ACORD 84 InstructionsACORD 84 (2004/12) - Dwelling Fire Application The underwriting process for any personal lines policy begins with the submission of a completed application. These instructions will assist in the completion of ACORD 84, Dwelling Fire Application.
Date Month/day/year (MM/DD/YYYY) on which the form is completed.
Producer's name
and address. Phone No. Producer's telephone
number. (Include area code and extension if applicable) Fax No. Producer's fax
number. (Include area code) Code Identification
code assigned to the agency or brokerage firm by the insurance company receiving
this form. Subcode If the agency
or brokerage uses a sub-code identification system with the company, enter the
appropriate code. Agency Customer ID Customer's identification
number assigned by the agency or brokerage. Applicant's Name and Mailing Address Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail.
NAIC Code The identification
code assigned to the company by the NAIC. Facility Code 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 CO/PLAN field. Policy # The number assigned
by the insurance company for the policy. In general, policy numbers will not
appear on new business applications since they are not known at that point in
time. Date at Curr Res Indicate the date
applicant moved into current residence. CO/Plan Name of the insurance
company (or residual market plan) that will receive the application. Do not
use group names, use the actual name of the company within the group in which
you wish to have the policy issued. Also, if applicable, indicate the type of
plan or policy program (example: Preferred) that you wish to use when issuing
the policy. Use the specific plan name that is unique to that company. Home Phone # Home telephone
number at which the applicant may be reached. Include area code. Effective Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will commence. Expiration Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will terminate unless renewed. Business Phone # Business telephone
number at which the applicant may be reached. Include area code and extension,
if applicable. APPLICANT INFORMATION Previous Address Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.
Enter the physical
address of the property to be insured only if it is different from the address
listed above. Applicant's/Co-applicant's Occupation Briefly describe
the occupation for the applicant(s) named in the identification section. State
the nature of business if self-employed. Applicant's/Co-Applicant's Employer Name
and Address Name and address of the organization that employs the applicant(s)
named in the identification section. Yrs in Curr. Occ. Number of years
in current occupation or business. Yrs w/Curr. Empl. Number of years
with present employer. If less than 3 years, provide the number of years in
career field or industry in the Remarks section. Yrs w/Prior Empl. Number of years
with the prior employer. Mar Stat Marital status of each named applicant. Codes:
Date of Birth Birth date of
each named applicant (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.) Social Security # Social security
number for each named applicant. How long have you known the applicant? Indicate how long
the applicant is known to the agent. Date Agent last inspected property Indicate when
the property was last inspected by the agent. COVERAGES/LIMITS OF LIABILITY Enter the anticipated dollar limit amounts for each applicable coverage. Policy Type Show the policy
form, form number or company form designation for the type of policy/coverage
desired. PREMIUM Premium Enter the estimated
total premium calculated by the insurance agency, as well as the applicant's
deposit and balance, if any owed. DED Deductibles Several deductible
fields are shown. One or more may be selected, depending on the company, the
jurisdiction for the policy and the property coverage. Enter the appropriate
deductible amount in each field. (Note: Deductibles may be the same amount or
they may differ by coverage.) ENDORSEMENTS Endorsements Enter the applicable
endorsements. Check the appropriate box for replacement cost dwelling and/or
replacement cost contents. PAYMENT PLAN Account # Indicate the account
number. Billing Indicate whether
the agency or the company (direct) will bill the insured or other payee for
the policy. If direct bill, also indicate who is to be billed, and the plan
for payment. Indicate the account number. Mail Policy to: Indicate to whom
the policy should be mailed. RATING/UNDERWRITING Provide the information below for each dwelling.
Check the primary
type of building material used to construct the dwelling. Also indicate the
siding type.
Yr Built Year the dwelling
was built. Use four digits (e.g., 1952). If significant alterations were made,
indicate the year and describe the alternations in the Remarks section. Also
complete the Renovation Update section. Sq Ft Dwelling's total
square footage of living area. # Rooms Total number of
rooms in a residence, including full and half rooms (bath). # Apts Complete only
for tenant or condominium policies. Enter the number of apartments (residences)
in the building. Market Value Estimated total
dollar amount for which the dwelling could be sold under current market conditions. Replacement Cost Estimated total
dollar amount required to rebuild the dwelling without depreciation. Structure Type Indicate the residence type. The full meaning of each abbreviation is:
Usage Type Applicant's use
for the dwelling within the guidelines listed. ("COC" refers to dwellings
in the "course of construction.") # Families Number of separate
family units in the dwelling. Not required for HO-4 or HO-6. # Hsehold Res Number of residents
in the household. Purchase Date/Price Year the applicant
acquired the dwelling and the purchase price. The year should be expressed in
YYYY format. # of Fire Div/ # of Units in Fire Div Complete only
for apartments, townhouses, rowhouses and condominiums. Enter the number of
residences that are in the same fire division with the insured residence (including
the insured's residence). A fire division is the number of units within the
building or within approved firewalls. Terr Code Dwelling location
based on individual state bureau or company homeowners manual pages. Prem Group Premium group
codes are found in individual state homeowner manuals. Some companies may require
this data, others will generate it. Premium Group is a combination of Protection
Class, Territory Code and Construction Type Code used to determine the applicable
rate based upon the dwelling's location, construction and fire protection code. Protect Class Dwelling's four-character
fire protection grade found in individual state homeowners manuals. Distance to Hydrant Distance in feet
from the nearest hydrant to support the protection class used. Distance to Fire Station Distance in miles
from the nearest fire station to support the protection class used. Fire/EC Rate Complete if residence
is specifically rated. Refer to the company rate manual. Fire District/Code Number Residence's fire
district name and corresponding code number, which can be found in the individual
state manual pages. Protection Device Type For temperature,
smoke and burglar alarms to qualify for credit, a copy of the manufacturer's
specification sheet must be submitted with the application. The combination
of dead bolt, smoke detector and fire extinguisher qualifies for a separate
credit with some companies. Heat Type Type of heating
device for the residence. If there is more than one type, indicate the primary
and secondary types. Use the Remarks section if necessary. Some possible types
are: * Electric - Permanent/Portable Housekeeping Condition Enter the evaluation
of the interior upkeep of the dwelling. Renovation Type If wiring, plumbing,
heating or roofing have been partially or completely replaced, provide the year
updated. If the exterior has been repainted, provide the year. Date Heating System Last Serviced Indicate the date
(MM/DD/YYYY) heating system was last serviced. Num of Amps (Elec. Syst) Indicate the number
of amps in the electrical system. Circuit Breakers Check the applicable
box. Fuses Check the applicable
box. Knob & Tube or Aluminum Wiring Check the applicable
box. Plumbing System Condition Indicate condition
of the plumbing system. Plumbing System & Any Known Leaks Indicate if there
are any known leaks in the plumbing system. Foundation Check the applicable
box. Dwelling Location Location of the
dwelling within the guidelines listed. Complete only if applicable. Occupancy Indicate if the
dwelling is occupied by the owner or a tenant, unoccupied or vacant. Deadbolt If all entry (exterior)
doors are fitted with deadbolt locks, check the box. Fire Extinguisher If the dwelling
is equipped with fire extinguisher(s), check the box. Indicate the number of
fire extinguishers and their locations in the blank space. Visible to Neighbors If the residence
is visible from a road, or from another residence usually occupied by an adult
during the day, check the box. Oil Storage Tank Location If the fuel type is oil, provide the location of the fuel oil storage tank. Options are:
Swimming Pool If a swimming
pool is on the residence property, check the appropriate boxes to indicate the
existence of the pool, whether the pool is above ground, in ground, has a diving
board, slide or approved fence. Windstorm Loss Mitigation Features Describe the construction features which may qualify for credit under the rules in the company manual. General categories of construction features are: * Roof Covering
Bldg Code Grade Enter the ISO
Building Code Grade, if applicable. Also check the appropriate box to indicate
whether or not the building was inspected. Tax Code Enter the city,
county or state tax code, if required. Rating Check the applicable
box. Occupied Daily Check the applicable
box. # Weeks Rented Number of weeks
the dwelling is rented by the insured to others. Wind Class Check the applicable
box. Roof Material Enter the material
used to construct the roof. Examples: * Composition
(fiberglass, asphalt, etc.) Condition of Roof Indicate the condition
of the roof. If Replacement Cost coverage applies Check the appropriate
box if an ACORD replacement cost worksheet has been used (i.e., ACORD 42.) Basement Indicate the number
of square feet in the basement. Leave this field blank if there is no basement. Garage Indicate the
number of square feet in the garage. Leave this field blank if there is no garage. Breezeway Indicate the
number of square feet in the breezeway. Leave this field blank if there is no
breezeway. Rating Credits Check the applicable
box(es) if any rating credits apply. Sprinkler If the dwelling
is equipped with a fire sprinkler system, indicate whether it is full or partial.
Leave this field blank if there is no sprinkler system. Fireplaces Enter the number
in the applicable box(es) to describe the fireplace(s.) PRIOR COVERAGE Prior Carrier Provide the prior
insurance company's name. Prior Policy Number /Expiration
Date List the complete policy number including prefix and suffix, and the policy's
expiration date. GENERAL INFORMATION QUESTIONS Use the Remarks
section to provide additional information for any questions answered with a
"Yes" response. (Except questions 15, 16 and 17.) 1. Any farming or other business conducted on premises? Describe the
business, where the business is conducted on the premises, and if applicable,
whether corporal punishment coverage is to be provided. If "Yes",
provide amount of gross receipts. 2. Any residence employees? Describe the number
and type of full and part time employees. 3. Any flooding, brush, forest fire hazard, landslide, etc.? Use the Remarks
section to describe the type of hazard and the distance between the residence
and the hazard. Some companies may require a photograph. 4. Any other residence owned, occupied or rented? Use the Remarks
section to describe the occupancy or use of the other residence. If no liability
coverage is requested for this residence and this policy will provide liability
coverage, detail where the coverage for the other residence is provided. 5. Any other insurance with this company? Indicate whether
other insurance is currently written for this applicant by the company. If a
submission was mailed to another department recently, note it in the Remarks
section along with any policy numbers available. 6. Has insurance been transferred within agency? Indicate why this
insurance has been moved from the last company. 7. Any coverage declined, cancelled, or non-renewed? Explain the circumstances
surrounding this situation. Indicate the reason for the cancellation, etc. This
question cannot be asked in Missouri. 8. Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? Use the Remarks
section to provide information regarding any real estate foreclosure, personal
property repossession, bankruptcy filing, judgment or lien during the specified
time period. 9. Are there any animals or exotic pets kept on the premises? Use the remarks
section to give the age, breed, or other information about livestock or pets
that may be vicious or dangerous to human beings. Also, give any history of
biting or causing injury to others or to other animals. 10. Is property located within two miles of tidal water? Use the Remarks
section to describe the coastal hazard, if applicable. 11. Is property situated on more than five acres? Use the Remarks
section to indicate if any part of the property is farmed, or used to grow crops
or animals for sale, or used for any other non-residential purpose. 12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)? Use the Remarks
section to describe the recreational vehicle. Include the year, type, make,
model, and any other information necessary to provide a complete description. 13. Is Building retrofitted for earthquake? Answer this question
only in those earthquake zones where existing buildings may be retrofitted to
comply with the latest "earthquake resistant" technology and building
codes. 14. 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 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.) Rhode Island law requires
that all applicants for property insurance must answer this question. 15. There is a manager on the premises. This question
should be answered by applicants who reside in condos or are renters only. 16. A security attendant. This question
should be answered by applicants who reside in condos or are renters only. 17. The building entrance is locked. This question
should be answered by applicants who reside in condos or are renters only. 18. Any uncorrected code violations? Describe any
violations of applicable building codes that have not been corrected. 19. Is building undergoing renovation or reconstruction? Describe the
type and scope of renovation or reconstruction of any part of the building. 20. Is the house for sale? Provide the length
of time the house has been for sale, and the expected sale date if known. 21. Is property within 300 ft. of a commercial or non-residential property? Describe the
occupancy of any commercial or non-residential property. 22. Is there a trampoline on the premises? Describe the device. 23. Was the structure originally built for other than a private residence and then converted? Describe what
the structure was originally built for. 24. Any lead paint hazard? Describe the location and extent of the hazard.
Give the First Party to the insurance and the applicable limit, and the Third Party and the applicable limit.
Check the appropriate
box if the applicant is the general contractor. LOSS HISTORY This section shows
the losses this applicant has had in the past. List losses for the time period
required by the company. Provision is made for the applicant to initial this
section. Date Date of Loss (MM/DD/YYYY) Type Identify the type
of loss. Description of Loss Describe the loss
in detail. CAT# CAT# refers to
a 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. Amount Indicate the amount
of the loss. ADDITIONAL INTEREST INT# Provide the interest number or rank (1st, 2nd)
Identify whether
the additional interest is the mortgage holder (i.e., bank in which the mortgage
is held), or other interest Name and Address Provide the address
of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) for
each entity having an interest in the dwelling(s) to be insured. Loan Number Provide the loan
number. BINDER/SIGNATURE This section is
to be used by producers with the permission of the company underwriter or when
the producer has binding authority for this line of business. If the coverage
is bound, complete the Insurance Binder section. If coverage is not bound, check
the box. Effective Date Month/day/year
(MM/DD/YYYY) on which the insurance applied for is bound. This insurance is
subject to the terms, conditions, and limitations of the company. Expiration Date Month/day/year
(MM/DD/YYYY) on which the binder terminates. Time Time the provisions
of the binder become effective. 12:01/ Noon Indicate the time
on which the binder terminates. Notice of Information Practices Check this box
if a copy of the Notice of Information Practices has been given to the applicant. Applicant's Signature The applicant
should read and understand the Fair Credit Reporting Act, the Privacy Act (where
applicable), the Applicant's Statement, and any other disclosure information
on the form before personally signing the application. Date Date the form
was signed. Producer's Signature The producer should
sign the application. This is required in most states. National Producer Number The National
Producer Number assigned by the NAIC should be shown. Sign up for Free Access to all ACORD forms. Return to Simply Easier ACORD Forms home page from ACORD 24 Instructions page.
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