|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 80 (2009/10) |
Homeowner Application |
The titile of the form. ACORD 80, Homeowner Application, is used in the underwriting process for the homeowners line of business. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION SECTION |
Contact Name |
Enter text: The name of the individual at the producer's establishment that is the primary contact. |
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IDENTIFICATION SECTION |
Phone No. |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
|
IDENTIFICATION SECTION |
Fax No. |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION SECTION |
E-Mail Address |
Enter text: The producer's contact person e-mail address. |
|
IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
|
IDENTIFICATION SECTION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
IDENTIFICATION SECTION |
Carrier |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. |
|
IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
|
IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
|
IDENTIFICATION SECTION |
Policy # |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
|
IDENTIFICATION SECTION |
Plan |
Enter code: The product code of the insurer for the policy. |
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IDENTIFICATION SECTION |
Facility Code |
Enter identifier: The identification code used by assigned risk plans, FAIR plans and other associations (only applicable in a few states). When using this field, also enter the name of the facility in the company or plan field. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Expiration Date |
Enter date: The date on which the terms and conditions of the policy will expire. |
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STATUS OF TRANSACTION |
New |
Check the box (if applicable): Indicates the response expected from the company is a new issued policy. |
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STATUS OF TRANSACTION |
Renew |
Check the box (if applicable): Indicates the response expected from the company is a renewed policy. |
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STATUS OF TRANSACTION |
Policy Change |
Check the box (if applicable): Indicates the policy is being submitted for a policy change. |
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STATUS OF TRANSACTION |
Other |
Check the box (if applicable): Indicates the response expected from the company is a policy other than those listed. |
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STATUS OF TRANSACTION |
Other Description |
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.). |
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STATUS OF TRANSACTION |
Policy Change Effective Date |
Enter date: The date the policy status becomes effective. This date is used for policy statuses of bound, change, and cancel. |
|
STATUS OF TRANSACTION |
Time |
Enter time: The time the policy status becomes effective. The time is used for policy statuses of bound, change, and cancel. |
|
STATUS OF TRANSACTION |
AM |
Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm. |
|
STATUS OF TRANSACTION |
PM |
Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or later. |
|
STATUS OF TRANSACTION |
Date agent last inspected property |
Enter date: The date the producer last inspected the structure. |
|
STATUS OF TRANSACTION |
How long have you known the applicant |
Enter text: The length of time the named insured has been known by the producer. |
|
APPLICANT INFORMATION |
Applicant's Name (First, Middle, Last) |
Enter text: The named insured's given name. |
|
APPLICANT INFORMATION |
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Enter text: The named insured's other given name initial. |
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APPLICANT INFORMATION |
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Enter text: The named insured's surname. |
|
APPLICANT INFORMATION |
Date of Birth |
Enter date: The date of birth of the insured. |
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APPLICANT INFORMATION |
Social Security # |
Enter identifier: The tax identifier of the named insured. |
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APPLICANT INFORMATION |
Marital Status |
Enter code: The insured's marital status. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other As used here, this field may not be utilized for policyholders applying for residential property insurance in CA. |
|
APPLICANT INFORMATION |
Applicant's Mailing Address |
Enter text: The named insured's mailing address line one. |
|
APPLICANT INFORMATION |
Address 2 |
Enter text: The named insured's mailing address line two. |
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APPLICANT INFORMATION |
City |
Enter text: The named insured's mailing address city name. |
|
APPLICANT INFORMATION |
State |
Enter code: The named insured's mailing address state or province code. |
|
APPLICANT INFORMATION |
Zip |
Enter code: The named insured's mailing address postal code. |
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APPLICANT INFORMATION |
Home |
Check the box (if applicable): Indicates the primary phone number is for a home phone. |
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APPLICANT INFORMATION |
Bus |
Check the box (if applicable): Indicates the primary phone number is for a business phone. |
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APPLICANT INFORMATION |
Cell |
Check the box (if applicable): Indicates the primary phone number is for a cell phone. |
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APPLICANT INFORMATION |
Primary Phone # |
Enter number: The named insured's primary phone number. |
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APPLICANT INFORMATION |
Home |
Check the box (if applicable): Indicates the secondary phone number is for a home phone. |
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APPLICANT INFORMATION |
Bus |
Check the box (if applicable): Indicates the secondary phone number is for a business phone. |
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APPLICANT INFORMATION |
Cell |
Check the box (if applicable): Indicates the phone number is for a cell phone. |
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APPLICANT INFORMATION |
Secondary Phone # |
Enter number: The named insured's secondary phone number. |
|
APPLICANT INFORMATION |
Primary e-mail address |
Enter text: The named insured's primary e-mail address. |
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APPLICANT INFORMATION |
Secondary e-mail address |
Enter text: The named insured's secondary e-mail address. |
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APPLICANT INFORMATION |
Years At Previous Address |
Enter number: The number of years at the previous address. |
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APPLICANT INFORMATION |
Previous Address |
Enter text: The first address line of the previous residence address. |
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APPLICANT INFORMATION |
Address Continued |
Enter text: The second address line of the previous residence. |
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APPLICANT INFORMATION |
City |
Enter text: The city of the previous residence. |
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APPLICANT INFORMATION |
State |
Enter code: The state or province code of the previous residence. |
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APPLICANT INFORMATION |
Zip |
Enter text: The postal code of the previous residence. |
|
APPLICANT INFORMATION |
Check if same as mailing Address |
Check the box (if applicable): Indicates the named insured's physical address is the same as the mailing address. |
|
APPLICANT INFORMATION |
Owned |
Check the box (if applicable): Indicates if the insured owns their current residence. |
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APPLICANT INFORMATION |
Rented |
Check the box (if applicable): Indicates if the insured rents their current residence. |
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APPLICANT INFORMATION |
Current Residence |
Enter text: The named insured's physical address line one. As used here, this is the current residence. |
|
APPLICANT INFORMATION |
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Enter text: The named insured's physical address line two. As used here, this is the current residence. |
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APPLICANT INFORMATION |
|
Enter text: The named insured's physical address city name. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter code: The named insured's physical address state or province code. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter code: The named insured's physical address postal code. As used here, this is the current residence. |
|
APPLICANT INFORMATION |
Date at Current Residence |
Enter date: The date insured moved into their current residence. (MM/DD/YYYY) |
|
APPLICANT INFORMATION |
Yrs with Current Employer |
Enter number: The number of years the named insured has been with their current employer. |
|
APPLICANT INFORMATION |
Applicant's Employer Name And Address |
Enter text: The employer name (business name if self-employed). |
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APPLICANT INFORMATION |
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Enter text: The first address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The second address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The city of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The state code of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The postal code of the employer's physical address. |
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APPLICANT INFORMATION |
Applicant's Occupation (State Nature of Business if Self-Employed) |
Enter text: The named insured's primary occupation or business activity. |
|
APPLICANT INFORMATION |
Years in Current Occupation |
Enter number: The number of years the named insured has been employed in their current occupation. |
|
APPLICANT INFORMATION |
Years with Previous Employer |
Enter number: The number of years the named insured has been with their previous employer. |
|
APPLICANT INFORMATION |
Co-Applicant's Name (First, Middle, Last) |
Enter text: The named insured's given name. |
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APPLICANT INFORMATION |
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Enter text: The named insured's other given name initial. |
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APPLICANT INFORMATION |
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Enter text: The named insured's surname. |
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APPLICANT INFORMATION |
Date of Birth |
Enter date: The date of birth of the insured. |
|
APPLICANT INFORMATION |
Social Security # |
Enter identifier: The tax identifier of the named insured. |
|
APPLICANT INFORMATION |
Marital Status |
Enter code: The insured's marital status. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other As used here, this field may not be utilized for policyholders applying for residential property insurance in CA. |
|
APPLICANT INFORMATION |
Check if same as Applicant |
Check the box (if applicable): Indicates the co-named insured's mailing address is the same as the named insured's mailing address. |
|
APPLICANT INFORMATION |
Co-Applicant's Address |
Enter text: The named insured's mailing address line one. |
|
APPLICANT INFORMATION |
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Enter text: The named insured's mailing address line two. |
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APPLICANT INFORMATION |
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Enter text: The named insured's mailing address city name. |
|
APPLICANT INFORMATION |
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Enter code: The named insured's mailing address state or province code. |
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APPLICANT INFORMATION |
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Enter code: The named insured's mailing address postal code. |
|
APPLICANT INFORMATION |
Home |
Check the box (if applicable): Indicates the primary phone number is for a home phone. |
|
APPLICANT INFORMATION |
Bus |
Check the box (if applicable): Indicates the primary phone number is for a business phone. |
|
APPLICANT INFORMATION |
Cell |
Check the box (if applicable): Indicates the primary phone number is for a cell phone. |
|
APPLICANT INFORMATION |
Primary Phone # |
Enter number: The named insured's primary phone number. |
|
APPLICANT INFORMATION |
Home |
Check the box (if applicable): Indicates the secondary phone number is for a home phone. |
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APPLICANT INFORMATION |
Bus |
Check the box (if applicable): Indicates the secondary phone number is for a business phone. |
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APPLICANT INFORMATION |
Cell |
Check the box (if applicable): Indicates the phone number is for a cell phone. |
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APPLICANT INFORMATION |
Secondary Phone # |
Enter number: The named insured's secondary phone number. |
|
APPLICANT INFORMATION |
Primary e-mail address |
Enter text: The named insured's primary e-mail address. |
