ACORD 125 Instructions


ACORD 125 Instructions
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Apartments Check the box (if applicable): Indicates the nature of business is apartments.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Condominiums Check the box (if applicable): Indicates the nature of business is condominiums.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Contractor Check the box (if applicable): Indicates the nature of business is a contractor.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Institutional Check the box (if applicable): Indicates the nature of business is institutional.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Manufacturing Check the box (if applicable): Indicates the nature of business is manufacturing.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Office Check the box (if applicable): Indicates the nature of business is an office.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Restaurant Check the box (if applicable): Indicates the nature of business is a restaurant.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Retail Check the box (if applicable): Indicates the nature of business is retail.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Service Check the box (if applicable): Indicates the nature of business is service.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Wholesale Check the box (if applicable): Indicates the nature of business is wholesale.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Other Check the box (if applicable): Indicates the nature of business is other than those listed.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Other Description Enter text: The description of the nature/type of business.
APPLICANT INFORMATION Date Business Started Enter date: The date the applicant began in business. This is important because it helps the underwriter determine the expertise and business success of the applicant.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Description Primary Of Operations Enter text: The text description of the operations of this risk or insured. As used here, this is the primary description of operations.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Installation, Service or Repair Work Percent Enter percentage: The percentage of total sales of a retail store attributed to installation, service or repair work.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Off Premises Installation, Service or Repair Work Percent Enter percentage: The percentage of total sales of a retail store attributed to installation, service or repair work completed off premises.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Description of Operations of Other Named Insureds Enter text: The text description of the operations of this risk or insured. As used here, this is the description of operations for other named insureds.
ADDITIONAL INTEREST Interest Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST Breach of Warranty Check the box (if applicable): Indicates the additional interest type is a breach of warranty.
ADDITIONAL INTEREST Co-Owner Check the box (if applicable): Indicates the additional interest type is a co-owner.
ADDITIONAL INTEREST Employee As Lessor Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST Leaseback Owner Check the box (if applicable): Indicates the additional interest type is a leaseback owner.
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 Owner Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST Registrant Check the box (if applicable): Indicates the additional interest type is a registrant.
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 Reason for Interest Enter text: The description for the 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 Evidence – Certificate Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST Evidence – Policy Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST Evidence – 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 Number Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST Interest End Date Enter date: The date the interest holder’s interest terminates.
ADDITIONAL INTEREST Lien Amount Enter amount: The amount of the loan.
ADDITIONAL INTEREST Phone Number Enter number: The primary phone number of the additional interest.
ADDITIONAL INTEREST Fax Number Enter number: The primary fax number of the additional interest.
ADDITIONAL INTEREST E-Mail Address Enter text: The primary e-mail address for the additional interest.
ADDITIONAL INTEREST 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 Airport: Enter identifier: The Federal Aviation Administration’s designator for the airport (e.g. ORD O’Hare International Airport).
ADDITIONAL INTEREST Aircraft: Enter number: The producer assigned number of the aircraft 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.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION Is the applicant a subsidiary of another entity? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is this company a subsidiary of another entity?”.
GENERAL INFORMATION Parent Company Name Enter text: The name of the parent organization.
GENERAL INFORMATION Relationship Description Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION % Owned Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION Does the applicant have any subsidiaries? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does the applicant have subsidiaries? If yes, explain.”.
GENERAL INFORMATION Subsidiary Company Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
GENERAL INFORMATION Relationship Description Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION % Owned Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION Is a formal safety program in operation? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is a formal safety Program in existence? If yes, explain.”.
GENERAL INFORMATION Safety Manual Check the box (if applicable): Indicates a safety manual is part of the formal safety program.
GENERAL INFORMATION Safety Position Check the box (if applicable): Indicates a safety position is part of the formal safety program.
GENERAL INFORMATION Monthly Meetings Check the box (if applicable): Indicates monthly meetings are is part of the formal safety program.
GENERAL INFORMATION OSHA Check the box (if applicable): Indicates the formal safety program meets OSHA guidelines.
GENERAL INFORMATION Other Check the box (if applicable): Indicates there is a formal safety program other than those listed.
GENERAL INFORMATION Other Description Enter text: The description of the formal safety program.
GENERAL INFORMATION Any exposure to flammables, explosives, chemicals? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any exposure to flammables, explosives, chemicals?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION Any other insurance with this company? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response 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 text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operation? (Not Applicable in MO) Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”. As used here, not applicable in Missouri.
GENERAL INFORMATION Non-Payment Check the box (if applicable): Indicates the policy is being cancelled due to non-payment of premium.
GENERAL INFORMATION Non-Renewal Check the box (if applicable): Indicates the policy is being cancelled due to non-renewal.
GENERAL INFORMATION Agent No Longer Represents Carrier Check the box (if applicable): Indicates the policy is being cancelled because the agent is no longer writing business for the insurer.
GENERAL INFORMATION Underwriting Check the box (if applicable): Indicates the policy is being cancelled due to underwriting reasons.
GENERAL INFORMATION Condition Corrected Check the box (if applicable): Indicates the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION Correction Description Enter text: The description of how the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION Other Check the box (if applicable): Indicates the policy is being cancelled due to reasons other than those listed.
GENERAL INFORMATION Other Description Enter text: The description of why the policy is being cancelled or terminated.
GENERAL INFORMATION Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 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? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the mandated number of years, 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?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION Any uncorrected fire code violations? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any uncorrected fire code violations?”.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
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 response to the question, “Has applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the past specified number of years?”.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
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 response to the question, “Has applicant had a judgment or lien during the past specified number of years?”.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Has business been placed in a trust? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has business been placed in a trust?”.
GENERAL INFORMATION Name of Trust Enter text: The additional interest’s full name. As used here, this is the name of the trust.
GENERAL INFORMATION Any foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries?”.
GENERAL INFORMATION Does applicant have other business ventures for which coverage is not requested? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does applicant have other business ventures for which coverage is not requested?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION REMARKS/PROCESSING INSTRUCTIONS Enter text: The commercial policy general remarks.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Automobile Liability Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Property Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Section Enter text: The line of business used in the “other” section of prior coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
LOSS HISTORY Check if None Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years.
LOSS HISTORY Losses Last Number of Years Enter number: The number of years of loss information required by the insurer.
LOSS HISTORY Total Losses Enter amount: The amount that has been paid on all losses to date.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
GENERAL INFORMATION Notice Of Information Practices Check the box (if applicable): Indicates that a copy of the Notice of Information Practices has been given to the applicant.
SIGNATURE SECTION 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.
SIGNATURE SECTION Producers Name Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE SECTION State Producer License Number Enter identifier: The State License Number of the producer.
SIGNATURE SECTION Applicant’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION Date Enter date: The date the form was signed by the named insured.
SIGNATURE SECTION 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.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).
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