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ACORD 126 — Commercial General Liability Section

Coverages and limits, contractor operations, subcontracted work and hazard details.

255 questions, grouped by the page they appear on in the printed ACORD form.

Fill in what applies to you and leave the rest blank — we will follow up on anything we still need. Other sections: 125 · 126 · 140

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Don't fill this out if you're human:

5. Agency Customer Id:

The customer's identification number assigned by the producer (e.g., agency or brokerage).

The date on which the form is completed. (MM/DD/YYYY)

The full name of the producer / agency.

The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of t...

The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC).

The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears...

The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/Y...

The named insured(s) as it / they will appear on the policy declarations page.

Check the box (if applicable): Indicates the claims made or occurrence option applies for the general liabi...Yes

The general liability, general aggregate limit amount. Any questions about appropriate limits or applicabl...

Check the box (if applicable): Indicates the "claims made" option applies on the general liability policy.Yes

Check the box (if applicable): Indicates the general liability policy, occurrence basis applies.Yes

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per...Yes

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per...Yes

Check the box (if applicable): Indicates the owners and contractors protective option applies for the gener...Yes

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per...Yes

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies to o...Yes

The description of the other option to which the general liability policy, general aggregate limit applies.

The premium for premises/operations coverage.

Check the box (if applicable): Indicates other coverage not found on the form exists for the general liabil...Yes

The description of other coverage (not the limit) on the general liability policy. Any questions about app...

The general liability, products and completed operations aggregate limit amount. Any questions about appro...

The general liability, personal and advertising injury limit amount. Any questions about appropriate limit...

The premium for products coverage.

Check the box (if applicable): Indicates if a property damage deductible is requested.Yes

The deductible applicable to the Property Damage coverage.

The general liability, each occurrence limit amount. Any questions about appropriate limits or applicable...

Check the box (if applicable): Indicates if a bodily injury deductible is requested.Yes

The deductible applicable to the Bodily Injury coverage.

Check the box (if applicable): Indicates that a per claim deductible applies to individual claims even if t...Yes

The general liability, damage to rented premises each occurrence limit amount. Any questions about appropr...

The premium for other general liability coverage.

Check the box (if applicable): Indicates that a deductible is requested on the coverage other than Property...Yes

The type of deductible being requested other than property damage and bodily injury.

The deductible applicable to the Other Coverage.

Check the box (if applicable): Indicates that a per occurrence deductible applies once to each occurrence n...Yes

The general liability, medical expense each person limit amount. Any questions about appropriate limits or...

The general liability employee benefits limit amount.

The total premium amount for the commercial general liability line of business.

The description of other coverage (not the limit) on the general liability policy. Any questions about app...

The general liability, other coverage limit amount. Any questions about appropriate limits or applicable p...

The remarks associated with the general liability line of business. Use this section to provide any additi...

Check the box (if applicable): Indicates if uninsured/underinsured motorist coverage is to be provided unde...Yes

Check the box (if applicable): Indicates that uninsured/underinsured motorist coverage is not to be provi...Yes

Check the box (if applicable): Indicates that medical payment coverage is to be provided under the policy.Yes

Check the box (if applicable): Indicates that medical payment coverage is not to be provided under the policy.Yes

The producer assigned identifier for the location number of the risk's location as it appears on the Applic...

A unique (within location) number distinguishing this unit-at-risk from the others.

The general liability class code that corresponds to the classification description shown in the previous f...

An industry code designating the rating basis of the exposure amount.

The amount of the exposure used for this class code in calculating the premium. The contents of this data...

The rating territory code based on location from the appropriate state exception page.

The separate Premises Operations manual rate applicable to the classification.

The separate Products rate applicable to the classification.

The premium associated with the premises operations coverage.

The premium associated with the products coverage.

The classification of the applicant's liability exposures by location, using the ISO Classification Table o...

The producer assigned identifier for the location number of the risk's location as it appears on the Applic...

A unique (within location) number distinguishing this unit-at-risk from the others.

The general liability class code that corresponds to the classification description shown in the previous f...

An industry code designating the rating basis of the exposure amount.

The amount of the exposure used for this class code in calculating the premium. The contents of this data...

The rating territory code based on location from the appropriate state exception page.

The separate Premises Operations manual rate applicable to the classification.

The separate Products rate applicable to the classification.

The premium associated with the premises operations coverage.

The premium associated with the products coverage.

The classification of the applicant's liability exposures by location, using the ISO Classification Table o...

The producer assigned identifier for the location number of the risk's location as it appears on the Applic...