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APPLICANT INFORMATION |
Secondary e-mail address |
Enter text: The named insured's secondary e-mail address. |
|
APPLICANT INFORMATION |
Yrs with Current Employer |
Enter number: The number of years the named insured has been with their current employer. |
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APPLICANT INFORMATION |
Co-Applicant's Employer Name And Address |
Enter text: The employer name (business name if self-employed). |
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APPLICANT INFORMATION |
|
Enter text: The first address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The second address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The city of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The state code of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The postal code of the employer's physical address. |
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APPLICANT INFORMATION |
Co-Applicant's Occupation (State Nature of Business if Self-Employed) |
Enter text: The named insured's primary occupation or business activity. |
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APPLICANT INFORMATION |
Years in Current Occupation |
Enter number: The number of years the named insured has been employed in their current occupation. |
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APPLICANT INFORMATION |
Years with Previous Employer |
Enter number: The number of years the named insured has been with their previous employer. |
|
COVERAGES / LIMITS OF LIABILITY |
Dwelling Limit |
Enter limit: The limit associated with dwelling coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Dwelling Premium |
Enter amount: The premium associated with dwelling coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Other Structures Limit |
Enter limit: The limit associated with other structures coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Other Structures Premium |
Enter amount: The premium associated with other structures coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Personal Property Limit |
Enter limit: The limit associated with personal property coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Personal Property Premiums |
Enter amount: The premium associated with personal property coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Loss of Use Limit |
Enter limit: The limit associated with loss of use coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Loss of Use Premiums |
Enter amount: The premium associated with loss of use coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Blanket Limit |
Enter limit: The limit associated with blanket coverage which includes dwelling, other structures, personal property, and loss of use). |
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COVERAGES / LIMITS OF LIABILITY |
Blanket Premium |
Enter amount: The premium associated with blanket coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Personal Liability Each Occurrence Limit |
Enter limit: The limit associated with personal liability each occurrence coverage. |
|
COVERAGES / LIMITS OF LIABILITY |
Personal Liability Each Occurrence Premium |
Enter amount: The premium associated with personal liability coverage. |
|
COVERAGES / LIMITS OF LIABILITY |
Medical Payments Each Person Limit |
Enter limit: The limit associated with medical payments each person coverage. |
|
COVERAGES / LIMITS OF LIABILITY |
Medical Payments Each Person Premium |
Enter amount: The premium associated with medical payments coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Coverage Description |
Enter text: The description of the coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Limit 1 |
Enter amount: The first limit associated with the coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Premium |
Enter amount: The premium for the coverage. |
|
COVERAGES / LIMITS OF LIABILITY |
Form # |
Enter code: Indicates the policy form being used (e.g. HO-2, HO-4, etc.) |
|
COVERAGES / LIMITS OF LIABILITY |
Replacement Cost - Full Value -Included |
Check the box (if applicable): Indicates that replacement cost full value coverage is included. |
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COVERAGES / LIMITS OF LIABILITY |
Max % |
Enter percentage: The maximum percentage of increased replacement cost selected in accordance with the company rules. |
|
COVERAGES / LIMITS OF LIABILITY |
Premium |
Enter amount: The premium for full value replacement cost coverage. |
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COVERAGES / LIMITS OF LIABILITY |
Replacement Cost - Dwelling -Included |
Check the box (if applicable): Indicates that replacement cost - dwelling coverage is included. |
|
COVERAGES / LIMITS OF LIABILITY |
Replacement Cost - Dwelling -Premium |
Enter amount: The premium for replacement cost - dwelling coverage. |
|
COVERAGES / LIMITS OF LIABILITY |
Replacement Cost - Contents -Included |
Check the box (if applicable): Indicates that replacement cost - contents coverage is included. |
|
COVERAGES / LIMITS OF LIABILITY |
Replacement Cost - Contents -Premium |
Enter amount: The premium for replacement cost - contents coverage. |
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DEDUCTIBLES |
Base Amount |
Enter deductible: The base deductible amount if the deductible is expressed as a dollar amount. |
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DEDUCTIBLES |
Base Percentage |
Enter percentage: The base percentage deductible if the deductible is expressed as a percentage. |
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DEDUCTIBLES |
Base Type |
Enter code: The deductible type (e.g. flat, percentage) for the base deductible. |
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DEDUCTIBLES |
Wind / Hail Amount |
Enter deductible: The wind/hail deductible amount if the deductible is expressed as a dollar amount. |
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DEDUCTIBLES |
Wind / Hail Percentage |
Enter percentage: The wind/hail percentage deductible if the deductible is expressed as a percentage. |
|
DEDUCTIBLES |
Wind / Hail Type |
Enter code: The deductible type (e.g. flat, percentage) for the wind/hail deductible. |
|
DEDUCTIBLES |
Theft Amount |
Enter deductible: The theft deductible amount if the deductible is expressed as a dollar amount. |
|
DEDUCTIBLES |
Theft Percentage |
Enter percentage: The theft percentage deductible if the deductible is expressed as a percentage. |
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DEDUCTIBLES |
Theft Type |
Enter code: The deductible type (e.g. flat, percentage) for the theft deductible. |
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DEDUCTIBLES |
Other |
Enter text: The coverage associated with the deductible you are entering. |
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DEDUCTIBLES |
Other Amount |
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount. |
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DEDUCTIBLES |
Other Percentage |
Enter percentage: The percentage deductible if the deductible is expressed as a percentage. |
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DEDUCTIBLES |
Other Type |
Enter code: The deductible type (e.g. flat, percentage) for the other deductible. |
|
DEDUCTIBLES |
Named Hurricane Amount |
Enter deductible: The named hurricane deductible amount if the deductible is expressed as a dollar amount. As used here, this is not applicable in North Carolina. |
|
DEDUCTIBLES |
Named Hurricane Percentage |
Enter percentage: The named hurricane percentage deductible if the deductible is expressed as a percentage. As used here, this is not applicable in North Carolina. |
|
DEDUCTIBLES |
Named Hurricane Type |
Enter code: The deductible type (e.g. flat, percentage) for the named hurricane deductible. As used here, this is not applicable in North Carolina. |
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DEDUCTIBLES |
Annual Hurricane Amount |
Enter deductible: The annual hurricane deductible amount if the deductible is expressed as a dollar amount. As used here, this is not applicable in North Carolina. |
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DEDUCTIBLES |
Annual Hurricane Percentage |
Enter percentage: The annual hurricane percentage deductible if the deductible is expressed as a percentage. As used here, this is not applicable in North Carolina. |
|
DEDUCTIBLES |
Annual Hurricane Type |
Enter code: The deductible type (e.g. flat, percentage) for the annual hurricane deductible. As used here, this is not applicable in North Carolina. |
|
DEDUCTIBLES |
Other |
Enter text: The coverage associated with the deductible you are entering. |
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DEDUCTIBLES |
Other Amount |
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount. |
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DEDUCTIBLES |
Other Percentage |
Enter percentage: The percentage deductible if the deductible is expressed as a percentage. |
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DEDUCTIBLES |
Other Type |
Enter code: The deductible type (e.g. flat, percentage) for the other deductible. |
|
DEDUCTIBLES |
Other |
Enter text: The coverage associated with the deductible you are entering. |
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DEDUCTIBLES |
Other Amount |
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount. |
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DEDUCTIBLES |
Other Percentage |
Enter percentage: The percentage deductible if the deductible is expressed as a percentage. |
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DEDUCTIBLES |
Other Type |
Enter code: The deductible type (e.g. flat, percentage) for the other deductible. |
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FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
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FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
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FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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PAYMENT PLAN |
Billing Account # |
Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number. |
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PAYMENT PLAN |
Deposit Amount $ |
Enter amount: The amount of the premium received as a deposit. |
|
PAYMENT PLAN |
Est Total Premium $ |
Enter amount: The estimated total cost amount of the policy. |
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PAYMENT PLAN |
Direct Bill - Policy |
Check the box (if applicable): Indicates if the policy is to be direct billed. |
|
PAYMENT PLAN |
Direct Bill - Acct |
Check the box (if applicable): Indicates if the account is to be direct billed. |
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PAYMENT PLAN |
Agency Bill |
Check the box (if applicable): Indicates if the policy is to be producer/agency billed. |
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PAYMENT PLAN |
Full Pay |
Check the box (if applicable): Indicates a full payment will be made on the policy. |
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PAYMENT PLAN |
Annual |
Check the box (if applicable): Indicates the policy will be paid annually. |
|
PAYMENT PLAN |
Semi-Annual |
Check the box (if applicable): Indicates the policy will be paid semi-annually. |
|
PAYMENT PLAN |
Quarterly |
Check the box (if applicable): Indicates the policy will be paid quarterly. |
|
PAYMENT PLAN |
Bi-Monthly |
Check the box (if applicable): Indicates the policy will be paid bi-monthly. |
|
PAYMENT PLAN |
Monthly |
Check the box (if applicable): Indicates the policy will be paid monthly. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -Quarterly, etc.). |
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PAYMENT PLAN |
Payment Method - Cash |
Check the box (if applicable): Indicates the invoice will be paid in cash. |
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PAYMENT PLAN |
Check |
Check the box (if applicable): Indicates the invoice will be paid by check. |
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PAYMENT PLAN |
Credit Card |
Check the box (if applicable): Indicates the invoice will be paid by credit card. As used here, this is not applicable in North Carolina. |
|
PAYMENT PLAN |
EFT |
Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer (EFT). |
|
PAYMENT PLAN |
Payroll Deduction |
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction. |
|
PAYMENT PLAN |
Pre-authorization Draft/Check (PAC) |
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or draft. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the invoice will be paid by a means other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter text: The method the invoice will be paid. |
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PAYMENT PLAN |
Agent |
Check the box (if applicable): Indicates if the policy paper should be sent to the producer. |
|
PAYMENT PLAN |
Insured |
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the named insured. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the agent or applicant. |
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PAYMENT PLAN |
Other Description |
Enter text: The description of whom the policy paper should be mailed to. |
|
PAYMENT PLAN |
Payor Insured |
Check the box (if applicable): Indicates the payor of the policy is the insured. |
