Preview
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF
ACORD
0 DOC.•' NO. 94
COMMERCIAL
APPLICANT
INSURANCE
INFORMATION
APPLICATION
SECTION
RECEIVED NYSCEF:
Dm-D«Ym
4/18/2016
05/04/2020
AGENCY CARRIER NAlcC
RICHARD D ANDREOLI .
6406 14TH AVENUE UNDERWETER: OFFICE:
UNDERWRFFER
POLICIES
ORPROGRAM REQUESTED POLICY
NUMBIER
COMMERCIAL PACKAGE
INDICATESECTIONSATTACHED ELECTRONICDATAPROC TRUCKERS/MOTOR CARRIER
COUAUNTS ABW EQUIPMENTFLOATER UMBRELIA
COT CT BOlLER& MACHINERY . GARAGEANDDEALERS VEHICLESCHEDULE
,C" BUSINESSAUTO. GIASSANDSIGN WORKERSCOMPENSATION
718 331 1770
718 256 2410 X INSTALLATION/BUILDERS
RISK YACHT
4 82ERTL°ÔkuTY ___
D Ess CE@AOL.COM CRNEMISCELLANEOUS CRIME OPENCARGO
RDAINS
CODE: 8UBCODE: DEALERS X PROPERTY
DRIVERINFOSCHEDULE T T N/
CUSTOMER
AGENCY ID:
STATUS OF TRANSACTION PACKAGE POUCY INFORMATION
QUOTE ISSUEPOLICY RENEW ENTERTHISINFORMATION WHENCOMMON DATESANDTERMSAPPLYTOSEVERAL LINES,ORFORMONOLINEPOLICIES.
BOUND(Give Copy):
Dateand/orAttach PROPOSEDEFFDATE PROPOSEDEXPDATE BLLINGPLAN PLAN
PAYMENT AUDIT
DATE TIME AM . DIRECTBlLL
CANCEL PM 4 17 16 4 17 17 . AGENCYBILL PACKAGEPOUCYPREMtUM:
$
APPUCANT INFORMATION
NAME(FirstNanted & OtherNamed
Insured Insuseds) MAILING
ADDRESSINCL FirstNamed
ZIP+4{of Insused)
EASTERN FRUIT & VEGETABLE INC 1230 1236 CONEY ISLAND AVENUE
BROOKLYN, NY 11218
fe'"i°"LT.'i
•'or•e $3.,E 646 750 1460
E-MAIL WEB8ITE
ADDRESS[ESÞ ADDRESS(ES):
S LLC
INDMDUAL X CORPORATION A D E S cRBUREAUNAME: ST
PaRT ERSI:1P JOINTVENTURE F ORG IDNUMBER:
INSPECTION
CONTACT: RECORDS
ACCOUNTTNG CONTACT:
PHONEExt):' E-MAIL PHONE E-MAIL
(AC,No, ADDRESSf Ex0:
(AC,No, ADDRESSf
PREMISES INFORMATION ACORD 823 attaChed for additl0nal
remises
LOC# BLD# CITY,COUNTY,STATE,ZIP+4
STREET, CITYLIMITS INTEREST ANNUALREVENUES DCCUPIED
sants INSIDE OWNER
OUTSIDE TENANT
INSIDE OWNER
OUTSIDE TENANT
INSIDE OWNER
OUTSIDE TENANT
INSIDE OWNER
OUTSIDE TENANT
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)
SUPERMARKET....NO COOKING
24 HOUR 7 DAYS A WEEK
ACORD125(2007/10) Page 1 Of 3 ©1993-2007 ACORD CORPORATION. All rights
reserved.
The ACORD narne marks of ACORD
and Iogo are ragistered
ACIC 0129
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
AGENCY CUSTOMER ID:
GENERAL INFORMATION
ALL"YEB"RESPONSES
EXPLAIN YN
Sa. ISTHEAPPLICANT OFANOTHER
ASUBSlDIARY ENTITY?
1b. DOESTHEAPPLICANTHAVEANYSUBSIDIARIES?
2. ISA FORMALSAFETYPROGRAM INOPERATION?
3. ANYEXPOSURE TOFLAMMABLES, CHEMICALS7
EXPLOSlVES,
4. ANYCATASTROPHE EXPOSURE?
5, ANYOTHERINSURANCE WITHTHISCOMPANY ORBEINGSUBMITTED?
6. ANYPOLICYORCOVERAGE CANCELLED
DECLINED, ORNON-RENEWED DURINGTHEPRIORTHREE(3) YEARS?(Notapplicablein MO)
7. ANYPASTLOSSES ORCLAIMSRELATINGTOSEXUALABUSEORMDLESTATION ALLEGATIONS,DISCRIMINATION
ORNEGLIGENTHIRING?
. . . . .. ..
. . .. .. .. . . . .. ... .. .. .
.. .. .
. . . .. . .
.. ... . .. .. .. . .
. . . .. .. . . ..
. . . . .. . .. . .. ..
..... . . . . . . . . . . .. . . .