A unique (within location) number distinguishing this unit-at-risk from the others.

The general liability class code that corresponds to the classification description shown in the previous f...

An industry code designating the rating basis of the exposure amount.

The amount of the exposure used for this class code in calculating the premium. The contents of this data...

The rating territory code based on location from the appropriate state exception page.

The separate Premises Operations manual rate applicable to the classification.

The separate Products rate applicable to the classification.

The premium associated with the premises operations coverage.

The premium associated with the products coverage.

The classification of the applicant's liability exposures by location, using the ISO Classification Table o...

The retroactive date you are requesting for the policy being applied for. This is the proposed earliest dat...

The retroactive date shown on the applicant's first Claims Made policy. If this is the first such policy,...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Has any product, wo...

An explanation of any work, accident or location that has been excluded, uninsured or self-insured from any...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Was tail coverage p...

An explanation if tail was coverage purchased under any previous policy.

The deductible per claim applicable to Employee Benefits Liability coverage.

The total number of employees covered by employee benefits plans.

The total number of employees.

The retroactive date that is the earliest date for which an occurrence could "trigger" coverage under Emplo...

The edition identifier of the form including the form number and edition (the date is typically formatted Y...

6. Agency Customer Id:Contractors

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant draw...

An explanation of any plans, designs or specifications drawn for others.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do any operations i...

An explanation of any operations that include blasting or utilize , store explosive material.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does any operation...

An explanation of any operations which include evacuation, tunneling, underground work or earth moving.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do subcontractors c...

An explanation of any of your subcontractors who carry coverages or limits less than yours.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are subcontractors...

An explanation of any subcontractors allowed to work without providing you with Certificates of Insurance.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant leas...

An explanation of any applicant who leases equipment to others with or without operators.

The total dollar amount for work that the contractor pays to subcontractors.

The percentage of the work described by the applicant as subcontracted out.

The number of individuals employed full time by the applicant.

The number of individuals employed part time by the applicant.

Describe the type of work and percentage subcontracted.

The name used to identify the product manufactured or sold or service provided by the applicant.

The whole dollar estimate of the annual sales receipts realized by this product or service.

The number of units of this product manufactured and/or sold each year.

The number of months the product or service has been marketed to the public.

The anticipated number of months of useful life of the product or service.

The intended use of the product.

The principal components of the product.

The name used to identify the product manufactured or sold or service provided by the applicant.

The whole dollar estimate of the annual sales receipts realized by this product or service.

The number of units of this product manufactured and/or sold each year.

The number of months the product or service has been marketed to the public.

The anticipated number of months of useful life of the product or service.

The intended use of the product.

The principal components of the product.

The name used to identify the product manufactured or sold or service provided by the applicant.

The whole dollar estimate of the annual sales receipts realized by this product or service.

The number of units of this product manufactured and/or sold each year.

The number of months the product or service has been marketed to the public.

The anticipated number of months of useful life of the product or service.

The intended use of the product.

The principal components of the product.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant inst...

An explanation of any installation, service or product demonstration applicant would perform.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Foreign products, s...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Research and develo...

An explanation of any research and development conducted on new products planned.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Guarantees, warrant...

An explanation of any guarantees, warranties, hold harmless agreements.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Products related to...

An explanation products related to aircraft/space industry.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Products recalled,...

An explanation products recalled, discontinued, changed.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Products of others...

An explanation of products of others sold or repackaged under applicant's label.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Products under labe...

An explanation of products under label of others.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Vendors coverage re...

An explanation any vendor's coverage required.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does any named insu...

An explanation of any named insured who sells to any other named insured.

7. Agency Customer Id:

Check the box (if applicable): Indicates that further additional interests appear on the attached ACORD 45.Yes

The ranking of 'this' additional interest when multiple additional interests are associated with the same i...

Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance.Yes

Check the box (if applicable): Indicates the additional interest type is an additional insured.Yes

The producer assigned number of the location which has an additional interest.

The producer assigned number of the building which has an additional interest.

Check the box (if applicable): Indicates the additional interest type is an employee as lessor.Yes

The additional interest's full name.

The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).

The producer assigned number of the scheduled item which has an additional interest.

Check the box (if applicable): Indicates the additional interest type is a lender's loss payable.Yes

The additional interest's mailing address line one.

Check the box (if applicable): Indicates the additional interest type is a lien holder.Yes

The additional interest's mailing address line two.

The description of the item of interest if needed to further clarify. For a vehicle, list the make, model...

Check the box (if applicable): Indicates the additional interest type is a loss payee.Yes

The additional interest's mailing address city name.

