ACORD 86 InstructionsACORD 86 - Personal Lines Package 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 86, Personal
Lines Package Application. ACORD 86 includes property, liability and umbrella
coverage's. For inland marine and watercraft, refer to ACORD 87, Personal Lines
Package Application Supplement. IDENTIFICATION SECTION 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. Lines of Business To Be Included Check the lines
of business to be included. 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. Telephone Number Telephone number
at which the applicant may be reached. Include area code. Date At Current Address 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. POL # 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. ACCT # Indicate account
number, if applicable. 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. Billing Plan Check the appropriate
box. How Long Has Producer Known Applicant? Provide the number
of years. 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. APPLICANT INFORMATION Applicant's/Co-Applicant's Occupation Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of the business if self employed.
Name and Address
Name and address of the organization that employs the applicant(s). Yrs in Curr. Occ. Number of years
in current occupation or business. Yrs w/ Curr. Empl Number of years
with the 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:
Social security
number for each named applicant. GENERAL INFORMATION Use the Remarks
section to provide additional information for any questions answered with a
"Yes" response. 1. Any farming or other business conducted on premises? Describe the business,
where business is conducted on the premises, and if applicable, whether corporal
punishment or day care coverage is to be provided. 2. Any residence employees? Use the Remarks
section to provide information regarding the number of employees, the nature
of their employment, hours worked per week, and whether employed inside (inservants)
or outside (outservants). 3. Any flooding/brush 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 owner, occupied or rented? Use the Remarks
section to detail the occupancy or use of the other residence. If no liability
coverage is requested for this residence, detail where the coverage is provided
if liability coverage is to be included in the policy for any property. 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. If other insurance is in force,
list types of insurance and provide policy numbers. Indicate whether insurance
is commercial or personal. 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, including the reason for the cancellation. This
question cannot be asked in Missouri. 8. Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien? Use the Remarks
section to provide information regarding any real estate foreclosure, personal
property repossession, or 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 years (ten in RI), 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 Rhode Island,
failure to disclose the existence of an arson conviction is a misdemeanor punishable
by a sentence of up to one 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 structure originally built & converted for other than private residence? Indicate what
the structure was originally built for. 24. Any lead paint hazard? Describe the
location and the extent of the hazard. 25. If a fuel tank is on premises, has other insurance been obtained for the tank? Give the First
Party and the applicable limit, and the Third Party and the applicable limit. 26. If building is under construction, is the applicant the general contractor? 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 last three
years unless the company requires a different time period. PRIOR COVERAGE Prior Carrier Provide the prior insurance company's name.
List the complete
policy number including prefix and suffix. Expiration Date List the expiration
date of the prior policy (MM/DD/YYYY). Line of Business List the line(s)
of business included. # Yrs W/Co List the number
of years with the prior carrier. PREMISES INFORMATION Provide the complete
physical address for all property to be included in this policy. Use a separate
application for each premises. 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:
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:
Hurricane Resistant Glass Check the applicable
box. 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:
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.) PROPERTY COVERAGE/LIMITS Enter the anticipated
dollar amounts for each applicable coverage. Also show property deductibles
in the Deductible column. PREMISES LIABILITY INFORMATION Enter the applicable
limits for each liability coverage. Also show any applicable deductible. OPTIONAL COVERAGES AND ENDORSEMENTS Use this space
to describe any optional coverages. Use endorsement numbers. Also use a separate
sheet if more space is needed. 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. UMBRELLA INFORMATION Policy Amount Limit of liability.
The amount of
liability retained by the insured. Retention is generally expressed in whole
numbers but can be a percentage. Optional Coverages to Apply Insurance companies often provide options or special coverages. Examples:
Premiums Methods for calculating
the policy premiums differ by company, but usually include a basic amount. Any
additional autos, residences, watercraft or special options involve additional
premiums based on an established schedule. Calculations The insurance
company may require use of specific multipliers or factors which can be shown
here. REMARKS Use the remarks
section to provide additional information for any questions answered with a
"Yes" response. ATTACHMENTS Check the appropriate
box(es) 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.
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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