| Section Name |
Field Name |
Field and/or Section Description |
| TITLE ACORD 131 (2009/10) |
Umbrella / Excess Section |
The title of the form. ACORD 131, Umbrella / Excess Section, captures information about a liability coverage affording high limit excess and/or extended coverage. It is a separate policy over and above other basic liability policies the same insured may have. A completed Umbrella / Excess Application consists of both the Applicant Information Section, ACORD 125 and the Umbrella / Excess Section, ACORD 131. This is necessary because some information about the applicant is only shown on the Applicant Information Section. Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Even though this data matches the data on the ACORD 125, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
| IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
| IDENTIFICATION SECTION |
Policy Number |
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 |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
| 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. |
| POLICY INFORMATION |
Transaction Type – New |
Check the box (if applicable): Indicates the response expected from the company is a new issued policy. |
| POLICY INFORMATION |
Renewal |
Check the box (if applicable): Indicates the response expected from the company is a renewed policy. |
| POLICY INFORMATION |
Umbrella |
Check the box (if applicable): Indicates the type of policy is umbrella. |
| POLICY INFORMATION |
Excess |
Check the box (if applicable): Indicates the type of policy is excess. |
| POLICY INFORMATION |
Occurrence |
Check the box (if applicable): Indicates “coverage trigger” is on an occurrence basis on an excess or umbrella liability policy. |
| POLICY INFORMATION |
Claims Made |
Check the box (if applicable): Indicates the “coverage trigger” is on a claims-made basis on an excess or umbrella liability policy. |
| POLICY INFORMATION |
Expiring Pol # |
Enter identifier: The policy number of the previous coverage. |
| POLICY INFORMATION |
Proposed Retroactive Date |
Enter date: The retroactive date you are requesting for the policy being applied for. This is the proposed earliest date for which an occurrence could “trigger” coverage under a Claims Made policy. |
| POLICY INFORMATION |
Current Retroactive Date |
Enter date: The current retroactive date should be shown if the Umbrella is over a Claims Made primary policy. If the current retroactive date is different from the proposed retroactive date, an explanation must be provided. |
| POLICY INFORMATION |
Limit of Liability – Each Occurrence |
Enter limit: The excess umbrella liability limit each occurrence limit. |
| POLICY INFORMATION |
Limit of Liability |
Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| POLICY INFORMATION |
|
Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| POLICY INFORMATION |
Limit of Liability |
Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| POLICY INFORMATION |
|
Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| POLICY INFORMATION |
Retained Limit |
Enter deductible: The excess or umbrella liability deductible or retention amount. |
| POLICY INFORMATION |
First Dollar Defense |
Enter Y for a “Yes” response. Input N for “No” response. Indicates that first dollar defense coverage is requested. |
| EMPLOYEE BENEFITSLIABILITY |
Limit of Insurance (ea Employee) |
Enter limit: The each employee limit for employee benefits coverage. |
| EMPLOYEE BENEFITS LIABILITY |
Aggregate Limit for EBL |
Enter limit: The aggregate limit for employee benefits coverage. |
| EMPLOYEE BENEFITS LIABILITY |
Retained Limit for EBL |
Enter amount: The retention amount for employee benefits coverage. |
| EMPLOYEE BENEFITS LIABILITY |
Retroactive Date for EBL |
Enter date: The retroactive date for employee benefits coverage. |
| EMPLOYEE BENEFITS LIABILITY |
Name of Benefit Program |
Enter text: The full name of the benefit program. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Number (#) |
Enter number: The location number for the premises. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Name |
Enter text: The name of the location. For commercial policies, this may be a company name. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Location |
Enter text: The first address line of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter text: The city of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The state of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
|
Enter code: The postal code of the commercial structure. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Description |
Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., “Metal Goods Manufacturing NOC” could include anything from paper clips to bridge girders). |
| PRIMARY LOCATION AND SUBSIDIARIES |
Annual Payroll |
Enter amount: The total annual payroll of the business in whole dollars. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Ann. Gross Sales |
Enter amount: The total annual gross sales or receipts. |
| PRIMARY LOCATION AND SUBSIDIARIES |
Foreign Sales |
Enter amount: The estimated annual foreign gross sales. |
| PRIMARY LOCATION AND SUBSIDIARIES |
# Empl. |
Enter number: The number of employees. |
| UNDERLYING INSURANCE |
Carrier / Policy Number |
Enter text: The full name of the insurer of the underlying automobile policy. |
| UNDERLYING INSURANCE |
|
Enter identifier: The policy number of the underlying automobile policy. |
| UNDERLYING INSURANCE |
Policy Effective Date |
Enter date: The effective date of the underlying automobile policy. |
