ACORD 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 location.
- 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 applicable).
- Fax No. Agency’s fax number. (Include area code)
- Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
- Subcode If the agency uses a subcode identification system with the company, enter the appropriate code.
- 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 issued.
- 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).
- Insured/Applicant 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.
- Headquarters 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.
- Applicable 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.
- Applicable 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 is required.
- Description 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.