ACORD 3 Instructions


Section Name Field Name Field and/or Section Description
TITLE General Liability Notice of
ACORD 3 (2008/01) Occurrence/Claim Use ACORD 3 to report both commercial and personal liability losses.
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.
Enter the Identification code assigned to your agency or brokerage firm by the
IDENTIFICATION SECTION Code insurance company receiving this form.
Enter the appropriate code, if your agency uses a sub-code identification
IDENTIFICATION SECTION Subcode system with the company.
IDENTIFICATION SECTION Agency Customer ID Enter the customer’s identification number assigned by the agency.
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
IDENTIFICATION SECTION Insured Location Code 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.
Check the appropriate A.M. or P.M. box should be checked (e.g., 01/11/1994 -
IDENTIFICATION SECTION AM or PM 12:15 A.M.).
IDENTIFICATION SECTION Carrier Name of the applicable insurance company. Do not use group names, use the actual name of the company within the group to which you are sending the loss notice.
IDENTIFICATION SECTION NAIC Code NAIC code of the insurance company that issued the policy.
IDENTIFICATION SECTION Policy Number Number exactly as it appears on the policy, including prefix and suffix symbols.
Enter the full name of the insured (First, Middle, Last name) as found on the
INSURED Name of Insured 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.
Section Name Field Name Field and/or Section Description
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.
OCCURRENCE Location of Occurrence Street Enter the physical street location of the occurrence. 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).
Section Name Field Name Field and/or Section Description
OCCURRENCE Location of Occurrence City, State, Zip Enter the city, state and zip code for the physical location of the occurrence.
OCCURRENCE Location of Occurrence Country Enter the country for the physical location of the occurrence.
OCCURRENCE 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.
OCCURRENCE Report Number Enter the report number, if a report was issued.
OCCURRENCE Description of Occurrence Describe the incident resulting in a potential loss to the insured.
TYPE OF LIABILITY Premises: Insured is Check the appropriate box of the relationship of the insured to the premises. List the type when "Other" is checked.
TYPE OF LIABILITY Premises: Insured is Other Describe the type when "Other" is checked.
TYPE OF LIABILITY Owner’s Name & Address Enter "insured", if this is the insured. If other than the insured, provide the owner’s name and address.
TYPE OF LIABILITY Type of Premises Describe the premises (e.g., mercantile with apartments).
TYPE OF LIABILITY Primary Phone Enter primary telephone number including area code.
TYPE OF LIABILITY Home Check if Primary Phone is Home
TYPE OF LIABILITY Bus Check if Primary Phone is Business
TYPE OF LIABILITY Cell Check if Primary Phone is Cell
TYPE OF LIABILITY Secondary Phone Enter secondary telephone number including area code.
TYPE OF LIABILITY Home Check if Secondary Phone is Home
TYPE OF LIABILITY Bus Check if Secondary Phone is Business
TYPE OF LIABILITY Cell Check if Secondary Phone is Cell
TYPE OF LIABILITY Primary E-Mail Address Enter the primary e-mail address of the insured.
TYPE OF LIABILITY Secondary E-Mail Address Enter the secondary e-mail address of the insured.
TYPE OF LIABILITY Products: Insured Is Check the appropriate box for products coverage, indicate the business the insured is in by placing an "X" in the appropriate box.
TYPE OF LIABILITY Products: Insured is Other Describe the type when "Other" is checked.
TYPE OF LIABILITY Manufacturer’s Name & Address Enter "insured", if this is the insured. If other than the insured, enter the manufacturer’s name and address.
TYPE OF LIABILITY Where Can Product Be Seen? Describe where the product can be inspected by the adjuster. If other than the insured’s address, include the address.
TYPE OF LIABILITY Type of Product Describe the insured’s product (e.g., automobile parts, sales, appliances repair).
TYPE OF LIABILITY Primary Phone Enter primary telephone number including area code.
TYPE OF LIABILITY Home Check if Primary Phone is Home
Section Name Field Name Field and/or Section Description
TYPE OF LIABILITY Bus Check if Primary Phone is Business
TYPE OF LIABILITY Cell Check if Primary Phone is Cell
TYPE OF LIABILITY Secondary Phone Enter secondary telephone number including area code.
TYPE OF LIABILITY Home Check if Secondary Phone is Home
TYPE OF LIABILITY Bus Check if Secondary Phone is Business
TYPE OF LIABILITY Cell Check if Secondary Phone is Cell
TYPE OF LIABILITY Primary E-Mail Address Enter the primary e-mail address of the insured.
TYPE OF LIABILITY Secondary E-Mail Address Enter the secondary e-mail address of the insured.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
INJURED/PROPERTY DAMAGED Name & Address Enter the name and address of any injured party, or owner of damaged property.
INJURED/PROPERTY DAMAGED Primary Phone Enter primary telephone number including area code of any injured party or owner of damaged properties.
INJURED/PROPERTY DAMAGED Home Check if Primary Phone is Home
INJURED/PROPERTY DAMAGED Bus Check if Primary Phone is Business
INJURED/PROPERTY DAMAGED Cell Check if Primary Phone is Cell
INJURED/PROPERTY DAMAGED Secondary Phone Enter secondary telephone number including area code of any injured party or owner of damaged properties.
