ACORD 410 InstructionsACORD 410 - Small Farm/Ranch Application As a general guideline, this form is intended to be used in lieu of ACORD 401 through 404, for small farm/ranch properties, not over three farm buildings and two residential buildings, and not over two different types of businesses (e.g., dairy, crops, livestock, etc.). Do not use if property is to be schedule or blanket rated.
Date Month/day/year on which the form is completed. Phone (A/C, No, Ext) Producer's telephone numbers. Include area code and extension, if applicable. Fax (A/C, No, Ext) Producer's fax number, include area code. Agency Producer's name and address. 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 Enter the NAIC code of the applicable insurance company. Company Policy or Program Name Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed. Program Code Show the program code assigned by the company, if applicable. Account No. Account number assigned by the applicable insurance company. New/Rnwl Indicate if the applicant is a risk that is new to the company or a renewal of an expiring policy with the same company. Effective Date Date on which the terms and conditions of the policy will commence. Expiration Date Date on which the terms and conditions of the policy will terminate unless renewed. Direct Bill/Agency Bill Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible. Examples: * Prepaid Status of Submission Indicate whether the company's response to this application is expected to be a quote or an issued policy. If the risk is bound, list the date and time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes. Policy Type Indicate the type of policy. Deposit Also show the deposit premium amount. APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) * Full name of the applicant as it should appear on the policy. (The first named insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names. (E.g., John and Mary Smith.) Wording such as ""et al"" or ""As their interests may appear"" is not acceptable as the name of the insured. These phrases do not designate legal entities. APPLICANT INFORMATION Relationship * * If more than one person is listed as the named insured, indicate the relationship to the first named insured. Mailing Adress (of First Named Insured) The physical address at which the first named insured is to receive all correspondence regarding the insurance. Phone (A/C, No, Ext) The first named insured's phone number at the mailing address. Include area code and extension, if applicable. E-Mail Address The first named insured's e-mail address. Phone # on Premises The first named insured's phone number at the premises. Include area code and extension, if applicable. Form of Business Organization Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, or an option not listed . Use the blank space to provide a description such as an Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section, list each named insured along with its form of organization. Date Business Started The date the applicant began in this business. This is important because it helps the underwriter determine the expertise and business success of the applicant. SIC Enter the Standard Industry Classification code that the applicant falls under. Contact Name of the person the carrier is to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number Phone (A/C, No, Ext) Phone number of the person the carrier is to contact to arrange for a premises inspection. This should be an individual under the insured's employment, not the insurance agent's name and number. TYPE OF FARM/RANCH Indicate the primary nature of the applicant's operation. Refer to your company for specific details, as they apply to the company's individual programs. Describe Farm/Ranch Operations This item is designated to inform the underwriter of what type of operation each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. PREMISES INFORMATION Provide premises information separately for each building. Indicate the location number (if a number has been assigned), and a building number if applicable. For each separate building, show the applicable public protection class, the total acreage, number of acres cultivated or in pasture, and indicate whether the business is farmed by the owner of the property, a tenant, a manager, or another entity, and the gross receipts in dollars. LOC # Provide premises information separately for each building. Indicate the location number (if a number has been assigned). BLD # Provide premises information separately for each building. Indicate a building number if applicable. Street, City, County, State, Zip Provide the address for each premises. Prot Class For each separate building, show the applicable public protection class. # Acres Total For each separate building, show the total acreage. # Acres Cultivated For each separate building, show the number of acres cultivated. # Acres in Pasture For each separate building, show the number of acres in pasture. Farmed By For each separate building, indicate whether the business is farmed by the owner of the property, a tenant, a manager, or another entity. Gross Receipts For each separate building, show the gross receipts in dollars. LOSS HISTORY Whenever possible, attach a copy of the previous carrier's loss run for each line of business. Loss reports should cover the previous five years of loss history. Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim. Type of Loss Indicate the line of business involved in the loss. Description Give a brief description of the loss. Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date. If the claim is still open, list the reserve amount the previous carrier is holding open for this claim.
Prior Carrier Indicate the prior carrier(s). Type of Insurance Indicate the type of insurance. Policy # Indicate the policy number(s). Amount of Coverage Indicate the
amount(s) of coverage. ADDITIONAL INTERESTS-PROPERTY Provide information about mortgage holders, loss payees, or other additional property interests, if applicable. Prem No / Bldg No Enter the premises number and the building number of the property. Name and Address List the additional interest's name and mailing address. Interest Check all appropriate boxes that apply to the additional interest. If the interest is other than the listed options, check the last box and list the interest type after it. Evidence Check the appropriate box to indicate whether a certificate or a copy of the policy is to be provided to the additional insured. ADDITIONAL INTERESTS-LIABILITY Provide information about mortgage holders, loss payees, or other additional property interests, if applicable. Rank Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee. Interest Check all appropriate boxes that apply to the additional interest. If the interest is other than the listed options, check the last box and list the interest type after it. Name and Address List the additional interest's name and mailing address. Evidence Check the appropriate
box to indicate whether a certificate or a copy of the policy is to be provided
to the additional insured. PROPERTY COVERAGE Location # Enter Location Number as shown in PREMISES INFORMATION section on page 1. Fire District Name Enter the name of the fire district. Distance to Hydrant Enter the distance in feet. Distance to Fire Station Enter the distance to the nearest mile. Bldg Type Describe the occupancy of the building. For dwellings only, enter the number of families. Construction Enter the construction type in accordance with the state manual. Type of Heat Enter the heat source (e.g., natural gas) and the type of heating unit. Age of Bldg Enter the age in years. Age of Roof Enter the age in years. Square Feet Enter the total square foot area for each building. RC/ACV Indicate if replacement cost (RC) or actual cash value (ACV) applies. Conisurance % Enter the coinsurance percentage applicable to the coverage. Prot Class Enter the protection class that applies to the structure. Note that some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply. Cause of Loss Perils that are to be covered Deductible Enter the deductible, if any. Value Enter the market value, if known. Limit of Insurance Enter the applicable limit in dollars. Premium Enter the premium for each building and personal property, if applicable. Additional Coverages, Restrictions, Endorsements and Rating Information Indicate any Additional
Coverages, Restrictions, Endorsements and Rating Information LIABILITY COVERAGE Coverages Provision is made
for recording Bodily Injury and Property Damage Liability, Personal and Advertising
Injury Liability Medical Payments, Fire Damage Coverage, Damage to Property
of Others, and Personal Liability Coverage (AAIS), if applicable. For other
combinations of liability coverage, use the blank lines. If Commercial General Liability is to apply, use Acord 125, Commercial Insurance Application, and ACORD 126, Commercial General Liability Section.
Show separate limits where applicable. Note that different aggregate limits may apply to separate coverages or exposures. Code Enter the applicable ISO, AAIS, or company code for each type of exposure. LOC # Show location number if applicable. Coverage Descriptions of coverage have been provided that track with ISO or AAIS rules. If company unique rules apply, use the blank spaces provided. INCR Limits Factor Show Increased Limit Factors for applicable exposures. Basis/Rate Show Basis Rates for applicable exposures. Premium Show Premium
for applicable exposures. GENERAL INFORMATION Question 1 Indicate if there is a year-round water source available for fire protection and check the applicable boxes. Question 2 Indicate if wood or coal fired stoves are used. Explain their use, including locations within the buildings Question 3 If there are any alarms on the premises, indicate the type of alarm and the floors protected. This question cannot be asked in Missouri. Question 4 Indicate if the applicant performs equipment maintenance, and if yes, describe. Question 5 Indicate whether or not the entire premises is occupied year round. If not, explain. Question 6-35 Answer questions
6 through 35 if Liability insurance is being requested. Explain all "yes"
responses under remarks. If necessary, use additional sheets of paper. REMARKS Use this section
to provide any additional information required for underwriting or rating. If
necessary, use additional sheets of paper. ATTACHMENTS Check the appropriate box. SIGNATURE SECTION Applicant's Signature Applicant must sign form. Producer's Signature Date applicant signed form. National Producer Number The National Producer Number assigned by the NAIC should be shown.
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