|
PAYMENT PLAN |
Mortgagee |
Check the box (if applicable): Indicates the payor of the policy is the mortgagee. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the payor of the policy is other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter text: The description of the payor of the policy. |
|
PAYMENT PLAN |
Premium Financed? Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the premium has been financed. |
|
PAYMENT PLAN |
Finance Company |
Enter text: The name of the company financing the premium, if applicable. |
|
RATING / UNDERWRITING |
Masonry Veneer (checkbox) |
Check the box (if applicable): Indicates the construction of the structure is masonry veneer. |
|
RATING / UNDERWRITING |
Percent Masonry Veneer (checkbox) |
Enter percentage: The percentage of the structure that is masonry veneer. |
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RATING / UNDERWRITING |
Frame (checkbox) |
Check the box (if applicable): Indicates the construction of the structure is frame. |
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RATING / UNDERWRITING |
Percent Frame |
Enter percentage: The percentage of the structure that is frame. |
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RATING / UNDERWRITING |
Masonry (checkbox) |
Check the box (if applicable): Indicates the construction of the structure is masonry. |
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RATING / UNDERWRITING |
Percent Masonry |
Enter percentage: The percentage of the structure that is masonry. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the construction of the structure is other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive |
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RATING / UNDERWRITING |
Percent Other |
Enter percentage: The percentage of the structure that is other than those types listed. |
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RATING / UNDERWRITING |
Aluminum Siding (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is aluminum. |
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RATING / UNDERWRITING |
Percent Aluminum Siding |
Enter percentage: The percentage of the structure that is sided in aluminum. |
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RATING / UNDERWRITING |
Stucco (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is stucco. |
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RATING / UNDERWRITING |
Percent Stucco |
Enter percentage: The percentage of the structure that is sided in stucco. |
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RATING / UNDERWRITING |
Vinyl Siding / Plastic (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic. |
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RATING / UNDERWRITING |
Percent Vinyl Siding / Plastic |
Enter percentage: The percentage of the structure that is sided in vinyl or plastic. |
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RATING / UNDERWRITING |
Cedar Wood Shingle (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is cedar or wood shingle. |
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RATING / UNDERWRITING |
Percent Cedar Wood Shingle |
Enter percentage: The percentage of the structure that is sided in cedar or wood shingle. |
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RATING / UNDERWRITING |
EIFSCB (on Cinder Block) (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and finishing system on cinder block (EIFSCB). |
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RATING / UNDERWRITING |
Percent EIFSCB (on Cinder Block) |
Enter percentage: The percentage of the structure that is sided in exterior insulation and finishing system on cinder block (EIFSCB) |
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RATING / UNDERWRITING |
EIFSS (on Studs) (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and finishing system on studs (EIFSS). |
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RATING / UNDERWRITING |
Percent EIFSS (on Studs) |
Enter percentage: The percentage of the structure that is sided in exterior insulation and finishing system on studs (EIFSS). |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the siding on the structure is other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The type of siding on the structure. |
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RATING / UNDERWRITING |
Percent Other Siding |
Enter percentage: The percentage of the structure that is sided in other than the those types listed. |
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RATING / UNDERWRITING |
Year EIFS Installed |
Enter year: The year the EIFS (exterior insulation and finishing system) was installed. |
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RATING / UNDERWRITING |
Primary (checkbox) |
Check the box (if applicable): Indicates that this is the primary residence. |
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RATING / UNDERWRITING |
Secondary (checkbox) |
Check the box (if applicable): Indicates that this is a secondary residence. |
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RATING / UNDERWRITING |
Seasonal (checkbox) |
Check the box (if applicable): Indicates that this is a seasonal residence. |
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RATING / UNDERWRITING |
Farm (checkbox) |
Check the box (if applicable): Indicates the residence is a farm. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the usage of the residence is other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The description of the usage of the residence. |
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RATING / UNDERWRITING |
Builders Risk (checkbox) |
Check the box (if applicable): Indicates the structure is new construction (builders risk). |
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RATING / UNDERWRITING |
Renovation (checkbox) |
Check the box (if applicable): Indicates the structure is being renovated. |
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RATING / UNDERWRITING |
Reconstruction (checkbox) |
Check the box (if applicable): Indicates the structure is being reconstructed. |
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RATING / UNDERWRITING |
Owner (checkbox) |
Check the box (if applicable): Indicates the residence is occupied by the owner. |
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RATING / UNDERWRITING |
Tenant (checkbox) |
Check the box (if applicable): Indicates the residence is occupied by tenants. |
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RATING / UNDERWRITING |
Unoccupied (checkbox) |
Check the box (if applicable): Indicates the residence is unoccupied. |
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RATING / UNDERWRITING |
Vacant (checkbox) |
Check the box (if applicable): Indicates the residence is vacant. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the residence is occupied by other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The description of the inhabitants of the residence. |
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RATING / UNDERWRITING |
Residence Type- Dwelling (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is a dwelling. |
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RATING / UNDERWRITING |
Apartment (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is an apartment. |
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RATING / UNDERWRITING |
Condominium (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is a condominium. |
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RATING / UNDERWRITING |
Townhouse (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is a townhouse. |
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RATING / UNDERWRITING |
Rowhouse (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is a row house. |
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RATING / UNDERWRITING |
Co-Op (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is a cooperative. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the type of residence being insured is other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The description of the type of residence (e.g. apartment, condominium, etc.). |
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RATING / UNDERWRITING |
Housekeeping Condition -Excellent (checkbox) |
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is excellent. |
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RATING / UNDERWRITING |
Good (checkbox) |
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is good. |
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RATING / UNDERWRITING |
Average (checkbox) |
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is average. |
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RATING / UNDERWRITING |
Below Average (checkbox) |
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is below average. |
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RATING / UNDERWRITING |
Plumbing Condition -Excellent (checkbox) |
Check the box (if applicable): Indicates the plumbing system condition is excellent. |
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RATING / UNDERWRITING |
Good (checkbox) |
Check the box (if applicable): Indicates the plumbing system condition is good. |
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RATING / UNDERWRITING |
Average (checkbox) |
Check the box (if applicable): Indicates the plumbing system condition is average. |
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RATING / UNDERWRITING |
Below Average (checkbox) |
Check the box (if applicable): Indicates the plumbing system condition is below average. |
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RATING / UNDERWRITING |
Any Known Leaks? (Y / N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates there are known leaks in the plumbing system. |
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RATING / UNDERWRITING |
Roof Condition - Excellent (checkbox) |
Check the box (if applicable): Indicates the condition of the roof is excellent. |
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RATING / UNDERWRITING |
Good (checkbox) |
Check the box (if applicable): Indicates the condition of the roof is good. |
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RATING / UNDERWRITING |
Average (checkbox) |
Check the box (if applicable): Indicates the condition of the roof is average. |
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RATING / UNDERWRITING |
Below Average (checkbox) |
Check the box (if applicable): Indicates the condition of the roof is below average. |
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RATING / UNDERWRITING |
Roof Material |
Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle |
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RATING / UNDERWRITING |
Distance To Tidal Water |
Enter number: The distance to the nearest tidal water. |
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RATING / UNDERWRITING |
Miles (checkbox) |
Check the box (if applicable): Indicates the distance to tidal water entered is in miles. |
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RATING / UNDERWRITING |
Feet (checkbox) |
Check the box (if applicable): Indicates the distance to tidal water entered is in feet. |
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RATING / UNDERWRITING |
Purchase Price |
Enter amount: The purchase price of the residence. |
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RATING / UNDERWRITING |
Purchase Date |
Enter date: The date the residence was purchased, (MM/DD/YYYY). |
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RATING / UNDERWRITING |
Security - Visible from road (checkbox) |
Check the box (if applicable): Indicates the structure is visible from the road. |
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RATING / UNDERWRITING |
Visible to neighbors (checkbox) |
Check the box (if applicable): Indicates the structure is visible from another dwelling that is occupied during the day. |
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RATING / UNDERWRITING |
Occupied Daily (checkbox) |
Check the box (if applicable): Indicates the residence usually has an adult home during the day. |
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RATING / UNDERWRITING |
Protection Device Type - Central / Smoke |
Check the box (if applicable): Indicates the smoke alarm notifies an outside service that in turn reports to the appropriate policy or fire station. |
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RATING / UNDERWRITING |
Central / Temp |
Check the box (if applicable): Indicates the temperature alarm reports to an outside service that in turn reports to the appropriate police or fire station. |
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RATING / UNDERWRITING |
Central / Burglar |
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company. |
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RATING / UNDERWRITING |
Direct / Smoke |
Check the box (if applicable): Indicates the smoke alarm reports directly to the appropriate fire station. |
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RATING / UNDERWRITING |
Direct / Temp |
Check the box (if applicable): Indicates the temperature alarm reports directly to the appropriate fire station. |
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RATING / UNDERWRITING |
