|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 74 (2008/04) |
Residence Based Business Supplement to Residential Section |
Use ACORD 74, Residence Based Business, as a supplement to any personal property insurance application, when there is a business located on the premises. Refer to your company for rules of use. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Customer's identification number assigned by the agency. |
|
IDENTIFICATION SECTION |
Loc # |
Enter the location number of the risk's location as it appears on ACORD 88, Personal Insurance Application, Applicant Information Section. |
|
IDENTIFICATION SECTION |
Date |
Month/day/year (MM/DD/YYYY) on which the form is completed. |
|
IDENTIFICATION SECTION |
Agency |
Agency's name. |
|
IDENTIFICATION SECTION |
Policy Number |
Use this field to provide the policy number if a policy has already been issued. |
|
IDENTIFICATION SECTION |
Carrier |
Name of the insurance company (or residual market plan) that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. |
|
IDENTIFICATION SECTION |
NAIC Code |
Individual company code assigned by the NAIC. |
|
IDENTIFICATION SECTION |
Named Insured |
Enter the Named Insured as it should appear on the policy. |
|
IDENTIFICATION SECTION |
DBA: |
If the insured is an individual or partnership doing business under an assumed name, enter the name of the business. |
|
APPLICANT INFORMATION |
Individual (Checkbox) |
Check this box if the business has a legal entity of Individual. |
|
APPLICANT INFORMATION |
Partnership (Checkbox) |
Check this box if the business has a legal entity of Partnership. |
|
APPLICANT INFORMATION |
Corporation (Checkbox) |
Check this box if the business has a legal entity of Corporation. |
|
APPLICANT INFORMATION |
Limited Corporation (Checkbox) |
Check this box if the business has a legal entity of Limited Corporation. |
|
APPLICANT INFORMATION |
Joint Venture (Checkbox) |
Check this box if the business has a legal entity of Joint Venture. |
|
APPLICANT INFORMATION |
Other (Checkbox) |
Check this box if the business has a legal entity that is not one of the options listed. |
|
APPLICANT INFORMATION |
Describe Other |
Provide a description of "other", such as Professional Association or a Limited Liability Company. 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 (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.) |
|
APPLICANT INFORMATION |
GL Code |
Enter the General Liability Code, if applicable. |
|
APPLICANT INFORMATION |
NAICS Code |
Enter the North American Industry Classification System (NAICS) code assigned to the particular type of business (if known). |
|
APPLICANT INFORMATION |
Federal ID # |
Enter the Federal Employer Identification Number (FEIN) assigned by the IRS. |
|
APPLICANT INFORMATION |
Inspection 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. |
|
APPLICANT INFORMATION |
Phone (A/C, No., Ext.): |
Phone number of the contact for premises inspection. (Include area code and extension if applicable) |
|
NATURE OF BUSINESS |
Office (Checkbox) |
Check this box if nature of business is office. |
|
NATURE OF BUSINESS |
Service (Checkbox) |
Check this box if nature of business is service. |
|
NATURE OF BUSINESS |
Retail (Checkbox) |
Check this box if nature of business is retail. |
|
NATURE OF BUSINESS |
Wholesale (Checkbox) |
Check this box if nature of business is wholesale. |
|
NATURE OF BUSINESS |
Crafts (Checkbox) |
Check this box if nature of business is crafts. |
|
NATURE OF BUSINESS |
Other (Checkbox) |
Check this box if nature of business is not one of the options listed. |
|
NATURE OF BUSINESS |
Other Description |
Identify the nature of business for other type of work. |
|
NATURE OF BUSINESS |
Date Business Started |
Enter the date (MM/DD/YYYY) the business began operations. This is important. It helps the underwriter determine the expertise and business success of the applicant. |
|
NATURE OF BUSINESS |
Class Code |
Enter the general liability classification code for this exposure. |
|
NATURE OF BUSINESS |
Sq. Ft. Used |
Enter area in square feet that the applicant occupies for business purposes. |
|
NATURE OF BUSINESS |
Annual Sales/Receipts $ |
Enter the amount of the total annual sales receipts at this location.. |
|
NATURE OF BUSINESS |
Total Payroll $ |
Enter the amount of the total annual payroll at this location. |
|
NATURE OF BUSINESS |
List Names of Owners/Operators |
List the names of the owners or operators other than applicant. |
|
NATURE OF BUSINESS |
# Visitors per Week |
Enter the average number of visitors the business receives each week. |
|
NATURE OF BUSINESS |
# Of Employees Full Time |
Enter the total number of full time staff. |
|
NATURE OF BUSINESS |
# Of Employees Part Time |
Enter the total number of part time staff. |
|
NATURE OF BUSINESS |
Business Opening Time |
Enter the normal opening time for the business. |
|
NATURE OF BUSINESS |
Business Closing Time |
Enter the normal closing time for the business. |
|
NATURE OF BUSINESS |
Description of Business |
This section is designed to tell the underwriter what business each applicant performs and the way it is conducted. The section should be completed in enough detail to enable the underwriter to understand and classify the business. |
|
NATURE OF BUSINESS |
# of Business Losses (Past 3 Years) |
Enter the number of losses associated with the business within the past three years. Enter the details of the losses on the ACORD 88 - Personal Insurance Application Applicant Information Section. |
|
PROPERTY COVERAGES |
Business Related Structure - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. |
|
PROPERTY COVERAGES |
Business Related Structure Deductible |
Enter the desired deductible. |
|
PROPERTY COVERAGES |
Business Related Structure -Valuation |
Value of the business property. |
|
PROPERTY COVERAGES |
Business Related Structure - Form Number |
Enter the form number used by the company. |
|
PROPERTY COVERAGES |
Business Related Structure - Form Date |