| UNDERLYING INSURANCE |
Policy Expiration Date |
Enter date: The expiration date of the underlying automobile policy. |
| UNDERLYING INSURANCE |
Limits – CSL Ea Acc |
Enter limit: The combined single limit on the underlying automobile policy. |
| UNDERLYING INSURANCE |
BI Ea Acc |
Enter limit: The bodily injury each accident limit or combined single limit on the underlying automobile policy. |
| UNDERLYING INSURANCE |
BI Ea Per |
Enter limit: The bodily injury each person limit on the underlying automobile policy. |
| UNDERLYING INSURANCE |
PD Ea Acc |
Enter limit: The property damage each accident limit on the underlying automobile policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The combined single limit premium on the underlying automobile policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The bodily injury premium amount on the underlying automobile policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The property damage premium amount on the underlying automobile policy. |
| UNDERLYING INSURANCE |
Rating Mod |
Enter rate: The combined rating modification and experience modification debit or credit as they apply. |
| UNDERLYING INSURANCE |
General Liability – Occur |
Check the box (if applicable): Indicates the underlying general liability policy is on an occurrence basis. |
| UNDERLYING INSURANCE |
Claims Made |
Check the box (if applicable): Indicates the underlying general liability policy is on a claims made basis. |
| UNDERLYING INSURANCE |
Carrier / Policy Number |
Enter text: The full name of the insurer of the underlying general liability policy. |
| UNDERLYING INSURANCE |
|
Enter identifier: The policy number of the underlying general liability policy. |
| UNDERLYING INSURANCE |
Policy Effective Date |
Enter date: The effective date of the underlying general liability policy. |
| UNDERLYING INSURANCE |
Policy Expiration Date |
Enter date: The expiration date of the underlying general liability policy. |
| UNDERLYING INSURANCE |
Each Occurrence |
Enter limit: The each occurrence limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
General Aggr |
Enter limit: The general aggregate limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Prod & Comp Ops Aggregate |
Enter limit: The products and completed operations limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Personal & Adv Injury |
Enter limit: The personal and advertising injury limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Damage To Rented Premises |
Enter limit: The fire damage (damage to rented premises) limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Medical Expense |
Enter limit: The medical expense limit on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Prem / Ops |
Enter amount: The premises operations premium amount on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Products |
Enter amount: The products premium on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Other |
Enter amount: The premium associated with other coverages on the underlying general liability policy. |
| UNDERLYING INSURANCE |
Rating Mod |
Enter rate: The combined rating modification and experience modification debit or credit as they apply. |
| UNDERLYING INSURANCE |
Employers Liability – Carrier/Policy Number |
Enter text: The full name of the insurer of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
|
Enter identifier: The policy number of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Policy Effective Date |
Enter date: The effective date of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Policy Expiration Date |
Enter date: The expiration date of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Each Accident |
Enter limit: The limit of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Disease Each Employee |
Enter limit: The disease each employee limit of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Disease Policy Limit |
Enter limit: The disease policy limit of the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The premium amount on the underlying employers liability policy. |
| UNDERLYING INSURANCE |
Rating Mod |
Enter rate: The combined rating modification and experience modification debit or credit as they apply. |
| UNDERLYING INSURANCE |
Blank Space – Type |
Enter text: The description of the underlying policy type. |
| UNDERLYING INSURANCE |
Carrier / Policy Number |
Enter text: The full name of the insurer of the underlying policy. As used here, contains the carrier name and the policy number. |
| UNDERLYING INSURANCE |
Policy Effective Date |
Enter date: The effective date of the underlying policy. |
| UNDERLYING INSURANCE |
Policy Expiration Date |
Enter date: The expiration date of the underlying policy. |
| UNDERLYING INSURANCE |
Limits |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE |
|
Enter limit: The combined single or total limit on the underlying policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The premium amount on the underlying policy. |
| UNDERLYING INSURANCE |
Rating Mod |
Enter rate: The combined rating modification and experience modification debit or credit as they apply. |
| UNDERLYING INSURANCE |
Type |
Enter text: The description of the underlying policy type. |
| UNDERLYING INSURANCE |
Carrier / Policy Number |
Enter text: The full name of the insurer of the underlying policy. As used here, contains the carrier name and the policy number. |
| UNDERLYING INSURANCE |
Policy Effective Date |
Enter date: The effective date of the underlying policy. |
| UNDERLYING INSURANCE |
Policy Expiration Date |