8. DURINGTHELASTFlVEYEARS(TENIN RI), HASANYAPPLICANT
BEENINDICTED
FORORCONVICTED OFANYDEGREEOFTHECRIMEOF FRAUD,BRIBERY, ARSONORANY
OTHERARSON-RELATEDCRIMElN CONNECTIONWITHTHISORANYOTHERPROPERTY?
byanyapplicantfor propertyinsurance,Failuretodisdosetheexistenceofanarsonconviction
(InRLthisquestionmustbeanswered Isamisdemeanor
punishable of uptoone
byasentence
yearoffmprisonment).
N
9. ANYUNCORRECTED FIRECODEVlOLATIONS?
TAXORCREDITLIENSAGAINST
10. ANYBANKRUPTCIES, THEAPPLICANTINTHEPASTF1VE(5)YEARS?
11. HASBUSINESSBEENPLACEDINA TRUST?
IF"YES NAMEOFTRUST:
12. ANYFOREIGNOPF..RATIONS,
FOREIGNPRODUCTS DISTRIBUTEDIN USA,ORUS PRODUCTS INrOREIGNCOUNTRIES7.. .. . . .
SOLD/DISTRIBUTED. . . . . . .. . . .
. ..
(lf"YES",altach
ACORD815forUabilityExposure
and/orACORD816forPropertyExposure)
REMARKS/PRocESSING
INsTRUCTlDNs
(Attach sheetsIfmorespaceis required)
additiona|
COPYOFTHENOTICEOFINFORMATIONPRACTICES HASBEENGIVEN
(PRIVACY) TOTHEAPPLICANT.
(Notapplicablein
aristates,consultyouragentorbrokerforyourstate's
requirements
)
NOTICEOF INSURANCEINFORMATIONPRACTICESYOU,INCLUDINGINFORMATIONFROMA CREDIT REPORT, MAYBE COLLECTED
FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATIONFOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATIONAS
WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATIONCOLLECTED BY US OR OUR AGENTS MAY IN CERTAIN C1RCUMSTANCESBE DISCLOSED TO TH1RD
PARTIES WITHOUT YOURAUTHOR1ZATION.YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATIONIN OUR FILES AND CAN REQUEST CORRECTIONOF
ANY INACCURACIES. A MORE DETAILED DESCRIPTIONOF YOUR RIGHTS AND OUR PRACTICES REGARDINGSUCH INFORMATIONIS AVAILABLE UPON REQUEST.
CONTACT YOURAGENTOR BROKER FOR INSTRUCTIONSON HOW TO SUBMITA REQUESTTO US.
ANY PERSON WHO KNOWINGLYAND WITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR ANOTHER PERSON FILES AN APPLICATIONFOR INSURANCE OR
STATEMENT OF CLAIM CONTAININGANY MATERIALLYFALSE INFORMATION.OR CONCEALS FOR THE PURPOSEOF MISLEADINGINFORMATIONCONCERNINGANY
FACT MATERIALTHERETO,COMMITSA FRAUDULENTINSURANCEACT, WHICH ISA CRIME AND SUBJECTSTHE PERSONTO CRIMINALAND [NY: SUBSTANTIAL] CIVIL
PENALTIES.(NOtapplicableInCO,FL,HI,MA,NE.OH,OK,OR,orVT; inDC,LA,ME,TN,VAandWA,insurancebenefitsmayalso bedenied)
IN FLORADA,ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CtAIM OR AN
APPLICATIONCONTAININGANY FALSE, INCOMPLETE,ORMISLEADING INFORMATIONIS GUILTYOF A FELONYOFTHE THIRD DEGREE,
THE UNDERSIGNEDIS AN AUTHORIZED REPHæENTATNE OF THE APPLICANTAND REPRESENTSTHAT REASONABLEENQUIRYHAS BEEN MADETO OBTAIN
THE ANSWERS TO QUESTIQNSóh ToyPION. HE/SHE REPRESENTSTHAT THE ANSWERS ARE TRUE, CORRECTAND COMPLETETO THE BEST OF
HIS/HER KNOWLEDGE. ----·
PRODUCER's
SIGNAT PROUCER'S
NAME (Please A DU CENSENO
Print)
APPUCANT's
8IGNATURE DATE NATIONAL NUMBER
PRODUCER
ACORD125(2 Page 2 of 3
ACIC 0130
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
AGENCY CUSTOMER ID:
PRIOR CARRIER INFORMATION
LINE CATEGORY
I
CARRIER ATLANTIC
POUCYNUMBER 146001424
POLICYTfPE DCCURRENCE OCCURRENCE DOCURRENCE OCCURRENCE occURRENCE
RETRODATE
EFF-EXPDATE 7 -16
N GENERALAGGREGATE
C PRODUCTS COMPOP
n R ASGREGATE . _. .. .