Enter the edition date of the form used by the company. |
|
PROPERTY COVERAGES |
Business Related Structure -Premium |
Enter the premium for this coverage. |
|
PROPERTY COVERAGES |
Business Personal Property - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. |
|
PROPERTY COVERAGES |
Business Personal Property -Deductible |
Enter the desired deductible. |
|
PROPERTY COVERAGES |
Business Personal Property -Valuation |
Value of the business personal property. |
|
PROPERTY COVERAGES |
Business Personal Property - Form Number |
Enter the form number used by the company. |
|
PROPERTY COVERAGES |
Business Personal Property - Form Date |
Enter the edition date of the form used by the company. |
|
PROPERTY COVERAGES |
Business Personal Property -Premium |
Enter the premium for this coverage. |
|
PROPERTY COVERAGES |
Property Other - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. |
|
PROPERTY COVERAGES |
Property Other - Deductible |
Enter the desired deductible. |
|
PROPERTY COVERAGES |
Property Other - Valuation |
Value of the business property. |
|
PROPERTY COVERAGES |
Property Other - Form Number |
Enter the form number used by the company. |
|
PROPERTY COVERAGES |
Property Other - Form Date |
Enter the edition date of the form used by the company. |
|
PROPERTY COVERAGES |
Property Other - Premium |
Enter the premium for this coverage. |
|
PROPERTY COVERAGES |
Property Other - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. |
|
PROPERTY COVERAGES |
Property Other - Deductible |
Enter the desired deductible. |
|
PROPERTY COVERAGES |
Property Other - Valuation |
Value of the business property. |
|
PROPERTY COVERAGES |
Property Other - Form Number |
Enter the form number used by the company. |
|
PROPERTY COVERAGES |
Property Other - Form Date |
Enter the edition date of the form used by the company. |
|
PROPERTY COVERAGES |
Property Other - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Combined Single Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Combined Single Limit - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Combined Single Limit - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Combined Single Limit - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Occurrence - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Occurrence - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Occurrence - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Occurrence - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Aggregate - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Aggregate - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Aggregate - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Bodily Injury & Prop Damage Aggregate - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Products/Compl. Operations Occurrence - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Products/Compl. Operations Occurrence - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Products/Compl. Operations Occurrence - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Products/Compl. Operations Occurrence - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Products/Compl. Operations -Aggregate Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Products/Compl. Operations -Aggregate Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Products/Compl. Operations -Aggregate Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Products/Compl. Operations -Aggregate Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Damage to Rented Premises -Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Damage to Rented Premises -Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Damage to Rented Premises -Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Damage to Rented Premises -Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Medical Expense Per Person -Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Medical Expense Per Person -Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Medical Expense Per Person -Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Medical Expense Per Person -Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Hired Auto - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Hired Auto - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Hired Auto - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Hired Auto - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Non-owned Auto - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Non-owned Auto - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Non-owned Auto - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Non-owned Auto - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Employee Benefits - Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Employee Benefits - Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Employee Benefits - Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Employee Benefits - Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Liability Other Coverage |
Use this space for a coverage not listed above. |
|
LIABILITY COVERAGES |
Liability Other Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Liability Other Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Liability Other Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Liability Other Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Liability Other Coverage |
Use this space for a coverage not listed above. |
|
LIABILITY COVERAGES |
Liability Other Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Liability Other Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Liability Other Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Liability Other Premium |
Enter the premium for this coverage. |
|
LIABILITY COVERAGES |
Liability Other Coverage |
Use this space for a coverage not listed above. |
|
LIABILITY COVERAGES |
Liability Other Limit |
List all limits as they will appear in the policy. Show limits in whole dollars. Several formats are included here for the collection of liability limits. Complete only those items that match the format of the program you are using to write the policy. |