Enter date: The expiration date of the underlying policy. |
| UNDERLYING INSURANCE |
Limits |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE |
|
Enter limit: The combined single or total limit on the underlying policy. |
| UNDERLYING INSURANCE |
Annual Renewal Premium |
Enter amount: The premium amount on the underlying policy. |
| UNDERLYING INSURANCE |
Rating Mod |
Enter rate: The combined rating modification and experience modification debit or credit as they apply. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| UNDERLYING INSURANCE (continued) |
1. Are defense costs – Within Aggregate Limits? |
Check the box (if applicable): Indicates defense costs are within aggregate limits. |
| UNDERLYING INSURANCE (continued) |
A Separate Limit? |
Check the box (if applicable): Indicates defense costs a separate limit? |
| UNDERLYING INSURANCE (continued) |
Unlimited? |
Check the box (if applicable): Indicates defense costs are unlimited. |
| UNDERLYING INSURANCE (continued) |
2. Indicate the edition date of the ISO form or similar filing for the underlying coverage |
Enter date: The edition date of the underlying general liability coverage form. Policy coverage may vary depending on the edition date of the policy paper. The underlying general liability coverage forms issued by Insurances Services Office (ISO) vary if they are based on the rules of “86” or the rules of “88”. |
| UNDERLYING INSURANCE (continued) |
3. Has any product, work, accident, or location been excluded, uninsured or self insured from any previous coverage? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Has any product, work, accident, or location been excluded, uninsured or self insured from any previous coverage?”. |
| UNDERLYING INSURANCE (continued) |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| UNDERLYING INSURANCE (continued) |
4. For Claims Made, indicate the retroactive date of current underlying policy |
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was a retroactive date. |
| UNDERLYING INSURANCE (continued) |
5. For Claims Made, indicate entry date into uninterrupted Claims Made coverage |
Enter date: The retroactive date shown on the applicant’s first Claims Made policy. If this is the first such policy, the date will be the same as the proposed retroactive date shown on the preceding field. If this is a renewal, it is the effective date of the first policy issued in the sequence of uninterrupted Claims Made policies. |
| UNDERLYING INSURANCE (continued) |
6. For Claims Made, was “tail” coverage purchased for any previous primary or excess policy? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “For Claims made, was “tail” coverage purchased for any previous primary or excess policy?”. |
| UNDERLYING INSURANCE |
|
Enter date: The effective date of the tail coverage. The proposed retroactive date for the |
| (continued) |
Effective Date |
policy being applied for should not be earlier than the effective date of the tail coverage. |
| UNDERLYING INSURANCE (continued) |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| UNDERLYING INSURANCE (continued) |
Coverage/Exposure – Any Auto -Coverage |
Check the box (if applicable): Indicates the underlying policy coverage any automobile (symbol 1). |
| UNDERLYING INSURANCE (continued) |
CGL – Claims Made – Coverage |
Check the box (if applicable): Indicates the underlying general liability policy is a claims made policy. |
| UNDERLYING INSURANCE (continued) |
CGL – Occurrence – Coverage |
Check the box (if applicable): Indicates the underlying general liability policy is an occurrence policy. |
| UNDERLYING INSURANCE (continued) |
Aircraft Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes aircraft liability coverage. |
| UNDERLYING INSURANCE (continued) |
Aircraft Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for aircraft liability coverage. |
| UNDERLYING INSURANCE (continued) |
Aircraft Passenger Liability -Coverage |
Check the box (if applicable): Indicates the underlying policy includes aircraft passenger liability coverage. |
| UNDERLYING INSURANCE (continued) |
Aircraft Passenger Liability -Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for aircraft passenger liability coverage. |
| UNDERLYING INSURANCE (continued) |
Additional Interests – Coverage |
Check the box (if applicable): Indicates the underlying policy includes additional interests coverage. |
| UNDERLYING INSURANCE (continued) |
Additional Interests – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for additional interests coverage. |
| UNDERLYING INSURANCE (continued) |
Care, Custody, Control – Coverage |
Check the box (if applicable): Indicates the underlying policy includes care, custody and control coverage. |
| UNDERLYING INSURANCE (continued) |
Care, Custody, Control – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for care, custody and control coverage. |
| UNDERLYING INSURANCE (continued) |
Employee Benefit Liability -Coverage |
Check the box (if applicable): Indicates the underlying policy includes employee benefits liability coverage. |
| UNDERLYING INSURANCE (continued) |
Employee Benefit Liability -Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for employee benefits liability coverage. |
| UNDERLYING INSURANCE (continued) |
Foreign Liability / Travel -Coverage |
Check the box (if applicable): Indicates the underlying policy includes foreign liability/travel coverage. |
| UNDERLYING INSURANCE (continued) |
Foreign Liability / Travel -Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for foreign liability/travel coverage. |
| UNDERLYING INSURANCE (continued) |
