Agent's Name

State Farm Fire and Casualty Company

XXXX XXX XXX
Home Office, Bloomington, IL 61710
Agent's Code

99-999
Commercial Liability Umbrella Application Policy Number

of Policy Number Effective Date Expiration Date

New Rew. Ren.
Inquiry Only

Applicant
Last Name First Name Middle Name or Initial

XXXX XXXX

DBA XXX

The named applicant is: XXXX XXX

Email Website
address [email protected] address XXX.XXX

Home phone (999) 999-9999 ext.999 Business phone (999) 999-9999 ext.999

Cell phone (999) 999-9999 ext.999 Fax number (999) 999-9999 ext.999

Attention, In care of,

subdivision, or other
Number and Street City State ZIP Code
Mailing
address XXX XXXX XX XXXX XX 99999-9999
County

XXX
Underwriting
List all affiliated companies (foreign and domestic) in which the applicant has a majority interest (50% or more). Complete a separate application for
each company if coverage is desired under the same policy.
States or Countries
Company Name Principal Location in Which Operating
XXX XXX XX, XX
Fully describe the applicant's entire scope of business activities on and off premises:
XXX

How many years has the applicant owned/operated this type of business?
9

Are all the applicant's properties and operations covered by State Farm® policy/policies? Yes No

If no, DO NOT BIND and explain:

XXXX

What products have been or will be installed, constructed or repaired away from the premises?
XXX

Does the applicant own or operate commercial property or a business outside the United States? Yes No

If yes, DO NOT BIND and explain:

XXX

EA 2525 cIL.5 Rev. 04-2023 Page 1 of 5 1003215 2014 140393 214 04-06-2023
 Does the applicant own commercial property, autos, or watercraft in any other state or province? Yes No

If yes, explain:
XXX

Does the applicant own, rent, lease, or borrow aircraft for business use? Yes No

If yes, explain:
XXX

Has any insurer or agency canceled or refused to issue or renew similar insurance in the past 5 years? Yes No

If yes, explain:
XXX

Has the applicant had any liability claims, including auto, insured or not, in the past 5 years? Yes No

Are all auto and other liability claims on file with State Farm? Yes No
Provide 5 year loss history documentation from prior carrier:
Insurance Company
Date of Loss Type of Liability Loss (including auto) Total Amount of Loss (Policy Number, if available)

99/99/9999 XXX $ 9999.00 99999

Does the applicant meet all eligibility and binding requirements shown in the Underwriting Guide? Yes No

Trucks Only
Are inflammables, chemicals, toxics, or explosives hauled? Yes No

Are trucks operated beyond a 200 mile radius? Yes No

If yes, give radius, frequency, and purpose

99

Professional Liability Only

Has the applicant, the applicant's firm, or any predecessor in business been involved in litigation or
received any notices of claim as respects injury or damage arising out of practice in the profession listed hereon? Yes No
Has any governmental agency (State or Federal) taken any legal action which resulted in the revocation or suspension
of the applicant's license to practice or has any such revocation or suspension been stayed subject to probationary terms? Yes No

Number of practitioners: 99
Limit of Insurance Requested
Limit of Liability: Each occurrence and Aggregate Limit $ 9,999,999 Self-Insured Retention $10,000

Underlying Insurance
Is any of the underlying insurance not insured with State Farm? Yes No If yes, Do Not Bind coverage

EA 2525 cIL.5 Rev. 04-2023 Page 2 of 5 1003215 2014 140393 214 04-06-2023
 Insurance Company and Policy Number
Type of Insurance Underlying Policy Limits (If State Farm, give policy number only) Effective Date
Each Person Each Accident
Bodily Injury/
Automobile Liability Personal Liability $ 999999.00 $ 99999.00
XXXX XXXXX - 999999
Property Damage $ 99999.00
Exclude
Single Limit $
Bodily Injury
Employers Liability by accident $ 99999.00 Each accident
Exclude Bodily Injury
by disease $ 99999.00
XXXXX - 99999 99/99/9999
Each employee
Bodily Injury
by disease $ 9999.00 Policy limit

