|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 1 (2008/01) |
Property Loss Notice |
Use the ACORD Property Loss Notice (ACORD 1) for reporting commercial and personal lines property losses including Homeowners, Dwelling Fire, Inland Marine, Commercial Property, Flood, Wind and others. |
|
IDENTIFICATION SECTION |
Date |
Enter the Month/day/year on which the form is completed. (MM/DD/YYYY) |
|
IDENTIFICATION SECTION |
Agency |
Enter the Agency's name and address. |
|
IDENTIFICATION SECTION |
Contact Name |
Enter the name individual at the agency that is the primary contact. |
|
IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Enter the Agency's telephone number. |
|
IDENTIFICATION SECTION |
FAX |
Enter the Agency's fax number. |
|
IDENTIFICATION SECTION |
E-Mail Address |
Enter the Agency's e-mail address. |
|
IDENTIFICATION SECTION |
Code |
Enter the Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. |
|
IDENTIFICATION SECTION |
Subcode |
Enter the appropriate code, if your agency uses a sub-code identification system with the company. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter the customer’s identification number assigned by the agency. |
|
IDENTIFICATION SECTION |
Insured Location Code |
Enter the code the policyholder defines that is used to allocate loss experience to cost centers. For example, if a grocery store chain is insured and the entire chain was under one policy, the grocery store chain might choose to allocate the losses for each store. To do this they would provide a store number or store code (something the insured defines) when they report a claim. The insured would include that store number in the "Insured Location Code" field so that the carrier can record the code in their claim system and then the right store is assessed the loss experience. |
|
IDENTIFICATION SECTION |
Date & Time of Loss |
Enter the date and approximate time that the loss occurred. |
|
IDENTIFICATION SECTION |
AM or PM |
Check the appropriate A.M. or P.M. box should be checked (e.g., 01/11/1994 - 12:15 A.M.). |
|
IDENTIFICATION SECTION |
Carrier |
Enter the company name for commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies and policy number for the types of policies written. Use the actual name of the company within the group to which you are sending the loss notice. Do not use group names. |
|
IDENTIFICATION SECTION |
NAIC Code |
Enter the NAIC code of the insurance company that issued the policy. |
|
IDENTIFICATION SECTION |
Policy Number |
Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
IDENTIFICATION SECTION |
Carrier |
Enter the company name for monoline flood policies. Do not repeat the property/homeowners company name and policy number unless flood is written separately. |
|
IDENTIFICATION SECTION |
NAIC Code |
Enter the NAIC code of the insurance company that issued the policy. |
|
IDENTIFICATION SECTION |
Policy Number |
Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
IDENTIFICATION SECTION |
Carrier |
Enter the company name for monoline wind/hail policies. Do not repeat the property/homeowners company name and policy number unless wind coverages are written separately. |
|
IDENTIFICATION SECTION |
NAIC Code |
Enter the NAIC code of the insurance company that issued the policy. |
|
IDENTIFICATION SECTION |
Policy Number |
Enter the policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
INSURED |
Name of Insured |
Enter the full name of the insured (First, Middle, Last name) as found on the declarations page of the policy. |
|
INSURED |
Date of Birth |
Enter the date of birth for the insured. |
|
INSURED |
Soc. Sec. # |
Enter the social security number for the insured. |
|
INSURED |
Marital Status |
Enter the insured's marital status. |
|
INSURED |
Primary Phone |
Enter primary telephone number including area code. |
|
INSURED |
Home |
Check if Primary Phone is Home |
|
INSURED |
Bus |
Check if Primary Phone is Business |
|
INSURED |
Cell |
Check if Primary Phone is Cell |
|
INSURED |
Secondary Phone |
Enter the secondary telephone number including area code. |
|
INSURED |
Home |
Check if Secondary Phone is Home |
|
INSURED |
Bus |
Check if Secondary Phone is Business |