Garage Keepers Liability -Coverage |
Check the box (if applicable): Indicates the underlying policy includes garage keepers liability coverage. |
| UNDERLYING INSURANCE (continued) |
Garage Keepers Liability -Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for garage keepers liability coverage. |
| UNDERLYING INSURANCE (continued) |
Incidental Medical Malpractice -Coverage |
Check the box (if applicable): Indicates the underlying policy includes incidental medical malpractice coverage. |
| UNDERLYING INSURANCE (continued) |
Incidental Medical Malpractice -Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for incidental medical malpractice coverage. |
| UNDERLYING INSURANCE (continued) |
Liquor Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes liquor liability coverage. |
| UNDERLYING INSURANCE (continued) |
Liquor Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for liquor liability coverage. |
| UNDERLYING INSURANCE (continued) |
Pollution Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes pollution liability coverage. |
| UNDERLYING INSURANCE (continued) |
Pollution Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for pollution liability coverage. |
| UNDERLYING INSURANCE (continued) |
Professional Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes professional liability (errors and omissions) coverage. |
| UNDERLYING INSURANCE (continued) |
Professional Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for professional liability (errors and omissions) coverage. |
| UNDERLYING INSURANCE (continued) |
Vendor Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes vendors liability coverage. |
| UNDERLYING INSURANCE (continued) |
Vendor Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for vendors liability coverage. |
| UNDERLYING INSURANCE (continued) |
Watercraft Liability – Coverage |
Check the box (if applicable): Indicates the underlying policy includes watercraft liability coverage. |
| UNDERLYING INSURANCE (continued) |
Watercraft Liability – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for watercraft liability coverage. |
| UNDERLYING INSURANCE (continued) |
Other – Coverage |
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed. |
| UNDERLYING INSURANCE (continued) |
Other – Description |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE (continued) |
Other – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for the coverage described. |
| UNDERLYING INSURANCE (continued) |
Other – Coverage |
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed. |
| UNDERLYING INSURANCE (continued) |
Other – Description |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE (continued) |
Other – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for the coverage described. |
| UNDERLYING INSURANCE (continued) |
Other – Coverage |
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed. |
| UNDERLYING INSURANCE (continued) |
Other – Description |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE (continued) |
Other – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for the coverage described. |
| UNDERLYING INSURANCE (continued) |
Other – Coverage |
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed. |
| UNDERLYING INSURANCE (continued) |
Other – Description |
Enter text: The description of the coverage. |
| UNDERLYING INSURANCE (continued) |
Other – Exposure |
Check the box (if applicable): Indicates the limits are less than those shown on the underlying insurance section of the form causing an exposure to exists for the coverage described. |
| UNDERLYING INSURANCE (continued) |
Underlying Insurance Coverage Information |
Enter text: The description of underlying insurance coverage information including all restrictions (e.g. laser endorsements, discrimination, subrogation waivers) or extensions of coverage. |
| UNDERLYING INSURANCE (continued) |
Previous Experience |
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
|
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
|
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
|
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
|
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
|
Enter date: The date the claim was filed. |
| UNDERLYING INSURANCE (continued) |
|
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| UNDERLYING INSURANCE (continued) |
|
Enter text: A brief description of the loss. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The amount that has been paid on this claim to date. |
| UNDERLYING INSURANCE (continued) |
|
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| UNDERLYING INSURANCE (continued) |
No Such Claims |
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. As used here, also indicates there were no claims exceeding $10,000. |
| CARE, CUSTODY, CONTROL |
Loc |
Enter number: The producer assigned number for the location if applicable to the ACORD 125. |
| CARE, CUSTODY, CONTROL |
Real Property/Personal Property |
Check the box (if applicable): Indicates the property in the care, custody and control of the insured is real property. |
| CARE, CUSTODY, CONTROL |
Personal Property |
Check the box (if applicable): Indicates the property in the care, custody and control of the insured is personal property. |
| CARE, CUSTODY, CONTROL |
Value |
Enter amount: The value of the entire building, not just the portion occupied, for real property or the value of the personal property. |
| CARE, CUSTODY, CONTROL |
A, B, C, D |
Check the box (if applicable): Indicates the insured is held harmless in the lease. |
| CARE, CUSTODY, CONTROL |
B |