Direct / Burglar |
Check the box (if applicable): Indicates the burglar alarm reports directly to the appropriate police station. |
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RATING / UNDERWRITING |
Local / Smoke |
Check the box (if applicable): Indicates that the smoke alarm sounds or appears on the premises. |
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RATING / UNDERWRITING |
Local / Temp |
Check the box (if applicable): Indicates the temperature alarm sounds or appears on the premises. |
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RATING / UNDERWRITING |
Local / Burglar |
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the premises. |
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RATING / UNDERWRITING |
Distance to Hydrant Feet |
Enter number: The distance in feet from the nearest hydrant that supports the protection class used. |
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RATING / UNDERWRITING |
Distance to Fire Station Miles |
Enter number: The distance in miles from the nearest fire station that supports the protection class used. |
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RATING / UNDERWRITING |
# of Fire Divisions |
Enter number: The number of fire divisions in the building. |
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RATING / UNDERWRITING |
# Units Fire Div |
Enter number: The number of units within a fire division. |
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RATING / UNDERWRITING |
Deadbolt (checkbox) |
Check the box (if applicable): Indicates that all exterior entry doors are fitted with deadbolt locks. |
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RATING / UNDERWRITING |
Spring (checkbox) |
Check the box (if applicable): Indicates that all exterior entry doors are fitted with spring locks. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates that all exterior entry doors are fitted with locks other than those listed. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The type of locks on exterior entry doors. |
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RATING / UNDERWRITING |
Sprinkler: Partial (checkbox) |
Check the box (if applicable): Indicates the building is equipped with a partial fire sprinkler system. |
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RATING / UNDERWRITING |
Full (checkbox) |
Check the box (if applicable): Indicates the building is equipped with a full fire sprinkler system. |
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RATING / UNDERWRITING |
Prot Class |
Enter code: The fire rating protection class for this location. Note: 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. |
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RATING / UNDERWRITING |
Fire Extinguisher (Y / N): |
Enter Y for a “Yes” response. Input N for “No” response. Indicate if the residence is equipped with fire extinguisher(s). |
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RATING / UNDERWRITING |
Territory |
Enter code: The industry or company specific code that identifies the rating territory for this item. The source of this code is individual insurer, Insurance Services Office or State Insurance Department manuals. |
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RATING / UNDERWRITING |
Fire District Name |
Enter text: The property's fire district name. |
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RATING / UNDERWRITING |
Fire District Code |
Enter code: The property's fire district code number which can be found in the individual states manual pages. |
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RATING / UNDERWRITING |
Primary Heat |
Enter text: The primary type of fuel/power used for heating. |
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RATING / UNDERWRITING |
None (checkbox) |
Check the box (if applicable): Indicates the residence has no primary heat source. |
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RATING / UNDERWRITING |
Secondary: |
Enter text: The secondary type of fuel/power used for heating. |
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RATING / UNDERWRITING |
None (checkbox) |
Check the box (if applicable): Indicates the residence has no secondary heat source. |
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RATING / UNDERWRITING |
Date Heating System Last Serviced |
Enter date: The date (MM/DD/YYYY) the heating system was last serviced. |
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RATING / UNDERWRITING |
Copper (checkbox) |
Check the box (if applicable): Indicates the residence has copper wiring. |
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RATING / UNDERWRITING |
Aluminum (checkbox) |
Check the box (if applicable): Indicates the residence has aluminum wiring. |
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RATING / UNDERWRITING |
Knob & Tube (checkbox) |
Check the box (if applicable): Indicates the residence has knob and tube wiring. |
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RATING / UNDERWRITING |
Last Inspected Date |
Enter date: The date the wiring was last inspected. |
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RATING / UNDERWRITING |
Circuit Breakers (checkbox) |
Check the box (if applicable): Indicates the electrical panel uses circuit breakers. |
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RATING / UNDERWRITING |
Fuses (checkbox) |
Check the box (if applicable): Indicates the electrical panel uses fuses. |
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RATING / UNDERWRITING |
Number of Amps |
Enter number: The electrical capacity of the wiring in amperes (amps). |
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RATING / UNDERWRITING |
Year Built |
Enter year: The year the structure was built (YYYY). |
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RATING / UNDERWRITING |
Market Value ($) |
Enter amount: The current market value for which the residence could be sold. |
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RATING / UNDERWRITING |
Replacement Cost ($) |
Enter amount: The estimated total dollar amount required to rebuild the residence without depreciation. |
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RATING / UNDERWRITING |
Total Living Area Sq Ft |
Enter number: The residence's total square footage of living area (excluding basements). |
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RATING / UNDERWRITING |
Basement Area |
Enter number: The residence's total square footage of the basement. |
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RATING / UNDERWRITING |
Garage Area |
Enter number: The residence's total square footage of the garage. |
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RATING / UNDERWRITING |
Breezeway Area |
Enter number: The residence's total square footage of the breezeway. |
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RATING / UNDERWRITING |
# Rooms |
Enter number: The total number of rooms in the residence, including full and half bathrooms. |
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RATING / UNDERWRITING |
# Apartments |
Enter number: The number of separate living units in structure. |
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RATING / UNDERWRITING |
# Weeks Rented |
Enter number: The number of weeks the residence is occupied or rented to others. |
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RATING / UNDERWRITING |
# Families |
Enter number: The number of separate family units in the dwelling. |
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RATING / UNDERWRITING |
# Household Residents |
Enter number: The number of residents in the household. |
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RATING / UNDERWRITING |
Tax Code |
Enter code: The code which normally represents the location for which a surcharge is being applied (city, county or state). |
|
RATING / UNDERWRITING |
Bldg Code Grade |
Enter code: The industry code used to collect the building code effectiveness grade code. The source of this code list is public protection classification or individual insurer rating manuals. |
|
RATING / UNDERWRITING |
Building Code Grade - Inspected Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicate if the structure has been inspected specific to its Building Code effectiveness grade. |
|
RATING / UNDERWRITING |
Fireplaces - Chimneys |
Enter number: The total number of outside and inside chimneys in the residence. As used here, enter '0' for none. |
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RATING / UNDERWRITING |
Hearths |
Enter number: The total number of hearths in the residence. As used here, enter '0' for none. |
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RATING / UNDERWRITING |
Pre-Fab |
Enter number: The total number of prefabricated fireplaces in the residence. As used here, enter '0' for none. |
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RATING / UNDERWRITING |
Wood stove insert |
Enter number: The total number of wood stove inserts in the residence. As used here, enter '0' for none. |
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RATING / UNDERWRITING |
Rating Credits - Non-Smoker (checkbox) |
Check the box (if applicable): Indicates that a non-smoking rating credit may apply to the location. |
|
RATING / UNDERWRITING |
Manned Security (checkbox) |
Check the box (if applicable): Indicates that a manned security rating credit may apply to the location. |
|
RATING / UNDERWRITING |
Lightning Protection (checkbox) |
Check the box (if applicable): Indicates that a lightning protection rating credit may apply to the location. |
|
RATING / UNDERWRITING |
Off Premises Theft Exclusion (checkbox) |
Check the box (if applicable): Indicates that an off premises theft exclusion rating credit may apply to the location. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates that other rating credits may apply to the location. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The description of the other rating credits that may apply. |
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RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates that other rating credits may apply to the location. |
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RATING / UNDERWRITING |
Other Description |
Enter text: The description of the other rating credits that may apply. |
|
RATING / UNDERWRITING |
Swimming Pool - None (checkbox) |
Check the box (if applicable): Indicates there is no swimming pool on the premises. |
|
RATING / UNDERWRITING |
Above ground (checkbox) |
Check the box (if applicable): Indicates the swimming pool is above ground. |
|
RATING / UNDERWRITING |
In-Ground (checkbox) |
Check the box (if applicable): Indicates the swimming pool is in the ground. |
|
RATING / UNDERWRITING |
Approved Fence (checkbox) |
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an approved height. |
|
RATING / UNDERWRITING |
Diving Board (checkbox) |
Check the box (if applicable): Indicates the swimming pool has a diving board. |
|
RATING / UNDERWRITING |
Slide (checkbox) |
Check the box (if applicable): Indicates the swimming pool has a slide. |
|
RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates there is additional information to describe the pool. |
|
RATING / UNDERWRITING |
Other Description (checkbox) |
Enter text: The additional information to describe the swimming pool. |
|
RATING / UNDERWRITING |
Dwelling Location - In City Limits (checkbox) |
Check the box (if applicable): Indicates the residence is within the city limits. |
|
RATING / UNDERWRITING |
In Fire District (checkbox) |
Check the box (if applicable): Indicates the residence is within a fire district. |
|
RATING / UNDERWRITING |
In Protected Suburb (checkbox) |
Check the box (if applicable): Indicates the residence is within a protected suburb. |
|
RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the residence is other than those listed. |
|
RATING / UNDERWRITING |
Other Description |
Enter text: The description of the residence location. |
|
RATING / UNDERWRITING |
Rating- Class (checkbox) |
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is class rating. |
|
RATING / UNDERWRITING |
Specific (checkbox) |
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is specific rating. |
|
RATING / UNDERWRITING |
Foundation - Open (checkbox) |
Check the box (if applicable): Indicates the foundation of the structure is open. |
|
RATING / UNDERWRITING |
Closed (checkbox) |
Check the box (if applicable): Indicates the foundation of the structure is closed. |
|
RATING / UNDERWRITING |
None (checkbox) |
Check the box (if applicable): Indicates there is no foundation on the structure. |
|
RATING / UNDERWRITING |
Fuel Storage Tank - None (checkbox) |
Check the box (if applicable): Indicates there is no fuel storage tank on the premises. |
|
RATING / UNDERWRITING |
Indoors, Above ground masonry floor (checkbox) |
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground on a masonry floor. |
|
RATING / UNDERWRITING |
Indoors, Above ground no masonry floor (checkbox) |
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground not on a masonry floor. |
|
RATING / UNDERWRITING |
Outdoors, Above ground (checkbox) |
Check the box (if applicable): Indicates the fuel storage tank is outdoors and above ground. |
|
RATING / UNDERWRITING |
Outdoors, Below ground (checkbox) |
