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t e <br /> ' ACORD COMMERCIAL INSURANCE APPLICATION DATE (MWDOM'4Y) <br /> *" APPLICANT INFORMATION SECTION 102 / 19 / 04 <br /> ! PRODUCER N 0 7 s 4 - o 0 2 2 CARRIER NAIL CODE: UNMWRRER NDEMMITER OFF, <br /> - T <br /> FAx ( 407 ) 260 - 1767 Zurich Halcyon <br /> .E14d;_ .__.—. . . _. .. . .. . _. <br /> ' POLICIES OR PROGRAM REQUESTED POLICY NUYBFA <br /> IGuignard company <br /> 11904 Boothe Circle Builders Risk $X48548003 <br /> LOI1gWOOd , FL 327rj INDICATE SECTIONS ATTACHED EQUIPMENT FLOATER GARAGE AND DEALERS <br /> PROPERTY X INSTALLATIONBUILOER$ RISK VEHICLESCHEOULE <br /> — -- --- — - — GLASS AND SIGN ELECTRONIC DATA PROC BOILER S MACHINERY <br /> I CODl: am CODE: ACCOUNTS RECEIVABLE/ CpMMERGAL <br /> VALUABLE PAPERS GENERAL LIABILITY WORKERS OOMPENSg710N <br /> gOENOT CUSTOMt q ID CRIMF.MISCELLAN50LIS CRIME HRUSINESS AUTO UMERELLA <br /> TRA <br /> PORT TION/ <br /> -----....... . .. . . . Mar? <br /> iRU0KER4fMOTOR CARRIER . . . . -- <br /> STATUS OF TRANSACTION PACKAGE POLICY INFORMATION <br /> OIJOTE X ISSUE POLICY RENEW ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO 1 ,VF,IT�14 1,1NE$5 OR FOR MONOLINE POLICIES, <br /> X BOUND (Give Dale andfW Allacn t:opy); PROPOSED EFF DATE PROPOSED EXP DATE SILLMO PLAN PAYMENT PLAN AUDIT <br /> OHANOaDIRECT BILL <br /> G,;�L DATE PMM 2 / 23 / 04 2 / 23 / 05 Annual <br /> U. ,1 4 12 /Too <br /> _ AGENCY ILL <br /> APPLICANT INFORMATION <br /> i NAME (Flint NagNA Insured F Other Nnaed Insunda) FEIF OR SOC ECS MAIL ADDROU MCL ZlPs4 (al Flint Narnaall cured) -- - <br /> ! �w lnwwj� <br /> ( 772 ) 778 - 3072 1717 Indian River Blvd . , # 202A <br /> Barth Construction , Inc . Vero Beach , FL 32960 <br /> IADM '1117 <br /> NTERNET �INDIVIDUAL X CORPORATIONH &GCMA <br /> ATION�� I PP �� CRNgw UID NUMSER BTA EPARTNERSHIP JO VENTURENOT R ArDib NAiTAG 93 � ,....,. <br /> INSPECTION CONTACT E : ( 7 7 2 ) 77_0 - 3072 ACCOUNTING RECORDS CONTACT H No ; ( 7 7 2 ) 778 - 3072 <br /> Jason Pykes <br /> PREMISES INFORMATION <br /> LDC a swal STREET, CITY, GOUrlry BTAT14 ZIPi4 - - CITY LWIITS INTEREST YR BUILT PART OCCUPIED <br /> INSIDE OWNER <br /> OUTSIDE TENANT <br /> INSIDE OWNER <br /> OUTSIDE TENANT <br /> INSIDE OWNER <br /> aUTTi1IaC TENANT <br /> ' NALURE OF §USINEOISIDESCRIPTION OF OPERATIONS BY PREMISE (S) <br /> �..� __.... .. . ... - - _---•- <br /> GENERAL INFORMATION <br /> EXPLAIN ALL "T!a" RESPONSES YES NO EXPLAIN ALL "70" REiPONBE; YES NO <br /> 78. IS THE APPLICANT A 9UBSIOIARY OF ANOTHER ENTITY , ANY PAST LO S OR CLAIMS REL A ING Tp 8 UAL USE OR <br /> 16. DOER THE AFRICAN? HAVE ANY SUB 10 IE9T B• DURINO THE LAST FIVE YEARS (TEN IN RI), HAG ANY APPLICANT <br /> 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? !In R1,, 0 <br /> �9% quesb�onOmust beboeswaaOF <br /> by mV aTHE �pl cmME Ot�prrMeerly Insurance. <br /> ' FWIr h:+4ie 4y saorkOr dbID01 mar dosdomoanor <br /> 3. ANY EXPOSURETO FLAMhMBlEB, EXPLOSIVES, OHEMICAL87 punas a <br /> 4, ANY CATASTROPHE EXPOSURE? 11. ANY UNCORRECTED FIRE 000E VIOLATIONS? <br /> b. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? 7 . ANY BANK PTGES A% OR CREDIT UEN3 AGAINST THE APPLICANT <br /> B ANY P LI Y OR COVERAGE of WN Imps CANCELLED OR NON4:WNEWEO <br /> ' REMARNSIPROCESSINO NOTRUCU0149 <br /> ' ANY PERSON W140 kNOWINGLY AN15 MTN INTENT DEFRA D ANY (tIlSURANCE COMPANY OR ANOTHER PERSON FILES AN <br /> I APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS <br /> i FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT <br /> INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL) CIVIL PENALTIES, (Not <br /> ' applicable In CO, HI, , OH , , , or VT, In DC, LA, ME and VA, Insurance benefits may also be denied) <br /> SIGN TURREE PRODUCER'S <br /> SIGNATURE <br /> ACORD 1Z71) q-j <br /> ) PLEASE COMPLETE REVERSE SIDE c0 ACORD CORPORATION 1993 <br /> PA T C;IgP).Glb JIWHAwnn RHHNn T nn F,q : q T: t7I?I0F.-6Z -93A <br />