Warehouse Program Supplemental Application

Scottsdale Insurance Company Fenced? Yes No Yes Home Office: One Nationwide Plaza Flammable or toxic substances Columbus, Ohio 43215 Yes No Yes stored? Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 If yes, what provisions are made for handling and storing them? (Please indicate location number and details.) Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Guard dogs? Yes No Yes Adm. Office: 8877 North Gainey Center Drive Lighted? Yes No Yes Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 WAREHOUSE PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)

Applicant’s Name:

Mailing Address:

PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A) 1. List all warehouses applicant owns or leases:

Loc. Complete Address No.

1 2 3 4 5

2. Warehouse operations are: Private Lessor’s Risk Mini-warehouse 3. Provide the following information for all locations: Loc. 1 Loc. 2 Cold storage warehouse? Yes No Yes

GLS-APP-37s (9-16) Page 1 of 5 Loc. 1 Loc. 2 b. Annual cost of subcontracting: ...... Manufacturing operations? Yes No Yes $ ...... Mini-warehouse? Yes No Yes c. Are certificates of insurance required from all Public access? Yes No Yes subcontractors?...... Yes No Public showroom? Yes No Yes d. Is applicant included as an additional insured on subcontractors’ policies?...... Yes No Customers’ goods on racks Racks Racks or pallets? Pallets Pallets e. Do written contracts contain hold-harmless agreements in favor of the applicant?. Yes Retail store operations? Yes No Yes No Security guards? Yes No Yes Wholesale store Yes No Yes operations? Does warehouse have a Yes No Yes sprinkler system? If yes, indicate location number and type of system:

Any other private fire protection system Yes No Yes available? If yes, indicate location number and details:

4. If warehouse/building is leased, who is responsible for the maintenance? Indicate location number and details:

5. If food stored, has applicant ever been cited for violations by any state or federal food and/or health inspection agency?.... Yes No Indicate location number and details:

6. To what extent is the movement of goods in the warehouse automated? Indicate location number and details:

7. Name any associations, groups, etc., the applicant belongs to as a business:

8. Does applicant subcontract any operations?.... Yes No If yes: a. Description of operations subcontracted:

GLS-APP-37s (9-16) Page 2 of 5 f. Minimum General Liability limits subcontractors the information contained herein shall be the basis of the are required to carry: contract should a policy be issued...... FRAUD WARNING: Any person who knowingly and with ...... intent to defraud any insurance company or other person 9. Does applicant have any operations as a moving files an application for insurance or statement of claim company?...... Yes No containing any materially false information or conceals If yes, explain: for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to 10. Are there any manufacturing operations on the criminal and civil penalties. (Not applicable in AL, CO, premises?...... Yes No DC, FL, KS, LA, ME, MD, MN, NE, NY, OH, OK, OR, RI, If yes, explain: TN, VA, VT or WA.) NOTICE TO ALABAMA APPLICANTS: Any person 11. Commodities stored: (Indicate percentage) who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents Electronic Media (CD, DVD, Antiques % false information in an application for insurance is guilty etc.) of a crime and may be subject to restitution fines or Appliances % Explosives confinement in prison, or any combination thereof. Art % Fireworks Auto Parts % Flammables

Beer/Wine % Fur Apparel

Boats % Furniture

Canned Foods % Jewelry/Gemstones

Cell Phones/Pagers % Liquor Chemicals % Museum Artifacts Clothing % Oriental Rugs Collectible/Memorabilia % Paper Products Sales Computer Equipment % Pharmaceutical Electronic Equipment/ % Photography Equipment Components

12. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?...... Yes No If yes, describe:

13. Does applicant have other business ventures for which coverage is not requested?.. Yes No If yes, explain and advise where insured:

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that

GLS-APP-37s (9-16) Page 3 of 5 NOTICE TO COLORADO APPLICANTS: It is unlawful information to an insurance company for the purpose of to knowingly provide false, incomplete, or misleading defrauding the company. Penalties may include facts or information to an insurance company for the imprisonment, fines or a denial of insurance benefits. purpose of defrauding or attempting to defraud the NOTICE TO MARYLAND APPLICANTS: Any person company. Penalties may include imprisonment, fines, who knowingly or willfully presents a false or fraudulent denial of insurance, and civil damages. Any insurance claim for payment of a loss or benefit or who knowingly company or agent of an insurance company who or willfully presents false information in an application for knowingly provides false, incomplete, or misleading facts insurance is guilty of a crime and may be subject to fines or information to a policy holder or claimant for the and confinement in prison. purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award NOTICE TO MINNESOTA APPLICANTS: A person who payable from insurance proceeds shall be reported to files a claim with intent to defraud or helps commit a the Colorado Division of Insurance within the fraud against an insurer is guilty of a crime. Department of Regulatory Agencies. NOTICE TO OHIO APPLICANTS: Any person who, with WARNING TO DISTRICT OF COLUMBIA intent to defraud or knowing that he is facilitating a fraud APPLICANTS: It is a crime to provide false or against an insurer, submits an application or files a claim misleading information to an insurer for the purpose of containing a false or deceptive statement is guilty of defrauding the insurer or any other person. Penalties insurance fraud. include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information NOTICE TO OKLAHOMA APPLICANTS: Any person materially related to a claim was provided by the who knowingly, and with intent to injure, defraud or applicant. deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete NOTICE TO FLORIDA APPLICANTS: Any person who or misleading information is guilty of a felony. knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application NOTICE TO RHODE ISLAND APPLICANTS: Any containing any false, incomplete, or misleading person who knowingly presents a false or fraudulent information is guilty of a felony of the third degree. claim for payment of a loss or benefit or knowingly presents false information in an application for insurance NOTICE TO KANSAS APPLICANTS: Any person who, is guilty of a crime and may be subject to fines and knowingly and with intent to defraud, presents, causes to confinement in prison. be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, FRAUD WARNING (APPLICABLE IN VERMONT, broker or any agent thereof, any written, electronic, NEBRASKA AND OREGON): Any person who electronic impulse, facsimile, magnetic, oral, or intentionally presents a materially false statement in an telephonic communication or statement as part of, or in application for insurance may be guilty of a criminal support of, an application for the issuance of, or the offense and subject to penalties under state law. rating of an insurance policy for personal or commercial FRAUD WARNING (APPLICABLE IN TENNESSEE, insurance, or a claim for payment or other benefit VIRGINIA AND WASHINGTON): It is a crime to pursuant to an insurance policy for commercial or knowingly provide false, incomplete, or misleading personal insurance which such person knows to contain information to an insurance company for the purpose of materially false information concerning any fact material defrauding the company. Penalties include thereto; or conceals, for the purpose of misleading, imprisonment, fines, and denial of insurance benefits. information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading

GLS-APP-37s (9-16) Page 4 of 5 NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. APPLICANT’S STATEMENT: I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)

APPLICANT’S SIGNATURE:

CO-APPLICANT’S SIGNATURE:

PRODUCER’S SIGNATURE:

AGENT NAME:

AGENT LICENSE NUMBER: (Applicable to Florida Agents Only)

IOWA LICENSED AGENT: (Applicable in Iowa Only)

IMPORTANT NOTICE As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

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