Check the box (if applicable): Indicates the fuel storage tank is outdoors and below ground. |
|
RATING / UNDERWRITING |
Fuel Line Location - Underground (checkbox) |
Check the box (if applicable): Indicates the fuel line is underground. |
|
RATING / UNDERWRITING |
Through foundation (checkbox) |
Check the box (if applicable): Indicates the fuel line goes through the foundation. |
|
RATING / UNDERWRITING |
Renovations - Wiring - Part |
Check the box (if applicable): Indicates if partial wiring improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Wiring - Complete |
Check the box (if applicable): Indicates if complete wiring improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Wiring - Year |
Enter year: The year the wiring improvements took place. |
|
RATING / UNDERWRITING |
Plumbing - Part |
Check the box (if applicable): Indicates if partial plumbing improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Plumbing - Complete |
Check the box (if applicable): Indicates if complete plumbing improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Plumbing - Year |
Enter year: The year the plumbing improvements took place. |
|
RATING / UNDERWRITING |
Heating - Part |
Check the box (if applicable): Indicates if partial heating improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Heating - Complete |
Check the box (if applicable): Indicates if complete heating improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Heating - Year |
Enter year: The year the heating improvements took place. |
|
RATING / UNDERWRITING |
Roofing - Part |
Check the box (if applicable): Indicates if partial roofing improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Roofing - Complete |
Check the box (if applicable): Indicates if complete roofing improvements have been made since the original construction. |
|
RATING / UNDERWRITING |
Roofing - Year |
Enter year: The year the roofing improvements took place. |
|
RATING / UNDERWRITING |
Exterior Paint - Year |
Enter year: The year the exterior of the structure was last painted. |
|
RATING / UNDERWRITING |
Wind Class - Resistive (checkbox) |
Check the box (if applicable): Indicates the wind class is resistive. |
|
RATING / UNDERWRITING |
Semi-resistive (checkbox) |
Check the box (if applicable): Indicates the wind class is semi-resistive. |
|
RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the wind class is other than those listed. |
|
RATING / UNDERWRITING |
Other Description. |
Enter text: The description of the wind class when "other" has been checked. |
|
RATING / UNDERWRITING |
Storm Shutters - A (checkbox) |
Check the box (if applicable): Indicates the wind storm shutters are a class that provides protection from wind and debris. |
|
RATING / UNDERWRITING |
B (checkbox) |
Check the box (if applicable): Indicates the wind storm shutters are a class that provides protection from wind only. |
|
RATING / UNDERWRITING |
Other (checkbox) |
Check the box (if applicable): Indicates the wind storm shutters are a class other than those listed. |
|
RATING / UNDERWRITING |
Other Description |
Enter text: The description of the wind storm shutter class. |
|
RATING / UNDERWRITING |
Hurricane Resistive Glass (checkbox) |
Check the box (if applicable): Indicates the glass is resistive to hurricanes. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
|
LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
|
LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
|
LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
|
LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
|
LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
|
LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
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LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
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LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
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LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
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LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
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LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
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PRIOR COVERAGE |
No Prior Coverage |
Check the box (if applicable): Indicates there was no prior coverage. |
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PRIOR COVERAGE |
Prior Carrier |
Enter text: The name of the previous insurer. |
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PRIOR COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
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PRIOR COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
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PRIOR COVERAGE |
Prior Carrier |
Enter text: The name of the previous insurer. |
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PRIOR COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
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PRIOR COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
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LOSS HISTORY |
Any Losses, whether or not paid by insurance, during the last__years, at this or at any other location? |
Enter number: The number of years of loss information required by the insurer. |
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LOSS HISTORY |
Any Losses at this or at any other location? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if there have been any losses at any location, whether paid or not paid by insurance, in the last mandated number of years. |
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LOSS HISTORY |
Applicant's Initials |
Initial here: The named insured's initials. |
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LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
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LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
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LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
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LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
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LOSS HISTORY |
Amount Paid ($) |
Enter amount: The amount that has been paid on this claim to date. |
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LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
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LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
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LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
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LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
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LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
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LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
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LOSS HISTORY |
Amount Paid ($) |
Enter amount: The amount that has been paid on this claim to date. |
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LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
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LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
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LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
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LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
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LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
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LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
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LOSS HISTORY |
Amount Paid ($) |
Enter amount: The amount that has been paid on this claim to date. |
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LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
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LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
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LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
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LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
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LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
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LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
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LOSS HISTORY |
Amount Paid ($) |
Enter amount: The amount that has been paid on this claim to date. |
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LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
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LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Premises Liability Extension - # Premises |
Enter number: The number of premises covered by the additional premises liability extension. This is used when you don't have the full detail about the individual locations. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium ($) |
Enter amount: The premium associated with additional premises liability extension. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loc # |
Enter number: The producer assigned location number for the premises covered by additional premises liability extension. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Terr: |
Enter code: The liability territory for the location specified. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium ($) |
Enter amount: The premium associated with additional premises liability extension. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loc # |
Enter number: The producer assigned location number for the premises covered by additional premises liability extension. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Terr: |
Enter code: The liability territory for the location specified. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium ($) |
Enter amount: The premium associated with additional premises liability extension. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Additional Residence Rented To Others - # of Premises |
Enter number: The number of premises covered by the additional residence rented to others. This is used when you don't have the full detail about the individual locations. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Med Pay (Y / N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if medical payments coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for additional residence rented to others coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loc # |
Enter number: The producer assigned location number for the premises covered by additional residence rented to others. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Med Pay (Y / N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if medical payments coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
# Families |
Enter number: The number of families of the additional residence rented to others . |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Terr: |
Enter code: The liability territory for the location specified. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for additional residence rented to others coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loc # |
Enter number: The producer assigned location number for the premises covered by additional residence rented to others. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Med Pay (Y / N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if medical payments coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
# Families |
Enter number: The number of families of the additional residence rented to others . |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Terr: |
Enter code: The liability territory for the location specified. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for additional residence rented to others coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Theft of building Materials Included (checkbox) |
Check the box (if applicable): Indicates the builders risk theft of building materials coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for builders risk theft of building materials coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for builders risk theft of building materials coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Builders Risk Only - Collapse due to hydro-static pressure - Included |
Check the box (if applicable): Indicates the builders risk collapse due to hydro-static pressure coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for builders risk collapse due to hydro-static pressure. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for builders risk collapse due to hydro-static pressure. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Building Ordinance or Law Coverage - Aggregate Limit |
Enter limit: The aggregate limit for building ordinance or law coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increase Limit |
Enter limit: The increased limit for building ordinance or law coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Included (checkbox) |
Check the box (if applicable): Indicates the building ordinance or law coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Rebuild % |
Enter percentage: The rebuild percentage for building ordinance or law coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for building ordinance or law coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Business Property At Home -Included |
Check the box (if applicable): Indicates the business property at home coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for business property at home coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for business property at home coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Business Property Away From Home - Included |
Check the box (if applicable): Indicates the business property away from home coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for business property away from home coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for business property away from home coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Debris Removal - Included |
Check the box (if applicable): Indicates the debris removal coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for debris removal coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for debris removal coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - % Ded |
Enter percentage: The percentage deductible for earthquake coverage if the deductible is expressed as a percentage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - Deductible Amount |
Enter deductible: The deductible amount for earthquake coverage if the deductible is expressed in dollars. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - Territory |
Enter code: The earthquake zone (territory) associated with the coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - Retrofit Type |
Enter text: The type of earthquake retrofit for the residence. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - % Masonry Veneer |
Enter percentage: The percentage of construction that is masonry veneer. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Earthquake - Premium |
Enter amount: The premium for earthquake coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Employers Liability Limit |
Enter limit: The limit amount for employers liability coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Employers Liability - # of Employees |
Enter number: The number of employees associated with employers liability coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Employers Liability - Premium |
Enter amount: The premium for employers liability coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fire Department Service Charge -Included (checkbox) |
Check the box (if applicable): Indicates the fire department service charge coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for fire department surcharge coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Flood - Building Limit |
Enter limit: The building limit for flood coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Flood - Contents Limit |
Enter limit: The contents limit for flood coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Flood - Premium |
Enter amount: The premium for flood coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fungus and Mold - Excl Liability |
Check the box (if applicable): Indicates that liability is excluded from fungus and mold coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fungus and Mold - Excl Prop Damage |
Check the box (if applicable): Indicates that property damage is excluded from fungus and mold coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fungus and Mold - Property |
Enter limit: The property limit for fungus and mold coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fungus and Mold - Liability |
Enter limit: The liability limit for fungus and mold coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Fungus and Mold - Premium |
Enter amount: The premium for fungus and mold coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts Included (checkbox) |
Check the box (if applicable): Indicates the golf cart liability coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts - # of Golf Carts |
Enter number: The number of golf carts to be covered. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts - Description |
Enter text: The description of the golf carts. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts - Premium |
Enter amount: The premium for golf cart liability coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts - Physical Damage -Limit |
Enter limit: The limit for golf cart physical damage coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Golf Carts - Physical Damage -Premium |
Enter amount: The premium for golf cart physical damage coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Identity Fraud Expense - Included (checkbox) |
Check the box (if applicable): Indicates identity fraud expense coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Identity Fraud Expense - Limit |
Enter limit: The limit for identity fraud expense coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Identity Fraud Expense - Premium |
Enter amount: The premium for identity fraud expense coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Incidentals Farming Pers Liab -Medical Payments |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if medical payments is included in the incidental farming personal liability coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Incidentals Farming Pers Liab -Premium |
Enter amount: The premium for incidental farming coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability Limits - Electrical Apparatus In and Out Of Vehicle - Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit - electronic apparatus in and out of vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit -electronic apparatus in and out of vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit - electronic apparatus in and out of vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability Limits - Electrical Apparatus In Vehicle -Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit - electronic apparatus in vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit -electronic apparatus in vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit - electronic apparatus in vehicle. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability -Guns - Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit - guns. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit -guns. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit - guns. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability -Money - Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit - money. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit -money. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit - money. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability -Securities - Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit - securities. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit -securities. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit - securities. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Cov C Special Liability -Silverware - Total Limit |
Enter limit: The total limit amount for increased coverage c special liability limit -silverware. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Increased Limit |
Enter limit: The increased limit amount for increased coverage c special liability limit silverware. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for increased coverage c special liability limit -silverware. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Inflation Guard - Percentage Increase |
Enter percentage: The increase percentage for inflation guard coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Inflation Guard Premium |
Enter amount: The premium for inflation guard coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loss Assessment - Limit |
Enter limit: The limit amount for loss assessment coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Loss Assessment - Premium |
Enter amount: The premium for loss assessment coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Mine Subsidence - Limit |
Enter limit: The limit for mine subsidence coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Mine Subsidence - Const Material |
Enter code: The type of construction material. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Mine Subsidence - Property Desc |
Enter text: The description of the property. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Mine Subsidence - Premium |
Enter amount: The premium for mine subsidence coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Office, Professional Private School, Studio - Residence Premises - Requires Incr Contents (checkbox) |
Check the box (if applicable): Indicates that increased contents is required for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Office, Professional Private School, Studio - Residence Premises - Incr Contents Limit |
Enter limit: The increased contents limit for office, professional private school, studio -residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Incr Cont Not Required (checkbox) |
Check the box (if applicable): Indicates that increased contents is not required for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Other Structures |
Enter limit: The other structures limit for office, professional private school, studio -residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Med Pay |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if medical payments is included in the office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Territory |
Enter code: The territory for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Structure Type |
Enter code: The type of structure for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Business / Structure Description |
Enter text: The description of the business or structure for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for office, professional private school, studio - residence premises coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Other Structures - Individual Structure - Limit |
Enter limit: The limit for other structures - individual structure coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Structure Desc |
Enter text: The description of the individual structure for other structures - individual structure coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for other structures - individual structure coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Plants, Shrubs & Trees - Included (checkbox) |
Check the box (if applicable): Indicates that plants, shrubs and trees coverage is included. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Plants, Shrubs & Trees - Limit |
Enter limit: The limit for plants, shrubs and trees coverage. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Plants, Shrubs & Trees - Premium |
Enter amount: The premium for plants, shrubs and trees coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Refrigerated Food Products -Included |
Check the box (if applicable): Indicates that refrigerated food products coverage is included. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Refrigerated Food Products - Limit |
Enter amount: The limit for refrigerated food products coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Refrigerated Food Products -Premium |
Enter amount: The premium for refrigerated food products coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Sink Hole Collapse - Included |
Check the box (if applicable): Indicates sink hole collapse coverage is included. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Sink Hole Collapse - Premium |
Enter amount: The premium for sink hole collapse. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Unit-Owners Additions & Alterations Special Coverage -Included |
Check the box (if applicable): Indicates unit owners additions and alterations special coverage is included. |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for unit owners additions and alterations special coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for unit owners additions and alterations special coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Unscheduled Jewelry, Watches, Furs - Aggregate |
Enter limit: The aggregate limit for unscheduled jewelry, watches and furs coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Increased |
Enter limit: The increased limit for unscheduled jewelry, watches and furs coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for unscheduled jewelry, watches and furs coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Water Backup of Sewers & Drains -Included |
Check the box (if applicable): Indicates water backup of sewers and drains coverage is included. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit |
Enter limit: The limit for water backup of sewers and drains coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for water backup of sewers and drains coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Watercraft Liability - Limit |
Enter limit: The limit for watercraft liability coverage if you are not using a Watercraft application. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Watercraft Liability - Premium |
Enter amount: The premium for watercraft liability coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Watercraft Physical Damage Physical Damage - Limit |
Enter limit: The limit for watercraft physical damage coverage if you are not using a Watercraft application. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Watercraft Physical Damage -Premium |
Enter amount: The premium for watercraft physical damage coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Windstorm Exclusion - Yes |
Check the box (if applicable): Indicates that windstorm exclusion applies. As used here, this is not applicable in Arkansas. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Windstorm Exclusion - Premium |
Enter amount: The premium for windstorm exclusion. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Workers Compensation - Full Time Inservant - # of Employees |
Enter number: The number of employees associated with workers compensation full time In Servant coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for workers compensation full time In Servant coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Code |
Enter code: The code associated with the type of coverage being requested. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Coverage Description |
Enter text: The description of the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 |
Enter amount: The first limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 Applies To |
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.). |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 |
Enter amount: The second limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 Applies To |
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible |
Enter amount: The deductible associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible Type |
Enter code: The type of deductible (e.g. Flat, Percent, etc.) |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Territory |
Enter code: The rating territory for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Yes / No |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" or "No" option for the coverage, if applicable. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Code |
Enter code: The code associated with the type of coverage being requested. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Coverage Description |
Enter text: The description of the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 |
Enter amount: The first limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 Applies To |
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 |
Enter amount: The second limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 Applies To |
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible |
Enter amount: The deductible associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible Type |
Enter code: The type of deductible (e.g. Flat, Percent, etc.) |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Territory |
Enter code: The rating territory for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Yes / No |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" or "No" option for the coverage, if applicable. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Code |
Enter code: The code associated with the type of coverage being requested. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Coverage Description |
Enter text: The description of the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 |
Enter amount: The first limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 Applies To |
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 |
Enter amount: The second limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 Applies To |
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible |
Enter amount: The deductible associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible Type |
Enter code: The type of deductible (e.g. Flat, Percent, etc.) |
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OPTIONAL COVERAGES -ENDORSEMENTS |
Territory |
Enter code: The rating territory for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Yes / No |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" or "No" option for the coverage, if applicable. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Code |
Enter code: The code associated with the type of coverage being requested. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Coverage Description |
Enter text: The description of the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Options |
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 |
Enter amount: The first limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 1 Applies To |
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 |
Enter amount: The second limit associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Limit 2 Applies To |
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.). |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible |
Enter amount: The deductible associated with the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Deductible Type |
Enter code: The type of deductible (e.g. Flat, Percent, etc.) |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Territory |
Enter code: The rating territory for the coverage. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Yes / No |
Enter Y for a “Yes” response. Input N for “No” response. Indicates a "Yes" or "No" option for the coverage, if applicable. |
|
OPTIONAL COVERAGES -ENDORSEMENTS |
Premium |
Enter amount: The premium for the coverage. |
|
GENERAL INFORMATION |
Any other insurance with this company? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any other insurance with this company?". |
|
GENERAL INFORMATION |
Line Of Business |
Enter code: The line of business of the other policy. |
|
GENERAL INFORMATION |
Policy Number |
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
GENERAL INFORMATION |
Line Of Business |
Enter code: The line of business of the other policy. |
|
GENERAL INFORMATION |
Policy Number |
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. |
|
GENERAL INFORMATION |
Any coverage declined, cancelled, or non-renewed during the last 3 years? Not applicable for applications for auto insurance. |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any coverage declined, cancelled or non-renewed during the mandated number of years (not applicable in Missouri)?". As used here, this is not applicable for applications for auto insurance. Missouri applicant: Do not answer this question. |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past specified number of years?". |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Has applicant had a judgement or lien during the past five (5) years? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Has applicant had a judgement or lien during the past specified number of years?". |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Any other residence, not listed on any application, owned, occupied or rented? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any other residence, not listed on any application, owned, occupied or rented?". |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
GENERAL INFORMATION (Continued) |
Has insurance been transferred within agency? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Has insurance been transferred within agency?". |
|
GENERAL INFORMATION (Continued) |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION (Continued) |
Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.), not scheduled on this policy? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, atvs, etc.), not shown on this policy?". |
|
GENERAL INFORMATION (Continued) |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION (Continued) |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION (Continued) |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION (Continued) |
Body Type |
Enter code: The body type of the vehicle. |
|
GENERAL INFORMATION (Continued) |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION (Continued) |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION (Continued) |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION (Continued) |
Body Type |
Enter code: The body type of the vehicle. |
|
GENERAL INFORMATION (Continued) |
During the last five (5) years [ten (10) in Rhode Island], has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "During the last five (5) years [ten (10) years in Rhode Island], has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related crime in connection with this or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)". |
|
GENERAL INFORMATION (Continued) |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION -RESIDENTIAL |
1. Any business conducted on premises? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any business conducted on premises?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Farming (checkbox) |
Check the box (if applicable): Indicates farming is done on the premises. |
|
GENERAL INFORMATION -RESIDENTIAL |
Telecommuter (checkbox) |
Check the box (if applicable): Indicates an individual telecommutes from the premises. |
|
GENERAL INFORMATION -RESIDENTIAL |
Day Care (checkbox) |
Check the box (if applicable): Indicates a day care is run from the premises. |
|
GENERAL INFORMATION -RESIDENTIAL |
Day Care # of children (checkbox) |
Enter number: The number of children attending the day care. |
|
GENERAL INFORMATION -RESIDENTIAL |
Home Office / business (checkbox) |
Check the box (if applicable): Indicates a home office or business is on the premises. |
|
GENERAL INFORMATION -RESIDENTIAL |
Other |
Check the box (if applicable): Indicates business is conducted on the premises other than those listed. |
|
GENERAL INFORMATION -RESIDENTIAL |
Other Description |
Enter text: The description of the business conducted on the premises. |
|
GENERAL INFORMATION -RESIDENTIAL |
2. Any residence employees? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any residence employees?". |
|
GENERAL INFORMATION -RESIDENTIAL |
# of Full Time Employees |
Enter number: The number of full time residence employees. |
|
GENERAL INFORMATION -RESIDENTIAL |
Description of Full Time Employees |
Enter text: The description of the type of work performed by full time residence employees. |
|
GENERAL INFORMATION -RESIDENTIAL |
# of Part Time Employees |
Enter number: The number of part time residence employees. |
|
GENERAL INFORMATION -RESIDENTIAL |
Description of Part Time Employees |
Enter text: The description of the type of work performed by part time residence employees. |
|
GENERAL INFORMATION -RESIDENTIAL |
3. Any flooding, brush, forest fire or landslide hazard? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any flooding, brush, forest fire or landslide hazard?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Hazards - Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION -RESIDENTIAL |
4. Are there any animals or exotic pets kept on the premises? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Are there any animals or exotic pets on the premises?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Animal Type |
Enter code: The type of animal (e.g. cat, dog, horse, etc.) |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Breed |
Enter code: The breed of the animal (e.g. Doberman, German shepherd, etc.) |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Bite History |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any animal currently in the household has ever been involved in a bite incident. |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Animal Type |
Enter code: The type of animal (e.g. cat, dog, horse, etc.) |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Breed |
Enter code: The breed of the animal (e.g. Doberman, German shepherd, etc.) |
|
GENERAL INFORMATION -RESIDENTIAL |
Animals - Bite History |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any animal currently in the household has ever been involved in a bite incident. |
|
GENERAL INFORMATION -RESIDENTIAL |
5. Is property situated on more than one acre? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is property situated on more than 1 acre?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Number of acres |
Enter number: The total area of the land in acres. |
|
GENERAL INFORMATION -RESIDENTIAL |
Land Used for |
Enter text: The description of what the land is used for. |
|
GENERAL INFORMATION -RESIDENTIAL |
6. Any uncorrected fire or building code violations? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any uncorrected fire or building code violations?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION -RESIDENTIAL |
7. Is the dwelling / mobile home for sale? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is the dwelling/mobile home for sale?". |
|
GENERAL INFORMATION -RESIDENTIAL |
8. Is property within 300 ft. of a commercial or non-Residential property |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is the property within 300 feet of a commercial or non-residential property?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION -RESIDENTIAL |
9. Is there a trampoline on the premises |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is there a trampoline on the premises?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Trampoline - Safety Net |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the trampoline on the premises has a safety net. |
|
GENERAL INFORMATION -RESIDENTIAL |
10. Was the structure originally built for other than private residence and then converted? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Was the structure originally built for other than a private residence and then converted?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Original Occupancy |
Enter text: The description of the original occupancy of the building. |
|
GENERAL INFORMATION -RESIDENTIAL |
11. Any lead paint? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any lead paint?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Lead Paint - Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION -RESIDENTIAL |
12. If a fuel tank is on premises, has other insurance been obtained for the tank? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "If a fuel tank is on premises, has other insurance been obtained for the tank?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Insurance Company |
Enter text: The insurer name on any other applicable insurance. |
|
GENERAL INFORMATION -RESIDENTIAL |
Limit |
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
|
GENERAL INFORMATION -RESIDENTIAL |
Clean-up / Sub Limit |
Enter limit: The other policy, coverage sub limit amount. |
|
GENERAL INFORMATION -RESIDENTIAL |
13. Is the residence in a gated community? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is the residence in a gated community?". |
|
GENERAL INFORMATION -RESIDENTIAL |
Community - Name of Community |
Enter text: The name of the gated community. |
|
GENERAL INFORMATION -RESIDENTIAL |
14. If building under construction, is the applicant the general contractor? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "If building is under construction, is the applicant the general contractor?". |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Start Date |
Enter date: The date construction began. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Completion Date |
Enter date: The estimated completion date for this construction project. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Int % |
Enter percentage: The percentage of construction taking place in the interior of the structure. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Ext % |
Enter percentage: The percentage of construction taking place in the exterior of the structure. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Addition Sq. Ft. |
Enter number: The total area of the addition under construction in square feet. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Additional Level Sq. Ft. |
Enter number: The total area of the additional level under construction in square feet. |
|
GENERAL INFORMATION -RESIDENTIAL |
Any structural changes? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if there will be structural changes as part of the construction. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Material Unattached Included |
Check the box (if applicable): Indicates materials that are not attached to the structure are included. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Material Unattached Excluded |
Check the box (if applicable): Indicates materials that are not attached to the structure are excluded. |
|
GENERAL INFORMATION -RESIDENTIAL |
House Occupied during renovation? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the structure will be occupied during construction and renovation. |
|
GENERAL INFORMATION -RESIDENTIAL |
General Contractor - Cost of Project. |
Enter amount: The total cost of construction of the structure |
|
GENERAL INFORMATION -RESIDENTIAL |
15. Is there a carbon monoxide alarm, in operating condition, within the mandated number of feet of every room used for sleeping purposes? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes?". |
|
GENERAL INFORMATION -RESIDENTIAL |
16. Is the named insured the owner of the property? (If "NO", provide the name of the owner). |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, " Is the named insured the owner of the property?". As used here, if no, provide the name of the owner. |
|
GENERAL INFORMATION -RESIDENTIAL |
Owner's Name |
Enter text: The additional interest's full name. As used here, this is the name of the owner of the property. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY |
1. Is there is a manager on the premises |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is there a manager on the premises?". As used here, if yes, provide the full name of the manager and the manager's phone number, including area code. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY |
Manager's Name |
Enter text: The full name of the manager of the structure. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY |
Phone Number |
Enter number: The phone number of the manager of the structure. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY |
2. Is there a security attendant |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is there a security attendant?". As used here, explain a "No" response to the question. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY |
Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. As used here, if no, provide an explanation. |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY (Continued) |
3. Is the building entrance is locked? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Is the building entrance locked?". |
|
GENERAL INFORMATION -RENTERS AND CONDOS ONLY (Continued) |
Description |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. As used here, if no, provide an explanation. |
|
ADDITIONAL INTEREST |
Interest Additional Insured |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Lienholder |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Loss Payee |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Trustee |
Check the box (if applicable): Indicates the additional interest type is a trustee. |
|
ADDITIONAL INTEREST |
Other |
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form. |
|
ADDITIONAL INTEREST |
Other Description |
Enter text: The description of the type of interest in the item. |
|
ADDITIONAL INTEREST |
Rank: |
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item. |
|
ADDITIONAL INTEREST |
Certificate Required |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Send Bill |
Check the box (if applicable): Indicates the bill should be sent to the additional interest. |
|
ADDITIONAL INTEREST |
Name And Address |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's country code. |
|
ADDITIONAL INTEREST |
Reference / Loan #: |
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
|
ADDITIONAL INTEREST |
Interest in Item Number Location: |
Enter number: The producer assigned number of the location which has an additional interest. |
|
ADDITIONAL INTEREST |
Building: |
Enter number: The producer assigned number of the building which has an additional interest. |
|
ADDITIONAL INTEREST |
Vehicle: |
Enter number: The producer assigned number of the vehicle which has an additional interest. |
|
ADDITIONAL INTEREST |
Boat: |
Enter number: The producer assigned number of the boat which has an additional interest. |
|
ADDITIONAL INTEREST |
Item Class: |
Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.). |
|
ADDITIONAL INTEREST |
Item: |
Enter number: The producer assigned number of the scheduled item which has an additional interest. |
|
ADDITIONAL INTEREST |
Item Description: |
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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ATTACHMENTS |
Earthquake Application |
Check the box (if applicable): Indicates an earthquake application is attached. |
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ATTACHMENTS |
Flood Exclusion Notice |
Check the box (if applicable): Indicates a flood exclusion notice is attached. |
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ATTACHMENTS |
Lead Free Paint Certification |
Check the box (if applicable): Indicates a lead free paint certification is attached. |
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ATTACHMENTS |
Mobile Home Supplement |
Check the box (if applicable): Indicates a mobile home supplement is attached to the policy. |
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ATTACHMENTS |
Pers Inland Marine Section |
Check the box (if applicable): Indicates an inland marine application is attached. |
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ATTACHMENTS |
Personal Umbrella Application Section |
Check the box (if applicable): Indicates a personal umbrella section is attached to the policy. |
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ATTACHMENTS |
Photograph |
Check the box (if applicable): Indicates a photograph is attached. |
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ATTACHMENTS |
Protection Device Certificate |
Check the box (if applicable): Indicates a protection device certificate is attached. |
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ATTACHMENTS |
Replacement Cost Estimate |
Check the box (if applicable): Indicates a replacement cost estimate is attached. |
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ATTACHMENTS |
Residence Based Businesses Supp |
Check the box (if applicable): Indicates a residence based business supplement is attached. |
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ATTACHMENTS |
Solid Fuel Supplement |
Check the box (if applicable): Indicates a solid fuel supplement is attached. |
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ATTACHMENTS |
State Supplement(s) |
Check the box (if applicable): Indicates a state supplement form is attached (if applicable). |
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ATTACHMENTS |
Watercraft Section |
Check the box (if applicable): Indicates a watercraft application is attached. |
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ATTACHMENTS |
Windstorm Loss Mitigation |
Check the box (if applicable): Indicates a windstorm loss mitigation form is attached. |
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ATTACHMENTS |
Other |
Check the box (if applicable): Indicates there is an attachment other than those listed. |
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ATTACHMENTS |
Other Description |
Enter text: The description of the attachment. |
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ATTACHMENTS |
Other |
Check the box (if applicable): Indicates there is an attachment other than those listed. |
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ATTACHMENTS |
Other Description |
Enter text: The description of the attachment. |
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REMARKS |
Remarks |
Enter text: The general remarks associated with the residential line of business. Use this section to provide any additional information required for underwriting or rating. Attach ACORD 101, Additional Remarks Schedule, is more space is required. |
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BINDER / SIGNATURE |
Effective Date |
Enter date: The date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy. |
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BINDER / SIGNATURE |
Time |
Enter time: The time of the binder effective date that the binder becomes effective. |
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BINDER / SIGNATURE |
Expiration Date |
Enter date: The date on which the terms and conditions of the policy will or have expired. Certain state laws limit the terms of a binder, so this date may not coincide with the policy expiration date. |
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BINDER / SIGNATURE |
12:01 AM |
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date. |
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BINDER / SIGNATURE |
Noon |
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date. |
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BINDER / SIGNATURE |
Coverage is not bound |
Check the box (if applicable): Indicates the coverage has not been bound. |
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BINDER / SIGNATURE |
Applicant's Initials |
Initial here: The named insured's initials. As used here, indicates the named insured has read and understands the credit reporting information. |
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BINDER / SIGNATURE |
Copy of the Notice of Information Practices Privacy has been given to the applicant. Not applicable in all states, consult your agent or broker for your state's requirements. |
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices has been given to the applicant. |
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BINDER / SIGNATURE |
Producer's Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) by all companies to issue Certificates. This is required in most states. |
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BINDER / SIGNATURE |
Producer's Name (Please Print) |
Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
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BINDER / SIGNATURE |
State Producer License No (Required in FL) |
Enter identifier: The State License Number of the producer. |
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BINDER / SIGNATURE |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
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BINDER / SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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BINDER / SIGNATURE |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