|
INSURED |
Cell |
Check if Secondary Phone is Cell |
|
INSURED |
Insured's Mailing Address |
Enter the mailing address of the insured as found on the declarations page of the policy. |
|
INSURED |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
INSURED |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
INSURED |
Name of Spouse |
Enter the full name of the spouse (First, Middle, Last name). |
|
INSURED |
Date of Birth |
Enter the date of birth for the spouse. |
|
INSURED |
Soc. Sec. # |
Enter the social security number for the spouse. |
|
INSURED |
Marital Status |
Enter the spouse's marital status. |
|
INSURED |
Primary Phone |
Enter primary telephone number including area code. |
|
INSURED |
Home |
Check if Primary Phone is Home |
|
INSURED |
Bus |
Check if Primary Phone is Business |
|
INSURED |
Cell |
Check if Primary Phone is Cell |
|
INSURED |
Secondary Phone |
Enter secondary telephone number including area code. |
|
INSURED |
Home |
Check if Secondary Phone is Home |
|
INSURED |
Bus |
Check if Secondary Phone is Business |
|
INSURED |
Cell |
Check if Secondary Phone is Cell |
|
INSURED |
Insured's Mailing Address |
Enter the mailing address of the insured as found on the declarations page of the policy. |
|
INSURED |
Primary E-Mail Address |
Enter the primary e-mail address of the insured. |
|
INSURED |
Secondary E-Mail Address |
Enter the secondary e-mail address of the insured. |
|
CONTACT |
Contact Insured |
Check this box, if the individual to contact for information is the same as the named insured, and leave blank the areas for contact name, address and phone numbers. |
|
CONTACT |
Name of Contact |
Enter the full name (First, Middle, Last) of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked. |
|
CONTACT |
Primary Phone |
Enter primary telephone number including area code. |
|
CONTACT |
Home |
Check if Primary Phone is Home |
|
CONTACT |
Bus |
Check if Primary Phone is Business |
|
CONTACT |
Cell |
Check if Primary Phone is Cell |
|
CONTACT |
Secondary Phone |
Enter secondary telephone number including area code. |
|
CONTACT |
Home |
Check if Secondary Phone is Home |
|
CONTACT |
Bus |
Check if Secondary Phone is Business |
|
CONTACT |
Cell |
Check if Secondary Phone is Cell |
|
CONTACT |
When to Contact |
Describe the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.). |
|
CONTACT |
Contact's Mailing Address |
Enter the mailing address of the contact as found on the declarations page of the policy. |
|
CONTACT |
Primary E-Mail Address |
Enter the primary e-mail address of the contact. |
|
CONTACT |
Secondary E-Mail Address |
Enter the secondary e-mail address of the contact. |
|
LOSS |
Location of Loss Street |
Enter the physical location of the loss. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured’s home or Loc 3, Bld 2; 151 Main St). |
|
LOSS |
Location of Loss City, State, Zip |
Enter the city, state and zip code for the physical location f the loss. |
|
LOSS |
Location of Loss Country |
Enter the country for the physical location f the loss. |
|
LOSS |
Police or Fire Department Contacted |
Enter the name of the municipal or county police or fire department to which the loss was reported, including the precinct or station number if available. |
|
LOSS |
Report Number |
Enter the report number, if a report was issued. |
|
LOSS |
Kind of Loss |
Check any appropriate box that may apply to the type of loss. If the loss is different from the pre-printed options, check the "other" option and list the loss type in the available space. |
|
LOSS |
Probable Amount Entire Loss |
Enter an estimated dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as "small" or "substantial". |
|
LOSS |
Description of Loss & Damage |
Describe the cause of the loss and resulting damage, including the areas of buildings which were damaged. Note: If the loss resulted in bodily injury to individuals or damage to the property of others, indicate in the Remarks Section and complete the appropriate additional claim form. |
|
LOSS |
Reported By |
Enter the name of the individual that reported the loss. |
|
LOSS |
Reported To |
Enter the name of the individual that the loss was reported too. |
