SF-NSUD N NY S? PYS BY 16. SUBJC : JNS C F SP GP H: 17. S HSP FS D FCY NND? NCDN PCC BY 18. CVGS PVDD F DCS / NUSS? 19. NDC # F DCS: NUSS: BDS: CD 131 (2007/03) Page 3 of 4
DDN XPSUS (continued) XPN "YS" SPNSS, PVD H NFN QUD P #: PUN BY YS N 20. D CUN PS PDUCS, H CPNNS, CNN HZDUS S H Y QU SPC DSPS HDS? 21. NDC H CVGS CD: G WH SNDD S PUN XCUSN G WH SNDD SUDDN & CCDN NY G WH PUN CVG NDSN SP PUN CVG PDUC BY 22. SSS, NGNS, GUDNC SYSS, FS NY H PDUC USD / NSD N CF? 23. NY FGN PNS, FGN PDUCS DSBUD N H US US PDUCS SD / DSBUD N FGN CUNS? (f "YS", ttach CD 815) 24. PDUC BY SS N PS H (3) YS? (SPCFY) 25. GSS SS F CH F S H (3) YS: PCV BY 26. DSCB NDPNDN CNCS (ttach additional sheets if more space is required) 27. DS PPCN WN S WCF? WCF BY # WND NGH HSPW # WND NGH HSPW PNS / CNDNUS / HS / S # SS # UNS # SWNG PS # DVNG BDS # SS # UNS # SWNG PS # DVNG BDS KS (ttach additional sheets if more space is required) SGNU NY PSN WH KNWNGY ND WH NN DFUD NY NSUNC CPNY NH PSN FS N PPCN F NSUNC SN F C CNNNG NY Y FS NFN, CNCS F H PUPS F SDNG, NFN CNCNNG NY FC H, CS FUDUN NSUNC C, WHCH S C ND SUBJCS H PSN CN ND [NY: SUBSN] CV PNS. (Not applicable in C, F, H, N, H, K,, or V; in DC,,, N, V and W, insurance benefits may also be denied) N FD, NY PSN WH KNWNGY ND WH NN NJU, DFUD, DCV NY NSU FS SN F C N PPCN CNNNG NY FS, NCP, SDNG NFN S GUY F FNY F H HD DG. F H CPNY WHCH PPYNG FFS UNNSUD SS (U) ND/ UNDNSUD SS (U) CVG N Y S: UNNSUD SS (U) CVG: * UNDNSUD SS (U) CVG: * F PPCB N YU S * PPCB NY N GG, USN, NW HPSH ND VN PPCB NY N GG ND USN: CKNWDG H U CVG HS BN XPND, ND HV BN FFD H PN F SCNG U S QU Y BY S, U S W HN Y BY S, JC U CVG NY. 1. SC U S NDCD N HS PPCN. PPCB NY N NW HPSH: (NS) 2. JC U CVG N S NY. (NS) CKNWDG H U CVG HS BN XPND, ND HV BN FFD H PN F SCNG U S QU Y BY S JC U CVG NY. 1. SC U S NDCD N HS PPCN. PPCB NY N VN: (NS) 2. JC U CVG N S NY. (NS) CKNWDG H HV BN FFD U CVG QU Y BY S. HV SCD H S NDCD N HS PPCN. PN - H SNS (NSWS) GVN BV U ND CCU. H PPCN HS N WFUY CNCD SPSND NY FC CCUSNC CNCNNG HS PPCN. HS PPCN DS N CNSU BND. PPCN'S SGNU D CD 131 (2007/03) Page 4 of 4