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ADDITIONAL INSURED/LOSS PAYEE INFORMATION

Additional Insured Controlling Interest in this business Co-owner of Insured Premises Manager or Lessor of Premises Lessor of Leased Equipment Owner or Lessor of Leased Land Grantor of Franchise

Loss Payee

Additional Insured Name

Address

Loss Payee Name

City

State & Zip

State/Political Subdivision (for permits relating to the premises)

Dispatcher or Referral Service (Blanket Form) Dispatcher or Referral Service (Scheduled Form)

Address

City

State & Zip

What interest does the additional insured have in the insured's business? (Response is mandatory.)

GENERAL UNDERWRITING INFORMATION:

Please carefully read questions 1 through 16 and respond by checking (X) the appropriate YES or NO box. If any question 1 through 16 is answered YES or is not answered, you will not be eligible for coverage and this application should not be submitted to RLI.

  • 1.

    Is your business property permanently kept anywhere other than this residence (residence includes outbuildings within 100 ft) or the second location identified on page 1 of this application?................................................................. YES

  • 2.

    Have you had more than two claims of any type, related to your business operation, in the last three years? ................. YES

  • 3.

    Have you had a single claim, related to your business, for more than $25,000 in the last three years? ........................... YES

  • 4.

    Do you own any business under the same legal name as the "Business Name" shown, which is permanently "operated" from a second location? (Note: Check "NO" if you have a storage location, second home or a partner working from their home. These are acceptable and should be listed as a second location on page 1 of this application.)....................................................................................................................................................................... YES

  • 5.

    Do you repackage food or personal care products to be sold under your own label? ....................................................... YES

  • 6.

    Are you involved in the sale or manufacturing of explosives, propellants and/or use of flammable liquids? ................. YES

  • 7.

    Do you install any products, excluding the installation of computer systems, office equipment, locksmith

NO NO NO

NO NO NO

YES devices or interior window treatments? ............................................................................................................................ 8. During the last five years (ten in RI), 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?............................. YES (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one

NO

NO

year of imprisonment.) 9. Did your gross annual sales/receipts from your business pursuits for the most recent calendar year exceed

$250,000 for sale of merchandise or $500,000 for a service business?............................................................................. Total estimated annual revenues ....................................................................$________________ Estimated annual revenues from your manufactured products.......................$________________

  • 10.

    Do you employ more than ten (10) employees, other than independent contractors or distributors?..............................

  • 11.

    Is your dwelling located within 1,500 feet from the seacoast on the Gulf of Mexico or the Atlantic Ocean (N/A in RI)?

  • 12.

    If you are a teacher/tutor (other than a personal fitness trainer), do you provide instruction for sports, physical

YES

YES YES

NO

NO NO

education, industrial arts, or martial arts? (Note: Check "NO" if this question is not applicable to your business.)......... YES 13. Do you perform any vehicle repair services (other than oil changes, oil filter changes, glass repair, interior detailing

NO

YES or vinyl/leather repair)? ..................................................................................................................................................... 14. Do you perform any of the following?.............................................................................................................................. Body Massage (other than face, scalp or hand); Hair Straightening by other than cold process; Tanning; Microdermabrasion; Acid Peels; Hair Replacement; Hair Removal (by electrolysis, thermolysis, or any process using radio waves); Ear Candling, Tattooing or Permanent Make-up; Ear or Body Piercing; Hydrotherapy/Saunas; or Body Waxing (other than facials). 15. Do you own or operate any other business under this entity that has not already been described on this application?.... YES 16. Are you an importer of foreign products?......................................................................................................................... YES YES

NO NO

NO NO

Page 2 of 3 Pages

HBP 108 (04/09) FL

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