Atlas General Insurance Services is a full service program
administrator that offers a wide range of insurance solutions. Atlas
has expertise in developing and underwriting specialty programs
with a variety of insurance carrier partners. Our knowledgeable staff
is committed to providing exceptional service and unique options
for our clients.
Atlas General Insurance Services offers products in the following
divisions:
• Workers’ Compensation
• General Commercial Lines
• Specialty Property
TARGET RISKS - COMMERCIAL DIVISION
ABOUT ATLAS
Take the Right Path. Join Atlas.
The Atlas Mission -
Customers Come First
Atlas General Insurance
Services combines proven
expertise, superior personal
service and a relationship-
based approach to provide
clients with a trusted insurance
partner committed to
delivering maximum value.
Our SUCCESS depends upon:
Relationships built on trust
Products that win
Responsive employees that
strive to make the most out
of every opportunity
address
6165 Greenwich Drive, STE 200
San Diego, CA 92122
toll free
(877) 66-ATLAS (28527)
marketing hotline
(858) 724-5091
e-mail:
[email protected]
web
atlas.us.com
This document provides an overview of coverages
and services. Coverages may differ in availability by
state. All coverages are individually underwritten.
For a complete description of all coverages, terms
and conditions, refer to the insurance policy. In the
event of a conflict, the terms, conditions and
exclusions of the policy prevail. All information and
representations herein are as of 2022. CA License
#0C66724. Rev. 4.20222
Apartments
Convenience Stores
Garage: Auto Service/Repair
Grocery Stores
Hotels/Motels
Lessors Risk Only (LRO)
Professional Offices
Restaurants & Food Service
Retail Stores
Vacant Buildings & Land
Coverages Available:
300+ General Liability Classes
Including:
- Building
- Contents
- Business Income
- Equipment Breakdown
- Enhanced Property
Endorsement
Hired & Non-Owned Auto
Personal Property of Others
Spoilage
Tenants Improvements
Umbrella & Excess Liability
Be sure to include:
ACORD 125
ACORD 126
ACORD 140
Loss Runs
CDsubmissions@atlas.us.com
please send submissions to:
COMMERCIAL DIVISION
for
info please call our marketing hotline:
(858) 724-5091
TM
NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
VEHICLE SCHEDULE
VACANT BUILDING SUPPLEMENT
STATE SUPPLEMENT (If applicable)
STATEMENT / SCHEDULE OF VALUES
RESTAURANT / TAVERN SUPPLEMENT
PROFESSIONAL LIABILITY SUPPLEMENT
PREMIUM PAYMENT SUPPLEMENT
LOSS SUMMARY
INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT
INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT
ADDITIONAL INTEREST
ATTACHMENTS
CONTRACTORS SUPPLEMENT
CONDO ASSN BYLAWS (for D&O Coverage only)
APARTMENT BUILDING SUPPLEMENT
ADDITIONAL PREMISES
COVERAGES SCHEDULE
DRIVER INFORMATION SCHEDULE
NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4)
NAICS
BUSINESS PHONE #:
TRUST
AND MANAGERS:
SUBCHAPTER "S" CORPORATION
NO. OF MEMBERS
NOT FOR PROFIT ORG
JOINT VENTURECORPORATION
PARTNERSHIPINDIVIDUAL LLC
WEBSITE ADDRESS
SICGL CODE FEIN OR SOC SEC #
ACORD 125 (2011/09)
$$
METHOD OF PAYMENT
PREMIUM
MINIMUM
$
DEPOSIT POLICY PREMIUMAUDITPAYMENT PLANBILLING PLAN
DIRECT AGENCY
PROPOSED EXP DATEPROPOSED EFF DATE
POLICY INFORMATION
$
SECTIONS ATTACHED
COMMERCIAL GENERAL LIABILITY
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
PREMIUMPREMIUMPREMIUM
BUSINESS OWNERS
EQUIPMENT FLOATER
INSTALLATION / BUILDERS RISK
ELECTRONIC DATA PROC
BUSINESS AUTO UMBRELLA
TRUCKERS / MOTOR CARRIERBOILER & MACHINERY
GARAGE AND DEALERS
CRIME / MISCELLANEOUS CRIME
GLASS AND SIGN
PROPERTY
INDICATE SECTIONS ATTACHED
ACCOUNTS RECEIVABLE /
VALUABLE PAPERS MOTOR TRUCK CARGO
TRANSPORTATION /
DEALERS
OPEN CARGO
YACHT
© 1993-2011 ACORD CORPORATION. All rights reserved.Page 1 of 4
The ACORD name and logo are registered marks of ACORD
APPLICANT INFORMATION
UNDERWRITER OFFICEUNDERWRITER
DATE (MM/DD/YYYY)
COMMERCIAL INSURANCE APPLICATION
APPLICANT INFORMATION SECTION
FAX
(A/C, No):
AGENCY
NAME:
CONTACT
(A/C, No, Ext):
PHONE
SUBCODE:CODE:
AGENCY CUSTOMER ID:
ADDRESS:
E-MAIL
STATUS OF
TRANSACTION
RENEWQUOTE ISSUE POLICY
BOUND (Give Date and/or Attach Copy):
CANCEL
CHANGE
DATE TIME
AM
PM
NAIC CODE
CARRIER
POLICY NUMBER
COMPANY POLICY OR PROGRAM NAME PROGRAM CODE
ACORD 125 (2011/09)
E-MAIL ADDRESS:REASON FOR INTEREST:
OWNER
LEASEBACK
WARRANTY
BREACH OF
TRUSTEE
REGISTRANT
FAX (A/C, No):PHONE (A/C, No, Ext):LIEN AMOUNT:
INTEREST END DATE:
ITEM:
CLASS:
AIRPORT: AIRCRAFT:CO-OWNER OWNER
SEND BILLPOLICYEVIDENCE:
AS LESSOR
INSURED
ITEM DESCRIPTION
INTEREST RANK:NAME AND ADDRESS
REFERENCE / LOAN #:
CERTIFICATE
INTEREST IN ITEM NUMBER
