ACORD 139 Instructions
139 - Statement of Values
ACORD 139, Statement
of Values was developed to assist in the collection of information when multiple
locations owned or operated by the same insured will be included in an average
or blanket rated property insurance policy.
This form is not intended to replace specific ACORD applications, such as ACORD
140, Property Section, or ACORD 160, Business Owners Application.
Note: Use ACORD 159, Schedule of Insurance, when an average or blanket rate
does not apply, but multiple locations owned or operated by the same insured
will be covered under a single policy, with separate limits applying to each
- Date Month/day/year
(MM/DD/YYYY) on which the form is completed.
- Agency Agency's
name and address.
- Phone (A/C,
No., Ext.) Agency's telephone number. Include area code and extension (if
- Fax No. Agency's
fax number. (Include area code)
- Code Identification
code assigned to the agency or brokerage firm by the insurance company receiving
- Subcode If
the agency uses a subcode identification system with the company, enter the
- Agency Customer
ID Customer's identification number assigned by the agency.
- Company Name
of the applicable insurance company. Do not use group names, use the actual
name of the company within the group in which you wish to have the policy
- NAIC Code The
company code assigned by the National Association of Insurance Commissioners.
- Page If more
than one ACORD 139 form is required because of the number of properties to
be included, indicate the page number applicable and the total number of pages
(e.g., Page 1 of 5, Page 2 of 4).
Show the name of the insured or applicant as it will appear on the policy.
- Policy # The
number assigned by the insurance company for the policy.
- Effective Date
Enter the effective date that will apply to the average blanket rate.
Address Enter the principle address of the insured.
- Coins % Check
the applicable coinsurance percentage, 80%, 90% or 100%. If a different percentage,
list next to blank box.
Cause of Loss Indicate the causes of loss for the subject of insurance.
- Specific Average
Rate/Blanket Rate/Other Check the appropriate box. If a specific average rate
or a blanket rate is not being requested, check the "blank" box
and state why the form is being used.
Form Numbers Use this space to provide information about endorsements, options,
and any information affecting rates or loss costs that cannot be shown in
the schedule on the form.
- Class Code
Enter the ISO or Company Class Code, if applicable.
- Location #
For each building, enter the location number as shown on the application or
change request that was used when the building was first insured.
- Bldg # For
each building, enter the building number as shown on the application or change
request that was used when the building was first insured. Provide a description
of the property where necessary. Use more than one line if additional space
and Address of Property For each building, enter the address as shown on the
application or change request that was used when the building was first insured.
Provide a description of the property where necessary. Use more than one line
if additional space is required.
- ACV/RC "Indicate
""ACV"" if actual cash value valuation is to apply. Enter
""RC"" if replacement cost valuation is to apply. If another
valuation basis applies, provide the necessary information.
- Subject Enter
the appropriate code to identify the subject of insurance as shown in the
instructions on the bottom of the form.
- 100% Values
Provide the value for each property in accordance with the valuation method
and the subject of insurance.
- Rate or Loss
Cost For class rated property, attach class rate information or equivalent
information for each location. For specifically rated property, attach specific
rate or loss cost information if known.
- Premium Enter
the premium for each property in this column.
- Total Values
Enter the total value for all properties in accordance with the valuation
method and the subject of insurance.
- Total Premium
Enter the total premium for all properties.
- Insured's Signature
Insured must sign this form.
- Title Indicate
the insured's title.
- Date Indicate
the date insured signed the form.