The additional interest's mailing address state or province code.

The additional interest's mailing address postal code.

The additional interest's country code.

Check the box (if applicable): Indicates the additional interest type is a mortgagee.Yes

Check the box (if applicable): Indicates the additional interest is other than those listed.Yes

The description of the other type of additional interest.

The loan number, account number or other controlling number that the additional interest may have assigned...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any medical facilit...

An explanation of any medical facilities provided or medical professionals employed or contracted.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any exposure to rad...

An explanation of any exposure to radioactive/nuclear materials

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do/have past, prese...

An explanation any operations that involve storing, treating, discharging, applying, disposing or transport...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any operations sold...

An explanation of any listed operations sold, acquired, or discontinued in the last five (5) years.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do you rent or loan...

An explanation of any machinery or equipment that is loaned or rented to others.

Check the box (if applicable): Indicates the subclass / grouping of property into which the item falls is s...Yes

Check the box (if applicable): Indicates the subclass / grouping of property into which the item falls is l...Yes

Enter Y for a “Yes” response. Input N for “No” response. Indicates whether instruction is given on how to u...

An explanation of any machinery or equipment that is loaned or rented to others.

Check the box (if applicable): Indicates the subclass / grouping of property into which the item falls is s...Yes

Check the box (if applicable): Indicates the subclass / grouping of property into which the item falls is l...Yes

Enter Y for a “Yes” response. Input N for “No” response. Indicates whether instruction is given on how to u...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any watercraft, doc...

An explanation of any watercraft, docks, floats owned, hired, or leased.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any parking facilit...

An explanation of any parking facilities owned/ rented.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is a fee charged fo...

An explanation of any fee charged for parking.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Recreation faciliti...

An explanation of any recreational facilities provided.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, " Are ther...

The number of separate living units in structure.

The area, in square feet, of the building used as apartments.

The description of other lodging operations.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is there a swimming...

Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an approved hei...Yes

Check the box (if applicable): Indicates there is limited access to the swimming pool.Yes

Check the box (if applicable): Indicates the swimming pool has a diving board.Yes

Check the box (if applicable): Indicates the swimming pool has a slide.Yes

Check the box (if applicable): Indicates the swimming pool is above ground.Yes

Check the box (if applicable): Indicates the swimming pool is in the ground.Yes

Check the box (if applicable): Indicates there is life guard for the swimming pool.Yes

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are social events s...

An explanation of any social events sponsored.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are athle...

Check the box (if applicable): Indicates the sport participants are 13 through 18 years old.Yes

Check the box (if applicable): Indicates the sport participants are 13 through 18 years old.Yes

The description of the type of sport in which the sponsored athletic team is involved.

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the sponsored athletic team is involv...

Check the box (if applicable): Indicates the sport participants are 12 years old or under.Yes

Check the box (if applicable): Indicates the sport participants are over 18 years old.Yes

The description of the type of sport in which the sponsored athletic team is involved.

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the sponsored athletic team is involv...

Check the box (if applicable): Indicates the sport participants are 12 years old or under.Yes

Check the box (if applicable): Indicates the sport participants are over 18 years old.Yes

The description of the extent of sponsorship the named insured provides for the athletic team.

The description of the extent of sponsorship the named insured provides for the athletic team.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any structural alte...

An explanation of any structural alterations contemplated.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any demolition expo...

An explanation of any demolition exposure contemplated.

8. Workers

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Has applicant been...

An explanation of any joint ventures in which the applicant may be currently active.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do you lease employ...

The additional interest's full name. As used here, this is the company to whom employees are leased.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is worker...

The additional interest's full name. As used here, this is the company from whom employees are leased.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is worker...

The additional interest's full name. As used here, this is the company to whom employees are leased.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is worker...

The additional interest's full name. As used here, this is the company from whom employees are leased.

Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is worker...

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is there a labor in...

An explanation of any labor interchange with any other business or subsidiaries.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are day care facili...

An explanation of any daycare facilities operated or controlled.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Have any crimes occ...

An explanation of any crimes that occurred or been attempted on your premises within the last three (3) years

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is there a formal,...

An explanation of any formal, written safety and security policy in effect.

Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does the business'...

An explanation of any business promotional literature that makes any representations about the safety or se...

The remarks associated with the general liability line of business. Use this section to provide any additi...

Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc....

The name of the authorized representative of the producer, agency and/or broker that signed the form.

The State License Number of the producer.

Sign here: Accommodates the signature of the applicant or named insured.

The date the form was signed by the applicant or named insured. (MM/DD/YYYY)

The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: Th...