Check the box (if applicable): Indicates the insured has a waiver of subrogation. |
| CARE, CUSTODY, CONTROL |
C |
Check the box (if applicable): Indicates the insured is a named insured on the fire policy. |
| CARE, CUSTODY, CONTROL |
D |
Enter text: The description of the insured’s liability for the described premises when other than those listed. |
| CARE, CUSTODY, CONTROL |
Sq Ft of Bldg Occ |
Enter number: The total square footage of the premises occupied by the applicant. |
| CARE, CUSTODY, CONTROL |
Occupancy / Description of Personal Property |
Enter text: The description of the building occupancy or of the property held by the insured in his care, custody and control. |
| VEHICLES |
# Owned |
Enter number: The number of owned private passenger vehicles. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned private passenger vehicles. |
| VEHICLES |
# Leased |
Enter number: The number of leased private passenger vehicles. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in private passenger vehicles. |
| VEHICLES |
Local |
Enter number: The number of private passenger vehicles that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”.. |
| VEHICLES |
Intermediate |
Enter number: The number of private passenger vehicles that fall within the category of intermediate radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of private passenger vehicles that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned light weight trucks. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned light weight trucks. |
| VEHICLES |
# Leased |
Enter number: The number of leased light weight trucks. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in light weight trucks. |
| VEHICLES |
Local |
Enter number: The number of light weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of light weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of light weight trucks that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned medium weight trucks. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned medium weight trucks. |
| VEHICLES |
# Leased |
Enter number: The number of leased medium weight trucks. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in medium weight trucks. |
| VEHICLES |
Local |
Enter number: The number of medium weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of medium weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of medium weight trucks that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned heavy weight trucks. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned heavy weight trucks. |
| VEHICLES |
# Leased |
Enter number: The number of leased heavy weight trucks. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in heavy weight trucks. |
| VEHICLES |
Local |
Enter number: The number of heavy weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of heavy weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of heavy weight trucks that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned extra heavy weight trucks. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned extra heavy weight trucks. |
| VEHICLES |
# Leased |
Enter number: The number of leased extra heavy weight trucks. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in extra heavy weight trucks. |
| VEHICLES |
Local |
Enter number: The number of extra heavy weight trucks that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of extra heavy weight trucks. that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of extra heavy weight trucks that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned heavy weight truck tractors. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned heavy weight truck tractors. |
| VEHICLES |
# Leased |
Enter number: The number of leased heavy weight truck tractors. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in heavy weight truck tractors. |
| VEHICLES |
Local |
Enter number: The number of heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of heavy weight truck tractors that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned extra heavy weight truck tractors. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned extra heavy weight truck tractors. |
| VEHICLES |
# Leased |
Enter number: The number of leased extra heavy weight truck tractors. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in extra heavy weight truck tractors. |
| VEHICLES |
Local |
Enter number: The number of extra heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of extra heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of extra heavy weight truck tractors that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| VEHICLES |
# Owned |
Enter number: The number of owned buses. |
| VEHICLES |
# Non-owned |
Enter number: The number of non-owned buses. |
| VEHICLES |
# Leased |
Enter number: The number of leased buses. |
| VEHICLES |
Property Hauled |
Enter text: The description of property hauled in buses. |
| VEHICLES |
Local |
Enter number: The number of buses that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “local”. |
| VEHICLES |
Intermediate |
Enter number: The number of buses that fall within the category of local radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “intermediate”. |
| VEHICLES |
Long Distance |
Enter number: The number of buses that fall within the category of long distance radius/distance in accordance with a company’s rating rules. The Insurance Services Office maintains the definition of “long distance”. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| ADDITIONAL EXPOSURES |
1. Media used, annual costs |