PERSONAL&ADVINJ
EACHOCCURRENCE
c FIREDAMAGE
a MEDICALEXPENSE
L
S BODILY OCCURRENCE
I INJURY AGGREGATE
PROPERWOCCURRENCE
DAMAGEAGGREGATE
COMBINEDSINGLELIMIT
MODIFICATION
FACTOR
TOTALPREMlUM
CARRIER
POLICYNUMBER
A POLICYTYPE
EFF-EXPDATE
B COMBINEDSINGLELIMIT
L BODILY EA PERSON
INJURY EAACCIDENT
E
PROPERTY DAMAGE
MODIFICATION
FACTOR
TOTALPREMlUM
CARRIER
POLICYNUMBER
POLICYTYPE
EFF-EXPDATE
E
BUILDING AMT
PERS PROP AMT
MODIFICATION
FACTOR
TOTALPREMlUM
CARRIER
POLICYNUMBER
POLICYTYPE
EFF-EXPDATE
LIMIT
MODIFICATION
FACTOR
TOTALPREMIUM
LOS:3 HISTORY
ENTERALLCLAIMSORLOSSdS(RE6ARDLESS OF FAULTANDWHETHER ORNOTINSURED) OROCCURRENCES THATMAYGIVERIShiTOCLAIMS CHk l-IkHE SEEATTACHEU
FOR7HEPRIOR IF NONE LOSSSUMMARY
CLAIM
OCCtIRRE
CE LINE TYPEfDESCRPTION
OFOcCURRENCEORCLAIM OF D
REMARKS NOTE: REQUIREs
FIDELITY LaSSHISTORY
YEAR
AFIVE ATTACHMENTs
(ifapplicable)
STATESUPPLEMENT(S)
ACORD125(2007/10) Page 3 of 3
ACIC 0131
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
DATE(MM/DDNYYY)
ACO COMMERCIAL GENERAL LIABILITY SECTION 4/1s/2016
AGENCY 718 331 1770 pc^•r
,No):718 256 2 410 •-d EASTERN FRUIT & VEGETABLE INC
- ·-Insured)
RICHARD D ANDREOLI
ENECWEWE WUtAmm WE DIRECTBILL PLAN
PAYMENT AUDIT
6406 14TH AVENUE
BROOKLYN, NY 11219 4/17/16 4/17/17 AGENCYBILL
FOR
COMPANY
CODE: SUBCODE: USERY
AGENCY
CUSTGMEID:
COVERAGES LIMITS
X COMMERCIAL UABlUTY
GENERAL GENERALAGOREGATE $ 3,000,000 PRE=MS
OCCURRENCE PRODUCTS OPERATlONS
&COMPLETED AGGREGATE a PREMISESFOPERATIONS
CLAIMSMADE 1, 000 , 00C
OWNER'S PROTECT
&CONTRACTOR's NE PERSONAL
&ADVERTISING
INJURY $ 000 , 00C
1,
EACHOCCURRENCE $ PRODUCM
1, 000 , 00C
DEDUGT1BLES DAMAGETORENTEDPREMISES{each
occurrence) $ 50 , 00C .
PROPERTYDAMAGE MEDICAL
EXPENSE
(Anyoneperson) $ OWER
___ $ 5 , 00C
BODILYINJURY $ cu EMPLOYEEBENEF1TS $
.g TDTAL
OTHER RESTRICTIONS
COVERAGES, ENDORSEMENTS
ANDFDR (Forhiredfnon-owned
autocoverages stateBusiness
attachtheapplicable AutoSection,
ACORD137)
SCHEDULE OF HAZARDS
LOC HAZ CLASg PREMIUM RATE PREMlUM
CLASSIF1CATEDN EXPDSURE
# cong BASIS
PREM/OPS PRODUCTS PREM/OPS PRODUCTS
GROCERY STORE
1 1 250 , 000
RATING
ANDPREMlUM
BASIS (P)PAYROLL-
PER
(S)GROSSSALES-PER$1,000/SALES (A)AREA-PER1,000/SQ
FT (M)ADMISSIONS-PER1.000/ADM (T) OTHER
CLAIMS MADE (Explain all __
ALL'YES"RESPONBEs
EXPLAIN Y/N
1.PROPOSED RETROACTIVE DATE:
2.ENTRY DATE INTO UNINTERRUPTEDCLAlMS MADECOVERAGE
3. HAS ANY PRODUCT,WORK. ACCIDENT, OR LOCATIONBEEN EXCLUDED, UNINSUREDOR SELF-lNSUREDFROMANY PREVlOUS COVERAGE?
4. WAS TAL COVERAGEPURCHASED UNDER ANY PREVIOUSPOLICY?
EMPLOYEE BENEFITS LIABILITY
1. DEDUCTIBLEPER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITSPLANS:
2. NUMBEROF EMPLOYEES: ____ 4. RETROACTIVEDATE:
ACORD126(2007/05) Pageiof4 ©ACORD CORPORATION1993-2007. All rights
reserved,
The ACORD name and logo are registered
marks of ACORD
ACIC 0132
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
CONTRACTORS
ALL"YI!S"RESPONSES
EXPLAIN (Forpastorpresarit
operations) Y/N
1. DOES APPLICANT DRAW PLANS,DESIGNS, OR SPECIFICATIONSFOR OTHERS?
2.DO ANY OPERATIONSINCLUDEBLASTING OR UTILIZEOR STORE EXPLOSIVEMATERIAL?
X DO ANY OPERATIONSINCLUDEEXCAVATION,TUNNELING, UNDERGROUNDWORK OR EARTHMOVING?