INJURED/PROPERTY DAMAGED Home Check if Secondary Phone is Home
INJURED/PROPERTY DAMAGED Bus Check if Secondary Phone is Business
INJURED/PROPERTY DAMAGED Cell Check if Secondary Phone is Cell
INJURED/PROPERTY DAMAGED Primary E-Mail Address Enter the primary e-mail address of the insured.
INJURED/PROPERTY DAMAGED Secondary E-Mail Address Enter the secondary e-mail address of the insured.
INJURED/PROPERTY DAMAGED Employer’s Name & Address Enter the name and address of any injured person’s employer.
INJURED/PROPERTY DAMAGED Primary Phone Enter primary telephone number including area code of the injured person's employer.
Section Name Field Name Field and/or Section Description
INJURED/PROPERTY DAMAGED Home Check if Primary Phone is Home
INJURED/PROPERTY DAMAGED Bus Check if Primary Phone is Business
INJURED/PROPERTY DAMAGED Cell Check if Primary Phone is Cell
INJURED/PROPERTY DAMAGED Secondary Phone Enter secondary telephone number including area code of any injured person's employer.
INJURED/PROPERTY DAMAGED Home Check if Secondary Phone is Home
INJURED/PROPERTY DAMAGED Bus Check if Secondary Phone is Business
INJURED/PROPERTY DAMAGED Cell Check if Secondary Phone is Cell
INJURED/PROPERTY DAMAGED Primary E-Mail Address Enter the primary e-mail address of the insured.
INJURED/PROPERTY DAMAGED Secondary E-Mail Address Enter the secondary e-mail address of the insured.
INJURED/PROPERTY DAMAGED Age Enter the age of any injured person.
INJURED/PROPERTY DAMAGED Sex Enter "F"-Female or "M"-Male.
INJURED/PROPERTY DAMAGED Occupation Describe the injured person’s occupation.
INJURED/PROPERTY DAMAGED Describe Injury Describe the injury. If fatal, check the available box.
INJURED/PROPERTY DAMAGED Where Taken Describe where the injured was taken (e.g. St. Luke’s Hospital, home).
INJURED/PROPERTY DAMAGED What Was Injured Doing? Describe the activities of the injured person when the accident took place.
INJURED/PROPERTY DAMAGED Describe Property Described the damaged property (e.g. printer # 31).
INJURED/PROPERTY DAMAGED Estimate Amount Enter an estimate for the cost of repair to the damaged property.
INJURED/PROPERTY DAMAGED Where Can Property Be Seen? Enter where the damaged property is located so the adjuster can inspect it.
Section Name Field Name Field and/or Section Description
WITNESSES Name & Address Enter the name and address of any witness.
WITNESSES Primary Phone Enter primary telephone number including area code of any witnesses.
WITNESSES Home Check if Primary Phone is Home
WITNESSES Bus Check if Primary Phone is Business
WITNESSES Cell Check if Primary Phone is Cell
WITNESSES Secondary Phone Enter secondary telephone number including area code of any witnesses.
WITNESSES Home Check if Secondary Phone is Home
WITNESSES Bus Check if Secondary Phone is Business
WITNESSES Cell Check if Secondary Phone is Cell
WITNESSES Primary E-Mail Address Enter the primary e-mail address of the insured.
WITNESSES Secondary E-Mail Address Enter the secondary e-mail address of the insured.
WITNESSES Name & Address Enter the name and address of any witness.
WITNESSES Primary Phone Enter primary telephone number including area code of any witnesses.
WITNESSES Home Check if Primary Phone is Home
WITNESSES Bus Check if Primary Phone is Business
WITNESSES Cell Check if Primary Phone is Cell
WITNESSES Secondary Phone Enter secondary telephone number including area code of any witnesses.
WITNESSES Home Check if Secondary Phone is Home
WITNESSES Bus Check if Secondary Phone is Business
WITNESSES Cell Check if Secondary Phone is Cell
WITNESSES Primary E-Mail Address Enter the primary e-mail address of the insured.
WITNESSES Secondary E-Mail Address Enter the secondary e-mail address of the insured.
WITNESSES Name & Address Enter the name and address of any witness.
WITNESSES Primary Phone Enter primary telephone number including area code of any witnesses.
WITNESSES Home Check if Primary Phone is Home
WITNESSES Bus Check if Primary Phone is Business
WITNESSES Cell Check if Primary Phone is Cell
WITNESSES Secondary Phone Enter secondary telephone number including area code of any witnesses.
WITNESSES Home Check if Secondary Phone is Home
WITNESSES Bus Check if Secondary Phone is Business
WITNESSES Cell Check if Secondary Phone is Cell
WITNESSES Primary E-Mail Address Enter the primary e-mail address of the insured.
WITNESSES Secondary E-Mail Address Enter the secondary e-mail address of the insured.
WITNESSES Remarks Describe any other additional information that will assist in properly reporting and settling this claim.
WITNESSES Reported By Enter the name of the individual that reported the loss.
WITNESSES Reported To Enter the name of the individual that the loss was reported too.


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