|
LIABILITY COVERAGES |
Liability Other Form Number |
Enter the form number used by the company. |
|
LIABILITY COVERAGES |
Liability Other Form Date |
Enter the edition date of the form. |
|
LIABILITY COVERAGES |
Liability Other Premium |
Enter the premium for this coverage. |
|
DEDUCTIBLES |
Per Claim/Per Occurrence check boxes |
Enter if the coverage will be per claim. |
|
DEDUCTIBLES |
|
Enter if the coverage will be per claim or per occurrence. |
|
DEDUCTIBLES |
Property Damage |
Enter the desired deductible for property damage. |
|
DEDUCTIBLES |
Bodily Injury |
Enter the desired deductible for bodily injury. |
|
DEDUCTIBLES |
Other Deductible |
Enter the coverage that has an additional deductible. |
|
DEDUCTIBLES |
Other Deductible Amount |
Enter the additional deductible required. |
|
GENERAL INFORMATION |
1. Any business conducted at any other location? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe the business in detail. |
|
GENERAL INFORMATION |
|
If yes, describe the business in detail. |
|
GENERAL INFORMATION |
2. Do you lease to or from other employers? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe the extent of leasing. |
|
GENERAL INFORMATION |
|
If yes, describe the extent of leasing. |
|
GENERAL INFORMATION |
3. Any workers compensation carried? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, give company and policy number. |
|
GENERAL INFORMATION |
|
If yes, give company and policy number. |
|
GENERAL INFORMATION |
4. Do you rent or loan equipment to others? |
Enter Y for a "YES" response. Enter N for a "NO" response. Describe the types of equipment. |
|
GENERAL INFORMATION |
|
Describe the types of equipment. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Customer's identification number assigned by the agency. |
|
IDENTIFICATION SECTION |
Loc # |
Enter the location number of the risk's location as it appears on ACORD 88, Personal Insurance Application, Applicant Information Section. |
|
GENERAL INFORMATION (continued) |
5. Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, explain and provide the names of other entities and/or subsidiaries. |
|
GENERAL INFORMATION (continued) |
|
If yes, explain and provide the names of other entities and/or subsidiaries. |
|
6. Does the business involve the |
|
|
GENERAL INFORMATION (continued) |
use or storage of petroleum-based products, paint, fertilizer, pesticides or other hazardous material or pollutants? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe and include the amounts of such products and materials. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe and include the amounts of such products and materials. |
|
7. Has any applicant filed for |
|
|
GENERAL INFORMATION |
bankruptcy (Business or Personal) |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, provide date, |
|
(continued) |
in the last five (5) years? |
explanation and resolution. |
|
GENERAL INFORMATION (continued) |
|
If yes, provide date, explanation and resolution. |
|
8. Any products directly imported |
|
|
GENERAL INFORMATION |
or exported outside the U.S., |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe and include |
|
(continued) |
Puerto Rico or Canada? |
the products and countries involved. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe and include the products and countries involved. |
|
GENERAL INFORMATION (continued) |
9. Any products repackaged, modified or mixed? |
Enter Y for a "YES" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
GENERAL INFORMATION (continued) |
10. Any used items sold? |
Enter Y for a "YES" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
11. Do you distribute your |
|
|
GENERAL INFORMATION |
products or services by means of |
|
|
(continued) |
the internet? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
GENERAL INFORMATION |
12. Does your company maintain |
|
|
(continued) |
or support an internet website? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
GENERAL INFORMATION (continued) |
13. Does the business involve demonstration of any products? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
14. Is the business run from a |
|
|
distinctly separate area in the |
|
|
GENERAL INFORMATION |
residence from household |
|
|
(continued) |
activities? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
15. Are you or any resident a |
|
|
professional entertainer, athlete, |
|
|
media personality, state or federal |
|
|
GENERAL INFORMATION |
political figure? (Not applicable in |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. This |
|
(continued) |
NC) |
question cannot be asked in North Carolina. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
16. Other than computer systems |
|
|
or office equipment, do you install |
|
|
GENERAL INFORMATION |
or service any products off |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe the products |
|
(continued) |
premises? |
installed and/or the services provided. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe the products installed and/or the services provided. |
|
17. Are all exterior doors equipped |
|
|
GENERAL INFORMATION |
with deadbolt locks or comparable |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe the type(s) of |
|
(continued) |
slider locks? |
locks. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe the type(s) of locks. |
|
18. If a financial planner or |
|
|
consultant, do you have |
|
|
discretionary trading authority |
|
|
GENERAL INFORMATION |
and/or access to customers data |
|
|
(continued) |
and/or funds? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
GENERAL INFORMATION (continued) |
19. If involved in real estate, do you manage property for others? |
Enter Y for a "YES" response. Enter N for a "NO" response. If yes, describe. |
|
GENERAL INFORMATION (continued) |
|
If yes, describe. |
|
REMARKS |
Remarks |
Use this space for any additional remarks or comments. |