Bodily Injury $ 999999.00

Watercraft Liability XXXX - 99999
Property
Damage $ 99999.00 Each occurence

Business Exposure Programs

Residential (Apartment, Residential Community, RDP, RCUP) and Commercial Condominium
Basis of Premium
Number of units: 99 Number of pools: 99 Number of locations: 99 Estimated annual rental income $ 999999
Insurance company and policy number
(If State Farm, give policy number only) XXXX - 99999 Policy Limit $ 999999.00
Business Owners Policy (BOP)
Basis of Premium

Annual rents $ 999999.00 Annual receipts $ 999999.00

Insurance company and policy number
(If State Farm, give policy number only) XXXX - 99999 Policy Limit $ 99999.00
Religious Organization
Basis of Premium
Does the religious organization Yes No If yes, how many
operate any day schools or nurseries? children/pupils are cared for? 9
Camps:
Number of sailboats/ Number of Number of
How many? 9 inboard motor boats: 9 outboard motor boats: 9 saddle animals: 9
Insurance company and policy number
(If State Farm, give policy number only) XXX - 99999 Policy Limit $ 999999.00
Artisan and Service Contractor Program
Basis of Premium

Annual payroll $ 999999.00 Annual payments to subcontractors $ 99999.00

Insurance company and policy number
(If State Farm, give policy number only) XXXX - 999999 Policy Limit $ 999999.00
Farm Ranch
Basis of Premium

Number of farms: 9 Total acres: 9

Insurance company and policy number
(If State Farm, give policy number only) XXX - 99999 Policy Limit $ 999999.00

Complete the following questions only if underlying insurance is not with State Farm or if the customer has
elected "Do Not Share"
Attach current Declarations pages from all non-State Farm Underlying Policies.

EA 2525 cIL.5 Rev. 04-2023 Page 3 of 5 1003215 2014 140393 214 04-06-2023
 Does applicant manufacture or market products under own label? Yes No
If yes, explain:
XXX

Does the applicant sell or distribute alcoholic beverages? Yes No

If yes, explain:
XXX

Does the applicant own, lease, or charter any recreational vehicles, aircraft, or watercraft? Yes No
If yes, explain:
XXX

Does the applicant lease vehicles for more than 6 months? Yes No
If yes, explain:
XXX

Is the auto coverage in an assigned risk pool or plan? Yes No

If yes, explain:
XXX

Does the underlying auto policy contain any restrictions or driver exclusions? Yes No
If yes, explain:
XXXX

Is the applicant or any employee engaged in any of the following:

(1) performing or subletting any demolition or railway work;
(2) working as seamen on or off vessels or installations in navigable waters; (3) any phase of nuclear energy work? Yes No
If yes, explain:
XXX

Additional Interests
Type Name

XXX XXX XXX XXX XXX

Number and Street City State ZIP Code

XXX XXX XXX XX XXX XX 99999-9999

Premium/Payment Information Application taken: 99-99-9999 99:99 PM
SFPP Payment 1 Amount Payment 2 Amount
Paid $ Paid $
Yes No Cash Cash
Check Check
Check Number Check Number
Credit Card Reference Number Amount Credit from Balance Total
EFT Paid $ 0.00 other policy $ 0.00 Due $ 9,999.00 Premium $ 9,999.00

Billing Information
Should named insured be billed for renewals? Yes No
Should named insured be billed for endorsements? Yes No

EA 2525 cIL.5 Rev. 04-2023 Page 4 of 5 1003215 2014 140393 214 04-06-2023
 Applicant(s) Acknowledgement
By submission of this application, you agree that: (1) You have read this application, (2) your statements on this
application are correct, (3) the minimum policy limits are in force, (4) all vehicles are insured, (5) the premium charged
must comply with State Farm's rules and rates and may be revised, and (6) Traffic violation reports may be obtained by
the company named hereon on any person named as a driver of the insured motor vehicle at any time.

Remarks
XXX

EA 2525 cIL.5 Rev. 04-2023 Page 5 of 5 1003215 2014 140393 214 04-06-2023