Package Credit:

Experience Rating Factors

Liability:

Liability Minimum:

Physical Damage:

Physical Damage Minimum:

Loss History:

Years of Loss History Known: Losses:

Losses:

[None]

Underwriting Questions

Quote Approval

Issue Policy

Bound

Applicant Information

Other Named Insureds:

[None]

Description of Operations:

1a. Is the applicant a subsidiary of another entity?
Parent Company Name:
Relationship: Percent Owned: %

1b. Does the applicant have any subsidiaries?

[None]

2. Is a formal safety program in operation?
Safety Manual: Monthly Meetings Safety Position OSHA

3. Any exposure to flammables, explosives, chemicals?
Describe:

4. Any other insurance with OMI?

[None]

5. Any policy or coverage declined, cancelled, or non-renewed in the prior three (3) years for any premises or operation?
Reason: Condition Corrected:

6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?

7. During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property?

8. Any uncorrected fire and/or safety code violations?

[None]

9. Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the last five years?

[None]

10. Has applicant had a judgement or lien during the last five (5) years?

[None]

11. Has business been placed in a trust?
Name of Trust:

12. Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries?

(if "Yes", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure)

13. Does any applicant have other business ventures for which coverage is not requested?

Remarks/Instructions:

Business Auto

Driver Information:

[None]

General Information

1. With the exception of any encumbrances, are any vehicles for which insurance is requested not solely owned by and registered to the applicant?

[None]

2. Do over 50% of employees use their autos in the business?

3. Is there a vehicle maintenance program in operation?

4. Are any vehicles leased to others?

5. Is any vehicle modified/special equipment?

[None]

6. Are ICC, PUC, or other filings required?

[None]

7. Do operations involve transporting hazardous material?

8. Any hold harmless agreements?

9. Any vehicles used by family members?
If so, identify:

10. Does applicant obtain MVR verifications?

11. Does the applicant have a specific driver recruiting method?

12. Are any drivers not covered by Workers Compensation?

13. Any vehicles owned but not scheduled on this application?

14. Any drivers with convictions for moving traffic violations?

[None]

15. Has agent inspected vehicles?
Describe:

16. Are all vehicles to be included part of a fleet?

[None]

Auto Symbols

1 Any "Auto"
2 Owned "Autos" Only
3 Owned Private Passenger "Autos" Only
4 Owned "Autos" Other Than Private Passenger "Autos" Only
5 Owned "Autos" Subject to No-Fault
6 Owned "Autos" Subject to a Compulsory Uninsured Motorists Law
7 Specifically Described "Autos"
8 Hired "Autos" Only
9 Non-owned "Autos" Only

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in CO, DC, FL, HI, MA, MN, NE, HO, OK, OR, VT, or WA; in LA, ME, TN, and VA insurance benefits may also be denied.)

In Massachusetts, Nebraska, Oregon, and Vermont, any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be comitting a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.

In Washington, it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.