4. DO YOUR SUBCONTRACTORSCARRY COVERAGESOR LIMITSLESS THAN YOURS?
5. ARE SUBCONTRACTORSALLOWEDTO WORK WITHOUT PROVIDINGYOU WITH A CERTIFICATEOF INSURANCE?
6. DOES APPLICANT LEASE EQUIPMENTTO OTHERS WITH OR WITHOUT OPERATORS?
THETYPEOFWORK
DESCRIBE SU.BCONTRACTED AD O O K PA T
PRODUCTS/COMPLETED OPERATIONS
PRODUCTS GROSS
ANNUAL SALES SOFUNLTS KET LI INTENDED
USE COMPONENTS
PRINCIPAL
ALL"YE9"RESPONSES
EXPLAIN produs.t
(Foranypastorpromentor operation)PLEASE
A'ITACH BROCHURES,
LITERATURE, ETCs
WARNINGS,
LABELS, WN
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATEPRODUCTS?
2. FOREIGNPRODUCTSSOLD, DISTRIBUTED,USED AS COMPONENTS? (If "YES", attachACORD 815)
3. RESEARCHAND DEVELOPMENTCONDUCTED OR NEW PRODUCTSPLANNED?
4. GUARANTEES,WARRANTIES, HOLD HARMLESSAGREEMENTS?
5. PRODUCTSRELATEDTO AIRCRAFT/SPACEINDUSTRY?
6. PRODUCTSRECALLED, DISCONTINUED,CHANGED?
7. PRODUCTSOF OTHERS SOLD OR REPACKAGED UNDER APPLICANT LABEL?
8. PRODUCTSUNDER LABEL OF OTHERS?
9. VENDORS COVERAGE REQUIRED?
10. DOESANY NAMED [NSUREDSELLTO OTHER NAMEDINSUREDS?
ACORD126(2007/05) ATTACHTOACORD125
ACIC 0133
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT ACORD 45 attachedforaddit,'=:!names
IN EREST RANK: NAMEANDADDRESS #:
REFERENCE C"T‡MCAMREQUIRED INTEREST NUM
INITEM BER
INSURED
ADDITIONAL LOCATION: BUILDING:
LOSSPAYEE VEHICLE- BOAT:
MORTGAGEE SCHEDULED
ITEMNUMBER:
LIENHOLDER OTHER
EMPLOYEEAs LESSOR
ITEMDESCRPTION:
GENERAL INFORMATION
ALL"YES"RESPONsES
EXPLAIN (Foranpastor presetitoperallons) YN
1. ANY MEDICALFACILITIESPROVIDEDOR MEDICALPROFESSIONALSEMPLOYEDOR CONTRACTED9
2. ANY EXPOSURETO RADIOACTIVE/NUCLEARMATERIALS?
3. DO/HAVE PAST, PRESENT OR DISCONTINUEDOPERATIONS INVOLVE(D) STORING,TREATING, DISCHARGING,APPLYiNG, DISPOSING,OR
TRANSPORTINGOFHAZARDOUSMATERIAL?(e.g.Ian@lls,wastes,fuel tanks,etc)
4. ANY OPERATIONS SOLD,ACQUIRED, OR DISCONTINUEDIN LAST FIVE (5) YEARS?
5. MACHINERYOR EQUIPMENTLOANED OR RENTEDTO OTHERS?
6. ANY WATERCRAFT,DOCKS, FLOATS OWNED, HIRED OR LEASED?
7. ANY PARKINGFACIUTIESOWNED/RENTED?
8. IS A FEE CHARGEDFOR PARKING?
9. RECREATIONFACIUTIES PROVIDED?
10. IS THERE A SWIMMINGPOOL ON THE PREMtSES?
11. SPORTING OR SOCIAL EVENTS SPONSORED?
12. ANY STRUCTURALALTERATIONSCONTEMPLATED?
13. ANY DEMOLITIONEXPOSURECONTEMPLATED?
14. HAS APPLICANTBEEN ACTIVE IN OR IS CURRENTLYACTNE IN JOINTVENTURES?
15. DO YOU LEASE EMPLOYEESTO OR FROM OTHER EMPLOYERS?
16. IS THERE A LABOR INTERCHANGEWITH ANY OTHER BUSINESSOR SUBSIDIARIÈS?
ACORD126(2007/05) Page 3 of 4
ACIC 0134
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018
NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020
GENERAL INFORMATION (co.7ü=cd)
ALL
EXPLAIN 8" RESPONSEs
(Forallpastar presetitaperallons)
17. ARE DAY CARE FACILITIESOPERATED OR CONTROLLED?
18. HAVE ANY CRIMESOCCURRED OR BEEN ATTEMPTEDON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?
19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITYPOLICYIN EFFECT?
20. DOES THE BUSINESSES' PROMOTIONALLITERATURE MAKEANY REPRESENTATIONSABOUT THE SAFETY OR SECURITYOF THE PREMISES?
REMARKS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANYOR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR
STATEMENTOF CLAlM CONTAININGANY MATERIALLYFALSE INFORMATION,OR CONCEALSFOR THE PURPOSE OF MISLEADINGINFORMATIONCONCERNINGANY
FACTMATERIALTHERETO, COMMITSA FRAUDULENTINSURANCEACT, WHICH ISA CRIMEAND SUBJECTSTHE PERSONTO CRIMINALAND [NY: SUBSTANTIAL]CML
PENALTIES.(NotapplicablelnCO,FL,HI,MA,NE,OH,OK,ORorVT. InDC,LA,ME,TN,VAandWAinsurance benâ‡its6ià ymisobedenied).
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECElVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN
APPLICATIONCONTAININGANY FALSE,INCOMPLETE,OR MISLEADINGINFORMATIONIS GUILTYOF A FELONYOFTHE THIRD DEGREE,
ACORD126(2007/05) Page 4 of 4
ACIC 0135
Preview
FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF ACORD 0 DOC.•' NO. 94 COMMERCIAL APPLICANT INSURANCE INFORMATION APPLICATION SECTION RECEIVED NYSCEF: Dm-D«Ym 4/18/2016 05/04/2020 AGENCY CARRIER NAlcC RICHARD D ANDREOLI . 6406 14TH AVENUE UNDERWETER: OFFICE: UNDERWRFFER POLICIES ORPROGRAM REQUESTED POLICY NUMBIER COMMERCIAL PACKAGE INDICATESECTIONSATTACHED ELECTRONICDATAPROC TRUCKERS/MOTOR CARRIER COUAUNTS ABW EQUIPMENTFLOATER UMBRELIA COT CT BOlLER& MACHINERY . GARAGEANDDEALERS VEHICLESCHEDULE ,C" BUSINESSAUTO. GIASSANDSIGN WORKERSCOMPENSATION 718 331 1770 718 256 2410 X INSTALLATION/BUILDERS RISK YACHT 4 82ERTL°ÔkuTY ___ D Ess CE@AOL.COM CRNEMISCELLANEOUS CRIME OPENCARGO RDAINS CODE: 8UBCODE: DEALERS X PROPERTY DRIVERINFOSCHEDULE T T N/ CUSTOMER AGENCY ID: STATUS OF TRANSACTION PACKAGE POUCY INFORMATION QUOTE ISSUEPOLICY RENEW ENTERTHISINFORMATION WHENCOMMON DATESANDTERMSAPPLYTOSEVERAL LINES,ORFORMONOLINEPOLICIES. BOUND(Give Copy): Dateand/orAttach PROPOSEDEFFDATE PROPOSEDEXPDATE BLLINGPLAN PLAN PAYMENT AUDIT DATE TIME AM . DIRECTBlLL CANCEL PM 4 17 16 4 17 17 . AGENCYBILL PACKAGEPOUCYPREMtUM: $ APPUCANT INFORMATION NAME(FirstNanted & OtherNamed Insured Insuseds) MAILING ADDRESSINCL FirstNamed ZIP+4{of Insused) EASTERN FRUIT & VEGETABLE INC 1230 1236 CONEY ISLAND AVENUE BROOKLYN, NY 11218 fe'"i°"LT.'i •'or•e $3.,E 646 750 1460 E-MAIL WEB8ITE ADDRESS[ESÞ ADDRESS(ES): S LLC INDMDUAL X CORPORATION A D E S cRBUREAUNAME: ST PaRT ERSI:1P JOINTVENTURE F ORG IDNUMBER: INSPECTION CONTACT: RECORDS ACCOUNTTNG CONTACT: PHONEExt):' E-MAIL PHONE E-MAIL (AC,No, ADDRESSf Ex0: (AC,No, ADDRESSf PREMISES INFORMATION ACORD 823 attaChed for additl0nal remises LOC# BLD# CITY,COUNTY,STATE,ZIP+4 STREET, CITYLIMITS INTEREST ANNUALREVENUES DCCUPIED sants INSIDE OWNER OUTSIDE TENANT INSIDE OWNER OUTSIDE TENANT INSIDE OWNER OUTSIDE TENANT INSIDE OWNER OUTSIDE TENANT NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S) SUPERMARKET....NO COOKING 24 HOUR 7 DAYS A WEEK ACORD125(2007/10) Page 1 Of 3 ©1993-2007 ACORD CORPORATION. All rights reserved. The ACORD narne marks of ACORD and Iogo are ragistered ACIC 0129 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 AGENCY CUSTOMER ID: GENERAL INFORMATION ALL"YEB"RESPONSES EXPLAIN YN Sa. ISTHEAPPLICANT OFANOTHER ASUBSlDIARY ENTITY? 1b. DOESTHEAPPLICANTHAVEANYSUBSIDIARIES? 2. ISA FORMALSAFETYPROGRAM INOPERATION? 3. ANYEXPOSURE TOFLAMMABLES, CHEMICALS7 EXPLOSlVES, 4. ANYCATASTROPHE EXPOSURE? 5, ANYOTHERINSURANCE WITHTHISCOMPANY ORBEINGSUBMITTED? 6. ANYPOLICYORCOVERAGE CANCELLED DECLINED, ORNON-RENEWED DURINGTHEPRIORTHREE(3) YEARS?(Notapplicablein MO) 7. ANYPASTLOSSES ORCLAIMSRELATINGTOSEXUALABUSEORMDLESTATION ALLEGATIONS,DISCRIMINATION ORNEGLIGENTHIRING? . . . . .. .. . . .. .. .. . . . .. ... .. .. . .. .. . . . . .. . . .. ... . .. .. .. . . . . . .. .. . . .. . . . . .. . .. . .. .. ..... . . . . . . . . . . .. . . . 