ADDITIONAL
LOSS PAYEE
MORTGAGEE
LIENHOLDER
EMPLOYEE
LOCATION: BUILDING:
VEHICLE: BOAT:
ITEM
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
PHONE #
SECONDARY
CELLHOME BUS
PHONE #
CELLHOME BUS
PRIMARY
$
SQ FT
ANY AREA LEASED TO OTHERS? Y / N
TOTAL BUILDING AREA:
SQ FTOPEN TO PUBLIC AREA:
ANNUAL REVENUES:INTERESTCITY LIMITS
OCCUPIED AREA: SQ FT
BLD #
LOC #
DESCRIPTION OF OPERATIONS:
ZIP:
STATE:
COUNTY:
CITY:
STREET
# PART TIME EMPL
# FULL TIME EMPL
INSIDE
OUTSIDE
OWNER
TENANT
%%
DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS
OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK
DESCRIPTION OF PRIMARY OPERATIONS
RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:
INSTALLATION, SERVICE OR REPAIR WORK
NATURE OF BUSINESS
MANUFACTURING
INSTITUTIONAL
DATE BUSINESS
STARTED (MM/DD/YYYY)
CONTRACTOR RESTAURANT
CONDOMINIUMS
APARTMENTS
WHOLESALERETAIL
SERVICE
OFFICE
Page 2 of 4
PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)
CONTACT NAME:
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
CONTACT TYPE:
CONTACT INFORMATION
SECONDARY E-MAIL ADDRESS:
PRIMARY E-MAIL ADDRESS:
CONTACT NAME:
CONTACT TYPE:
AGENCY CUSTOMER ID:
ACORD 125 (2011/09)
REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Page 3 of 4
13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?
3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
SAFETY POSITION OSHA
MONTHLY MEETINGSSAFETY MANUAL
2. IS A FORMAL SAFETY PROGRAM IN OPERATION?
Y / NEXPLAIN ALL "YES" RESPONSES
SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED
PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
1a.
1b.
4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
POLICY NUMBER POLICY NUMBERLINE OF BUSINESS LINE OF BUSINESS
NAME OF TRUST
HAS BUSINESS BEEN PLACED IN A TRUST?
11.
RESOLUTION
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
DATE
HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?
10.
RESOLUTION
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
DATE
HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?
9.
CONDITION CORRECTED (Describe):UNDERWRITING
AGENT NO LONGER REPRESENTS CARRIER
NON-RENEWAL
NON-PAYMENT
ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR
OPERATIONS? (Missouri Applicants - Do not answer this question)
5.
GENERAL INFORMATION
ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?6.
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?
(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable
by a sentence of up to one year of imprisonment).
7.
RESOLUTION
RESOLUTION
DATE
EXPLANATION
OCCURRENCE
DATE
ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?
8.
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)
12.
AGENCY CUSTOMER ID:
ACORD 125 (2011/09)
(Attach Loss Summary for Additional Loss Information)Check if none
YEARS TOTAL LOSSES: $
DATE OF
OCCURRENCE
DATE OF CLAIM AMOUNT PAID
SUBRO-
GATION
Y / N
AMOUNT RESERVED
CLAIM
OPEN
Y / N
ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS
FOR THE LAST
LINE
TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM
LOSS HISTORY
IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR
BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF,
OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A
CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO
CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING
THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF
FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
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.
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 COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE
A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN
APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
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 [NY: SUBSTANTIAL] CIVIL
PENALTIES. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
SIGNATURE
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN
CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US
OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW
YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND
OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT
A REQUEST TO US.
COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE
ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER
KNOWLEDGE.
Page 4 of 4
$$$$
EFFECTIVE DATE
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
$$$$
EFFECTIVE DATE
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
$$$$
EFFECTIVE DATE
YEAR
EXPIRATION DATE
PREMIUM
POLICY NUMBER
CARRIER
OTHER:PROPERTYAUTOMOBILEGENERAL LIABILITYCATEGORY
PRIOR CARRIER INFORMATION
AGENCY CUSTOMER ID: