Scottsdale Insurance Company Adm. Office: 8877 North Gainey Center Drive Home Office: One Nationwide Plaza Scottsdale, Arizona 85258 Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale Surplus Lines Insurance Scottsdale, Arizona 85258 Adm. Office: 8877 North Gainey Center Drive Scottsdale Indemnity Company Scottsdale, Arizona 85258 Home Office: One Nationwide Plaza Columbus, Ohio 43215 LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Agency Name: Applicant’s Name: Agent No.: Phone No.: 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) A. Land Use and Acreage: 1. Indicate location address and total acreage in applicable column: Real Estate Land Leased Loc. Vacant Land Development Location Address to Others No. (acreage) Property (acreage) (acreage) 1 2 3 2. What was the prior use of the land? 3. Is applicant involved in or exposed to any hydraulic fracturing or hydrofracking operations? Yes No If yes, describe: 4. Is land zoned for residential use? Yes No 5. Was land ever used as a landfill? Yes No 6. Is land a hunting preserve? Yes No 7. Is land used for snowmobiling or motorized vehicles and bikes? Yes No 8. Are there logging or lumbering operations on owned or leased land? Yes No 9. Any underground fuel tanks on the property? Yes No 10. Any below ground mines on the property? Yes No If yes: Sealed Not Sealed 11. Any water wells on the property? If yes: Sealed Not Sealed
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant’s Name: Mailing Address: Agency Name: Agent No.: Phone No.: 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) A. Land Use and Acreage: 1. Indicate location address and total acreage in applicable column: Loc. No. Location Address Vacant Land (acreage) Real Estate Development Property (acreage) Land Leased to Others (acreage) 1 2 3 2. What was the prior use of the land? 3. Is applicant involved in or exposed to any hydraulic fracturing or hydrofracking operations? Yes No If yes, describe: 4. Is land zoned for residential use? Yes No 5. Was land ever used as a landfill? Yes No 6. Is land a hunting preserve? Yes No 7. Is land used for snowmobiling or motorized vehicles and bikes? Yes No 8. Are there logging or lumbering operations on owned or leased land? Yes No 9. Any underground fuel tanks on the property? Yes No 10. Any below ground mines on the property? Yes No If yes: Sealed Not Sealed 11. Any water wells on the property? If yes: Sealed Not Sealed