8. DURINGTHELASTFlVEYEARS(TENIN RI), HASANYAPPLICANT BEENINDICTED FORORCONVICTED OFANYDEGREEOFTHECRIMEOF FRAUD,BRIBERY, ARSONORANY OTHERARSON-RELATEDCRIMElN CONNECTIONWITHTHISORANYOTHERPROPERTY? byanyapplicantfor propertyinsurance,Failuretodisdosetheexistenceofanarsonconviction (InRLthisquestionmustbeanswered Isamisdemeanor punishable of uptoone byasentence yearoffmprisonment). N 9. ANYUNCORRECTED FIRECODEVlOLATIONS? TAXORCREDITLIENSAGAINST 10. ANYBANKRUPTCIES, THEAPPLICANTINTHEPASTF1VE(5)YEARS? 11. HASBUSINESSBEENPLACEDINA TRUST? IF"YES NAMEOFTRUST: 12. ANYFOREIGNOPF..RATIONS, FOREIGNPRODUCTS DISTRIBUTEDIN USA,ORUS PRODUCTS INrOREIGNCOUNTRIES7.. .. . . . SOLD/DISTRIBUTED. . . . . . .. . . . . .. (lf"YES",altach ACORD815forUabilityExposure and/orACORD816forPropertyExposure) REMARKS/PRocESSING INsTRUCTlDNs (Attach sheetsIfmorespaceis required) additiona| COPYOFTHENOTICEOFINFORMATIONPRACTICES HASBEENGIVEN (PRIVACY) TOTHEAPPLICANT. (Notapplicablein aristates,consultyouragentorbrokerforyourstate's requirements ) NOTICEOF INSURANCEINFORMATIONPRACTICESYOU,INCLUDINGINFORMATIONFROMA CREDIT REPORT, MAYBE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATIONFOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATIONAS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATIONCOLLECTED BY US OR OUR AGENTS MAY IN CERTAIN C1RCUMSTANCESBE DISCLOSED TO TH1RD PARTIES WITHOUT YOURAUTHOR1ZATION.YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATIONIN OUR FILES AND CAN REQUEST CORRECTIONOF ANY INACCURACIES. A MORE DETAILED DESCRIPTIONOF YOUR RIGHTS AND OUR PRACTICES REGARDINGSUCH INFORMATIONIS AVAILABLE UPON REQUEST. CONTACT YOURAGENTOR BROKER FOR INSTRUCTIONSON HOW TO SUBMITA REQUESTTO US. ANY PERSON WHO KNOWINGLYAND WITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR ANOTHER PERSON FILES AN APPLICATIONFOR INSURANCE OR STATEMENT OF CLAIM CONTAININGANY MATERIALLYFALSE INFORMATION.OR CONCEALS FOR THE PURPOSEOF MISLEADINGINFORMATIONCONCERNINGANY FACT MATERIALTHERETO,COMMITSA FRAUDULENTINSURANCEACT, WHICH ISA CRIME AND SUBJECTSTHE PERSONTO CRIMINALAND [NY: SUBSTANTIAL] CIVIL PENALTIES.(NOtapplicableInCO,FL,HI,MA,NE.OH,OK,OR,orVT; inDC,LA,ME,TN,VAandWA,insurancebenefitsmayalso bedenied) IN FLORADA,ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CtAIM OR AN APPLICATIONCONTAININGANY FALSE, INCOMPLETE,ORMISLEADING INFORMATIONIS GUILTYOF A FELONYOFTHE THIRD DEGREE, THE UNDERSIGNEDIS AN AUTHORIZED REPHæENTATNE OF THE APPLICANTAND REPRESENTSTHAT REASONABLEENQUIRYHAS BEEN MADETO OBTAIN THE ANSWERS TO QUESTIQNSóh ToyPION. HE/SHE REPRESENTSTHAT THE ANSWERS ARE TRUE, CORRECTAND COMPLETETO THE BEST OF HIS/HER KNOWLEDGE. ----· PRODUCER's SIGNAT PROUCER'S NAME (Please A DU CENSENO Print) APPUCANT's 8IGNATURE DATE NATIONAL NUMBER PRODUCER ACORD125(2 Page 2 of 3 ACIC 0130 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 AGENCY CUSTOMER ID: PRIOR CARRIER INFORMATION LINE CATEGORY I CARRIER ATLANTIC POUCYNUMBER 146001424 POLICYTfPE DCCURRENCE OCCURRENCE DOCURRENCE OCCURRENCE occURRENCE RETRODATE EFF-EXPDATE 7 -16 N GENERALAGGREGATE C PRODUCTS COMPOP n R ASGREGATE . _. .. . PERSONAL&ADVINJ EACHOCCURRENCE c FIREDAMAGE a MEDICALEXPENSE L S BODILY OCCURRENCE I INJURY AGGREGATE PROPERWOCCURRENCE DAMAGEAGGREGATE COMBINEDSINGLELIMIT MODIFICATION FACTOR TOTALPREMlUM CARRIER POLICYNUMBER A POLICYTYPE EFF-EXPDATE B COMBINEDSINGLELIMIT L BODILY EA PERSON INJURY EAACCIDENT E PROPERTY DAMAGE MODIFICATION FACTOR TOTALPREMlUM CARRIER POLICYNUMBER POLICYTYPE EFF-EXPDATE E BUILDING AMT PERS PROP AMT MODIFICATION FACTOR TOTALPREMlUM CARRIER POLICYNUMBER POLICYTYPE EFF-EXPDATE LIMIT MODIFICATION FACTOR TOTALPREMIUM LOS:3 HISTORY ENTERALLCLAIMSORLOSSdS(RE6ARDLESS OF FAULTANDWHETHER ORNOTINSURED) OROCCURRENCES THATMAYGIVERIShiTOCLAIMS CHk l-IkHE SEEATTACHEU FOR7HEPRIOR IF NONE LOSSSUMMARY CLAIM OCCtIRRE CE LINE TYPEfDESCRPTION OFOcCURRENCEORCLAIM OF D REMARKS NOTE: REQUIREs FIDELITY LaSSHISTORY YEAR AFIVE ATTACHMENTs (ifapplicable) STATESUPPLEMENT(S) ACORD125(2007/10) Page 3 of 3 ACIC 0131 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 DATE(MM/DDNYYY) ACO COMMERCIAL GENERAL LIABILITY SECTION 4/1s/2016 AGENCY 718 331 1770 pc^•r ,No):718 256 2 410 •-d EASTERN FRUIT & VEGETABLE INC - ·-Insured) RICHARD D ANDREOLI ENECWEWE WUtAmm WE DIRECTBILL PLAN PAYMENT AUDIT 6406 14TH AVENUE BROOKLYN, NY 11219 4/17/16 4/17/17 AGENCYBILL FOR COMPANY CODE: SUBCODE: USERY AGENCY CUSTGMEID: COVERAGES LIMITS X COMMERCIAL UABlUTY GENERAL GENERALAGOREGATE $ 3,000,000 PRE=MS OCCURRENCE PRODUCTS OPERATlONS &COMPLETED AGGREGATE a PREMISESFOPERATIONS CLAIMSMADE 1, 000 , 00C OWNER'S PROTECT &CONTRACTOR's NE PERSONAL &ADVERTISING INJURY $ 000 , 00C 1, EACHOCCURRENCE $ PRODUCM 1, 000 , 00C DEDUGT1BLES DAMAGETORENTEDPREMISES{each occurrence) $ 50 , 00C . PROPERTYDAMAGE MEDICAL EXPENSE (Anyoneperson) $ OWER ___ $ 5 , 00C BODILYINJURY $ cu EMPLOYEEBENEF1TS $ .g TDTAL OTHER RESTRICTIONS COVERAGES, ENDORSEMENTS ANDFDR (Forhiredfnon-owned autocoverages stateBusiness attachtheapplicable AutoSection, ACORD137) SCHEDULE OF HAZARDS LOC HAZ CLASg PREMIUM RATE PREMlUM CLASSIF1CATEDN EXPDSURE # cong BASIS PREM/OPS PRODUCTS PREM/OPS PRODUCTS GROCERY STORE 1 1 250 , 000 RATING ANDPREMlUM BASIS (P)PAYROLL- PER (S)GROSSSALES-PER$1,000/SALES (A)AREA-PER1,000/SQ FT (M)ADMISSIONS-PER1.000/ADM (T) OTHER CLAIMS MADE (Explain all __ ALL'YES"RESPONBEs EXPLAIN Y/N 1.PROPOSED RETROACTIVE DATE: 2.ENTRY DATE INTO UNINTERRUPTEDCLAlMS MADECOVERAGE 3. HAS ANY PRODUCT,WORK. ACCIDENT, OR LOCATIONBEEN EXCLUDED, UNINSUREDOR SELF-lNSUREDFROMANY PREVlOUS COVERAGE? 4. WAS TAL COVERAGEPURCHASED UNDER ANY PREVIOUSPOLICY? EMPLOYEE BENEFITS LIABILITY 1. DEDUCTIBLEPER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITSPLANS: 2. NUMBEROF EMPLOYEES: ____ 4. RETROACTIVEDATE: ACORD126(2007/05) Pageiof4 ©ACORD CORPORATION1993-2007. All rights reserved, The ACORD name and logo are registered marks of ACORD ACIC 0132 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 CONTRACTORS ALL"YI!S"RESPONSES EXPLAIN (Forpastorpresarit operations) Y/N 1. DOES APPLICANT DRAW PLANS,DESIGNS, OR SPECIFICATIONSFOR OTHERS? 2.DO ANY OPERATIONSINCLUDEBLASTING OR UTILIZEOR STORE EXPLOSIVEMATERIAL? X DO ANY OPERATIONSINCLUDEEXCAVATION,TUNNELING, UNDERGROUNDWORK OR EARTHMOVING? 4. DO YOUR SUBCONTRACTORSCARRY COVERAGESOR LIMITSLESS THAN YOURS? 5. ARE SUBCONTRACTORSALLOWEDTO WORK WITHOUT PROVIDINGYOU WITH A CERTIFICATEOF INSURANCE? 6. DOES APPLICANT LEASE EQUIPMENTTO OTHERS WITH OR WITHOUT OPERATORS? THETYPEOFWORK DESCRIBE SU.BCONTRACTED AD O O K PA T PRODUCTS/COMPLETED OPERATIONS PRODUCTS GROSS ANNUAL SALES SOFUNLTS KET LI INTENDED USE COMPONENTS PRINCIPAL ALL"YE9"RESPONSES EXPLAIN produs.t (Foranypastorpromentor operation)PLEASE A'ITACH BROCHURES, LITERATURE, ETCs WARNINGS, LABELS, WN 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATEPRODUCTS? 2. FOREIGNPRODUCTSSOLD, DISTRIBUTED,USED AS COMPONENTS? (If "YES", attachACORD 815) 3. RESEARCHAND DEVELOPMENTCONDUCTED OR NEW PRODUCTSPLANNED? 4. GUARANTEES,WARRANTIES, HOLD HARMLESSAGREEMENTS? 5. PRODUCTSRELATEDTO AIRCRAFT/SPACEINDUSTRY? 6. PRODUCTSRECALLED, DISCONTINUED,CHANGED? 7. PRODUCTSOF OTHERS SOLD OR REPACKAGED UNDER APPLICANT LABEL? 8. PRODUCTSUNDER LABEL OF OTHERS? 9. VENDORS COVERAGE REQUIRED? 10. DOESANY NAMED [NSUREDSELLTO OTHER NAMEDINSUREDS? ACORD126(2007/05) ATTACHTOACORD125 ACIC 0133 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 ADDITIONAL INTEREST/CERTIFICATE RECIPIENT ACORD 45 attachedforaddit,'=:!names IN EREST RANK: NAMEANDADDRESS #: REFERENCE C"T‡MCAMREQUIRED INTEREST NUM INITEM BER INSURED ADDITIONAL LOCATION: BUILDING: LOSSPAYEE VEHICLE- BOAT: MORTGAGEE SCHEDULED ITEMNUMBER: LIENHOLDER OTHER EMPLOYEEAs LESSOR ITEMDESCRPTION: GENERAL INFORMATION ALL"YES"RESPONsES EXPLAIN (Foranpastor presetitoperallons) YN 1. ANY MEDICALFACILITIESPROVIDEDOR MEDICALPROFESSIONALSEMPLOYEDOR CONTRACTED9 2. ANY EXPOSURETO RADIOACTIVE/NUCLEARMATERIALS? 3. DO/HAVE PAST, PRESENT OR DISCONTINUEDOPERATIONS INVOLVE(D) STORING,TREATING, DISCHARGING,APPLYiNG, DISPOSING,OR TRANSPORTINGOFHAZARDOUSMATERIAL?(e.g.Ian@lls,wastes,fuel tanks,etc) 4. ANY OPERATIONS SOLD,ACQUIRED, OR DISCONTINUEDIN LAST FIVE (5) YEARS? 5. MACHINERYOR EQUIPMENTLOANED OR RENTEDTO OTHERS? 6. ANY WATERCRAFT,DOCKS, FLOATS OWNED, HIRED OR LEASED? 7. ANY PARKINGFACIUTIESOWNED/RENTED? 8. IS A FEE CHARGEDFOR PARKING? 9. RECREATIONFACIUTIES PROVIDED? 10. IS THERE A SWIMMINGPOOL ON THE PREMtSES? 11. SPORTING OR SOCIAL EVENTS SPONSORED? 12. ANY STRUCTURALALTERATIONSCONTEMPLATED? 13. ANY DEMOLITIONEXPOSURECONTEMPLATED? 14. HAS APPLICANTBEEN ACTIVE IN OR IS CURRENTLYACTNE IN JOINTVENTURES? 15. DO YOU LEASE EMPLOYEESTO OR FROM OTHER EMPLOYERS? 16. IS THERE A LABOR INTERCHANGEWITH ANY OTHER BUSINESSOR SUBSIDIARIÈS? ACORD126(2007/05) Page 3 of 4 ACIC 0134 FILED: KINGS COUNTY CLERK 05/04/2020 10:41 AM INDEX NO. 510798/2018 NYSCEF DOC. NO. 94 RECEIVED NYSCEF: 05/04/2020 GENERAL INFORMATION (co.7ü=cd) ALL EXPLAIN 8" RESPONSEs (Forallpastar presetitaperallons) 17. ARE DAY CARE FACILITIESOPERATED OR CONTROLLED? 18. HAVE ANY CRIMESOCCURRED OR BEEN ATTEMPTEDON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? 19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITYPOLICYIN EFFECT? 20. DOES THE BUSINESSES' PROMOTIONALLITERATURE MAKEANY REPRESENTATIONSABOUT THE SAFETY OR SECURITYOF THE PREMISES? REMARKS ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUDANY INSURANCE COMPANYOR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENTOF CLAlM CONTAININGANY MATERIALLYFALSE INFORMATION,OR CONCEALSFOR THE PURPOSE OF MISLEADINGINFORMATIONCONCERNINGANY FACTMATERIALTHERETO, COMMITSA FRAUDULENTINSURANCEACT, WHICH ISA CRIMEAND SUBJECTSTHE PERSONTO CRIMINALAND [NY: SUBSTANTIAL]CML PENALTIES.(NotapplicablelnCO,FL,HI,MA,NE,OH,OK,ORorVT. InDC,LA,ME,TN,VAandWAinsurance benâ‡its6ià ymisobedenied). IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECElVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATIONCONTAININGANY FALSE,INCOMPLETE,OR MISLEADINGINFORMATIONIS GUILTYOF A FELONYOFTHE THIRD DEGREE, ACORD126(2007/05) Page 4 of 4 ACIC 0135