Enter code: The type of advertising media used (e.g. Print, Television, Radio, etc.) |
| ADDITIONAL EXPOSURES |
Annual Cost |
Enter amount: The annual cost of the advertising media used. |
| ADDITIONAL EXPOSURES |
2. Services of advertising agency used? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Are services of an Advertising Agency used?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
3. Any coverage provided under agency’s policy? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Any coverage provided under agency’s policy?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
4. Does applicant own, lease or operate aircraft? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Does applicant own/lease/operate aircraft?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
5. Are explosives, caustics, flammables or other dangerous cargo hauled? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Are explosives, caustics, flammables or other dangerous cargo hauled?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
6. Are passengers carried for a fee? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Are passengers carried for a fee?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
7. Any units not insured by underlying policies? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Any units not insured by underlying policies?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
8. Are any vehicles leased or rented to others? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Are any vehicles leased or rented to others?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
9. Is Hired and Non-Owned coverage provided? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Is hired and non-owned coverage provided?” |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
10. Is bridge, dam or marine work performed? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Is bridge, dam or marine work performed?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
11. Describe typical jobs performed |
Enter text: The description of work performed by the insured. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| ADDITIONAL EXPOSURES |
12. Describe agreement |
Enter text: The description of the contractual agreement(s) pertaining to the work performed. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| ADDITIONAL EXPOSURES |
13. Does applicant own, rent, or otherwise use cranes? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Does applicant own, rent or otherwise use cranes?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
14. Do subcontractors carry coverages or limits less than applicant? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Do subcontractors carry coverages or limits less than applicant?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
15. Is applicant self-insured in any state? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Is applicant self-insured in any state?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
16. Regulation: – Jones Act |
Check the box (if applicable): Indicates the employee/self-insured is subject to the Jones Act. |
| ADDITIONAL EXPOSURES |
FELA |
Check the box (if applicable): Indicates the employee/self-insured is subject to the Federal Employers Liability Act. |
| ADDITIONAL EXPOSURES |
Stop Gap |
Check the box (if applicable): Indicates the employee/self-insured is subject to Stop Gap. |
| ADDITIONAL EXPOSURES |
Other |
Check the box (if applicable): Indicates the employee/self-insured is subject to regulations not listed. |
| ADDITIONAL EXPOSURES |
Other Description |
Enter text: The description of the regulations the employee/self-insured is subject to. |
| ADDITIONAL EXPOSURES |
17. Hospital or first aid facility maintained? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Hospital or first aid facility maintained?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
18. Coverage provided for doctors/nurses? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Coverage provided for doctors/nurses?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
19. Indicate # of doctors, nurses, beds. |
Enter number: The number of doctors. |
| ADDITIONAL EXPOSURES |
Nurses |
Enter number: The number of nurses. |
| ADDITIONAL EXPOSURES |
Beds |
Enter number: The number of beds/bunks. |
| ADDITIONAL EXPOSURES |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| ADDITIONAL EXPOSURES |
EPA # |
Enter identifier: The number assigned to the insured by the Environmental Protection Agency. |
| ADDITIONAL EXPOSURES |
20. Do current or past products, or their components, contain hazardous materials that may require special disposal methods? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Do current or past products, or their components, contain hazardous materials that may require special disposal methods?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
21. Indicate the coverages carried: – GL with Standard ISO Pollution Exclusion |
Check the box (if applicable): Indicates the insured carries a general liability policy with standard Insurance Services Office pollution exclusion coverage. |
| ADDITIONAL EXPOSURES |
GL with Standard Sudden & Accidental Only |
Check the box (if applicable): Indicates the insured carries a general liability policy with standard sudden and accidental only coverage. |
| ADDITIONAL EXPOSURES |
GL with Pollution Coverage Endorsement |
Check the box (if applicable): Indicates the insured carries a general liability policy with a pollution coverage endorsement. |
| ADDITIONAL EXPOSURES |
Separate Pollution Coverage |
Check the box (if applicable): Indicates the insured carries separate pollution coverage. |
| ADDITIONAL EXPOSURES |
22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
23. Any foreign operations, foreign products distributed in the USA or US products sold / distributed in foreign countries? (If “YES”, Attach ACORD 815) |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Any foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries?”. |
| ADDITIONAL EXPOSURES |
24. Product liability loss in past three (3) years? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Any product liability loss in past specified number of years?”. |
| ADDITIONAL EXPOSURES |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| ADDITIONAL EXPOSURES |
25. Gross sales from each of the last three (3) years. |
Enter amount: The gross sales or receipts amount. |
| ADDITIONAL EXPOSURES |
Gross Sales |
Enter amount: The gross sales or receipts amount. |
| ADDITIONAL EXPOSURES |
Gross Sales |
Enter amount: The gross sales or receipts amount. |
| ADDITIONAL EXPOSURES |
26. Describe independent contractors |
Enter text: The description of independent contractors. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| ADDITIONAL EXPOSURES |
27. Does applicant own or lease watercraft? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, “Does applicant own or lease watercraft?”. |
| ADDITIONAL EXPOSURES |
Loc # |
Enter number: The location number for the premises. |
| ADDITIONAL EXPOSURES |
# Owned |
Enter number: The number of watercraft owned. As used here, the number of watercraft owned of the same type. |
| ADDITIONAL EXPOSURES |
Length |
Enter number: The length of the watercraft expressed in feet. |
| ADDITIONAL EXPOSURES |
Horsepower |
Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks. |
| ADDITIONAL EXPOSURES |
Loc # |
Enter number: The location number for the premises. |
| ADDITIONAL EXPOSURES |
# Owned |
Enter number: The number of watercraft owned. As used here, the number of watercraft owned of the same type. |
| ADDITIONAL EXPOSURES |
Length |
Enter number: The length of the watercraft expressed in feet. |
| ADDITIONAL EXPOSURES |
Horsepower |
Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks. |
| ADDITIONAL EXPOSURES |
Loc # |
Enter number: The location number for the premises. |
| ADDITIONAL EXPOSURES |
# Stories |
Enter number: The number of stories, counting the ground floor as one, which this building has. |
| ADDITIONAL EXPOSURES |
# Units |
Enter number: The number of separate living units in the structure. |
| ADDITIONAL EXPOSURES |
# Swimming Pools |
Enter number: The number of swimming pools on the premises. |
| ADDITIONAL EXPOSURES |
# Diving Boards |
Enter number: The number of diving boards on the premises. |
| ADDITIONAL EXPOSURES |
Loc # |
Enter number: The location number for the premises. |
| ADDITIONAL EXPOSURES |
# Stories |
Enter number: The number of stories, counting the ground floor as one, which this building has. |
| ADDITIONAL EXPOSURES |
# Units |
Enter number: The number of separate living units in the structure. |
| ADDITIONAL EXPOSURES |
# Swimming Pools |
Enter number: The number of swimming pools on the premises. |
| ADDITIONAL EXPOSURES |
# Diving Boards |
Enter number: The number of diving boards on the premises. |
| REMARKS |
Remarks |
Enter text: The remarks associated with the commercial umbrella line of business. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| REMARKS |
Remarks |
Enter text: The remarks associated with the commercial umbrella line of business. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
| SIGNATURE |
Uninsured Motorists (UM) Coverage |
Enter limit: The limit for commercial umbrella / excess uninsured motorists coverage (if applicable in your states). |
| SIGNATURE |
Underinsured Motorists (UIM) Coverage |
Enter limit: The limit for commercial umbrella / excess underinsured motorists coverage (if applicable in your state). |
| SIGNATURE |
Applicable Only in Louisiana – 1. I Select UM Limits |
Initial here: The named insured’s initials. As used here, applicable in Louisiana. |
| SIGNATURE |
2. I Reject UM Coverage |
Initial here: The named insured’s initials. As used here, applicable in Louisiana. |
| SIGNATURE |
Applicable Only in New Hampshire – 1. I Select UM Limits |
Initial here: The named insured’s initials. As used here, applicable in New Hampshire. |
| SIGNATURE |
2. I Reject UM Coverage |
Initial here: The named insured’s initials. As used here, applicable in New Hampshire. |
| SIGNATURE |
Applicable Only in Wisconsin – 1. I Select UM Limits |
Initial here: The named insured’s initials. As used here, applicable in Wisconsin. |
| SIGNATURE |
2. I Reject UM Coverage |
Initial here: The named insured’s initials. As used here, applicable in Wisconsin. |
| SIGNATURE |
3. I Select UIM Limits |
Initial here: The named insured’s initials. As used here, applicable in Wisconsin. |
| SIGNATURE |
4. I Reject UIM Coverage |
Initial here: The named insured’s initials. As used here, applicable in Wisconsin. |
| 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. |
| 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. |
| SIGNATURE |
State Producer License No |
Enter identifier: The State License Number of the producer. As used here, this is required in Florida. |
| SIGNATURE |
Applicant’s Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
| SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
| 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. |
| Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |