ACORD 190 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 190 (2009/12) Supplemental PropertyApplication The title of the form. ACORD 190, Supplemental Property Application, is used to collect additional detailed underwriting information on property risks which are susceptible to arson or other fraudulent losses. This application may be used in conjunction with the Commercial Property Section – ACORD 140,The Business Owners Application – ACORD 160,The Agriculture Property Section – ACORD 402, and the Residential Section -ACORD 89. The Supplemental Property Application is a uniquely designed ACORD application. “Yes” responses to the underwriting questions on the front side should be explained in detail in corresponding sections on the back of the application. Both sides of this application must be completed. The instruction information below is formatted by sections; it does not deal with the front side first and then the back.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION LOC # Enter number: The location number for the premises.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION 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 thefile 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.
LOCATION OF PROPERTY Street Enter text: The first address line of the physical location.
LOCATION OF PROPERTY Enter text: The city of the physical location.
LOCATION OF PROPERTY Enter text: The county of the location.
LOCATION OF PROPERTY Enter code: The state or province of the physical location.
LOCATION OF PROPERTY Enter code: The postal code of the physical location.
UNDERWRITING INFORMATION Is the applicant other than an individual or a sole proprietorship? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is the applicant other than an individual or a sole proprietorship?”. As used here, if “Yes”, complete section (A) on page 2.
UNDERWRITING INFORMATION Are mortgage paymentsoverdue by three months or more? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are mortgage payments overdue by three months or more?”. As used here, if “Yes”, complete section (B) on page 2.
UNDERWRITING INFORMATION Are tax liens against this property or business taxes unpaidor overdue for one year or more? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are tax liens against this property or business taxes unpaid or overdue for one year or more?”. As used here, if “Yes”, complete section (B) on page 2.
UNDERWRITING INFORMATION Are there any current violations of fire, safety, health, building or construction codes at any listed locations? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any current violations of fire, safety, health, building or construction codes at any listed locations?”. As used here, if “Yes”, complete section (C) on page 2.
UNDERWRITING INFORMATION During the last ten years, has anyone with a financial interest in this property including the mortgagee been convicted of any degree of arson, fraud, or other crime related to loss on this or any other property? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the last 10 years, has anyone with a financial interest in this property including the mortgagee (if other than a federally or state chartered lending institution) been convicted of any degree of arson, fraud, or other crime related to loss on this or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)”. As used here, if “Yes”, complete section (D) on page 2.
UNDERWRITING INFORMATION During the last ten years, has anyone with a financial interest in this property including the mortgagee had any fire or explosion losses exceeding $1,000 on this or any other property? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “During the last 10 years, has anyone with a financial interest in this property including the mortgagee (if other than a federally or state chartered lending institution) had any fire or explosion losses exceeding $1,000 on this or any other property?”. As used here, if “Yes”, complete section (D) on page 2.
UNDERWRITING INFORMATION Is the lender other than a federally or state chartered lending institution? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is the lender other than a federally or state chartered lending institution?”. As used here, if “Yes”, complete section (E) on page 2.
UNDERWRITING INFORMATION Is any portion of the building vacant, unoccupied or seasonal? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is any portion of the building vacant, unoccupied or seasonal ?”. As used here, if “Yes”, complete section (F) on page 2.
UNDERWRITING INFORMATION “If an apartment, are more than 10% of the rental units unoccupied? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “If an apartment, are more than 10% of the rental units unoccupied?” As used here, if “Yes”, complete section (F) on page 2.
UNDERWRITING INFORMATION Is there any other insurance in force or to be secured on this property? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is there any other insurance in force or to be secured on this property?”. As used here, if “Yes”, complete section (G) on page 2.
BUILDING INFORMATION H. Purchase Date Enter date: The date the property was purchased, (MM/DD/YYYY). As used here, if within the last 3 years, complete Real Estate Transactions information, section (H), on page 2.
BUILDING INFORMATION Purchase Price Enter amount: The amount the insured paid for the property.
BUILDING INFORMATION Rental Income Enter amount: The expected annual rental income amount.
BUILDING INFORMATION Approximate Cost of Subsequent Improvements Enter amount: The approximate cost of subsequent improvements to the property.
BUILDING INFORMATION Approximate Replacement Costs Enter amount: The estimated total dollar amount required to rebuild the building, without depreciation, in case of total loss.
BUILDING INFORMATION Approximate Fair Market Value (Exclusive of Land) Enter amount: The current market value for which the building could be sold (exclusive of land).
BUILDING INFORMATION Indicate the value used to determine the amount of: Purchase Price Check the box (if applicable): Indicates the purchase prices was used to determine the amount of insurance.
BUILDING INFORMATION Replace Cost Check the box (if applicable): Indicates the replacement cost was used to determine the amount of insurance.
BUILDING INFORMATION Fair Mkt Value Check the box (if applicable): Indicates the fair market value was used to determine the amount of insurance.
BUILDING INFORMATION How was the value determined? (check all that apply) Professional Appraiser Check the box (if applicable): Indicates the insurance value was determined by a professional appraiser.
BUILDING INFORMATION By Applicant / Insured Check the box (if applicable): Indicates the insurance value was determined by the applicant / insured.
BUILDING INFORMATION By Agent / Broker Check the box (if applicable): Indicates the insurance value was determined by the agent / broker.
BUILDING INFORMATION Company Appraisal Guide Check the box (if applicable): Indicates the insurance value was determined by the company appraisal guide.
BUILDING INFORMATION Name of Company: Enter text: The name of the company providing the appraisal guide.
BUILDING INFORMATION Other Checkbox Check the box (if applicable): Indicates the insurance value was determined by a means other than those listed.
BUILDING INFORMATION Other Description Enter text: The description of how the insurance value was determined.
STATEMENT / SIGNATURE Signature of Agent / Broker 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. As used here, the agent / broker signature is not required in New York.
STATEMENT / SIGNATURE Producer’s Name Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
STATEMENT / SIGNATURE State Producer License No Enter identifier: The State License Number of the producer.
STATEMENT / SIGNATURE Signature of Insured /Applicant Sign here: Accommodates the signature of the applicant or named insured.
STATEMENT / SIGNATURE Title of Insured / Applicant Enter number: The title of the contact for the named insured.
STATEMENT / 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.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION LOC # Enter number: The location number for the premises.
(A) OWNERSHIP INFORMATION Name One Enter text: The additional interest’s full name.
(A) OWNERSHIP INFORMATION Address One Enter text: The additional interest’s mailing address line one.
(A) OWNERSHIP INFORMATION Enter text: The additional interest’s mailing address city name.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address state or province code.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address postal code.
(A) OWNERSHIP INFORMATION Position One Enter text: The title of the additional interest’s authorized representative.
(A) OWNERSHIP INFORMATION Interest % One Enter percentage: The percentage of ownership the additional interest has in the item.
(A) OWNERSHIP INFORMATION Name Two Enter text: The additional interest’s full name.
(A) OWNERSHIP INFORMATION Address Two Enter text: The additional interest’s mailing address line one.
(A) OWNERSHIP INFORMATION Enter text: The additional interest’s mailing address city name.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address state or province code.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address postal code.
(A) OWNERSHIP INFORMATION Position Two Enter text: The title of the additional interest’s authorized representative.
(A) OWNERSHIP INFORMATION Interest % Two Enter percentage: The percentage of ownership the additional interest has in the item.
(A) OWNERSHIP INFORMATION Name Three Enter text: The additional interest’s full name.
(A) OWNERSHIP INFORMATION Address Three Enter text: The additional interest’s mailing address line one.
(A) OWNERSHIP INFORMATION Enter text: The additional interest’s mailing address city name.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address state or province code.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address postal code.
(A) OWNERSHIP INFORMATION Position Three Enter text: The title of the additional interest’s authorized representative.
(A) OWNERSHIP INFORMATION Interest % Three Enter percentage: The percentage of ownership the additional interest has in the item.
(A) OWNERSHIP INFORMATION Name Four Enter text: The additional interest’s full name.
(A) OWNERSHIP INFORMATION Address Four Enter text: The additional interest’s mailing address line one.
(A) OWNERSHIP INFORMATION Enter text: The additional interest’s mailing address city name.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address state or province code.
(A) OWNERSHIP INFORMATION Enter code: The additional interest’s mailing address postal code.
(A) OWNERSHIP INFORMATION Position Four Enter text: The title of the additional interest’s authorized representative.
(A) OWNERSHIP INFORMATION Interest % Four Enter percentage: The percentage of ownership the additional interest has in the item.
(B) MORTGAGE PAYMENT Mortgagee Enter text: The additional interest’s full name.
(B) MORTGAGE PAYMENT Enter text: The additional interest’s mailing address line one.
(B) MORTGAGE PAYMENT Enter text: The additional interest’s mailing address city name.
(B) MORTGAGE PAYMENT Enter code: The additional interest’s mailing address state or province code.
(B) MORTGAGE PAYMENT Enter code: The additional interest’s mailing address postal code.
(B) MORTGAGE PAYMENT Date Due Enter date: The date the payment is due. As used here, the date the late payment was due.
(B) MORTGAGE PAYMENT Amount Due Enter amount: The amount due. As used here, the amount of the late payment.
(B) MORTGAGE PAYMENT Other Encumbrances Enter text: The description of any other encumbrances that may be on the property.
(B) TAX LIENS / OVERDUE TAXES Tax Lien One Check the box (if applicable): Indicates there is a tax lien on the property.
(B) TAX LIENS / OVERDUE TAXES Overdue Tax One Check the box (if applicable): Indicates there is overdue tax on the property.
(B) TAX LIENS / OVERDUE TAXES Date Due One Enter date: The date the tax is / was due.
(B) TAX LIENS / OVERDUE TAXES Amount Due One Enter amount: The amount of tax due.
(B) TAX LIENS / OVERDUE TAXES Tax Lien Two Check the box (if applicable): Indicates there is a tax lien on the property.
(B) TAX LIENS / OVERDUE TAXES Overdue Tax Two Check the box (if applicable): Indicates there is overdue tax on the property.
(B) TAX LIENS / OVERDUE TAXES Date Due Two Enter date: The date the tax is / was due.
(B) TAX LIENS / OVERDUE TAXES Amount Due Two Enter amount: The amount of tax due.
( C ) CODE VIOLATION Code Violations Date One Enter date: The date the violation was issued.
( C ) CODE VIOLATION Code Violations Description One Enter text: The description of the violation.
( C ) CODE VIOLATION Code Violations Date Two Enter date: The date the violation was issued.
( C ) CODE VIOLATION Code Violations Description Two Enter text: The description of the violation.
(D) CONVICTIONS Convictions Date One Enter date: The date of the conviction. As used here, the date of the conviction of arson, fraud or property related crime.
(D) CONVICTIONS Convictions Description One Enter text: The description of the conviction. As used here, the description of the conviction of arson, fraud or property related crime.
(D) CONVICTIONS Convictions Individual One Enter text: The full name of the individual convicted. As used here, the name of the individual convicted of arson, fraud or property related crime.
(D) CONVICTIONS Convictions Date Two Enter date: The date of the conviction. As used here, the date of the conviction of arson, fraud or property related crime.
(D) CONVICTIONS Convictions Description Two Enter text: The description of the conviction. As used here, the description of the conviction of arson, fraud or property related crime.
(D) CONVICTIONS Convictions Individual Two Enter text: The full name of the individual convicted. As used here, the name of the individual convicted of arson, fraud or property related crime.
(D) LOSSES Losses Date One Enter date: The date that the loss occurred. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Amount One Enter amount: The estimated dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as “small” or “substantial”. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Location One Enter text: The first address line of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter text: The city of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The state or province of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The postal code of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Description One Enter text: The description of the incident resulting in a potential loss to the insured. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Date Two Enter date: The date that the loss occurred. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Amount Two Enter amount: The estimated dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as “small” or “substantial”. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Location Two Enter text: The first address line of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter text: The city of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The state or province of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The postal code of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Description Two Enter text: The description of the incident resulting in a potential loss to the insured. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Date Three Enter date: The date that the loss occurred. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Amount Three Enter amount: The estimated dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as “small” or “substantial”. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Location Three Enter text: The first address line of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter text: The city of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The state or province of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Enter code: The postal code of the physical location. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES Losses Description Three Enter text: The description of the incident resulting in a potential loss to the insured. As used here, describes fire or explosion losses exceeding $1,000.
(E) LENDER Name Enter text: The additional interest’s full name.
(E) LENDER Explanation Enter code: The relationship of the additional interest to the named insured.
(F) VACANCY / UNOCCUPANCY Season When Unused – Start Date Enter text: The time span when the property is not in use. For seasonal property and risks when vacancy or unoccupancy is planned, enter the start and end dates of the vacancy or unoccupancy.
(F) VACANCY / UNOCCUPANCY End Date Enter text: The time span when the property is not in use. For seasonal property and risks when vacancy or unoccupancy is planned, enter the start and end dates of the vacancy or unoccupancy.
(F) VACANCY / UNOCCUPANCY Total # of Apartment Units Enter number: The number of separate living units in structure.
(F) VACANCY / UNOCCUPANCY # of Unoccupied Apartment Units Enter number: The number of unoccupied apartments in structure.
(F) VACANCY / UNOCCUPANCY Other Buildings, % Vacant Enter percentage: The percentage of the building, excluding apartments, that is vacant (unoccupied and no furniture).
(F) VACANCY / UNOCCUPANCY Other Buildings, % Unoccupied Enter percentage: The percentage of the building, excluding apartments, that is unoccupied (furnished, but no residents).
(F) VACANCY / UNOCCUPANCY Anticipated Date of Occupancy Enter date: The anticipated date of occupancy for tenants that are scheduled to occupy the building.
(F) VACANCY / UNOCCUPANCY Reason for Vacancy / Unoccupancy Enter text: The reasons for the vacancy or unoccupancy, such as seasonal rental property or building renovation.
(F) VACANCY / UNOCCUPANCY How is Building Protected from Entry? Enter text: The description of other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm). Indicate if the building has skylights and if windows are visible from the street. As used here, list any security measures to protect the building from unlawful entry.
(F) VACANCY / UNOCCUPANCY Is there a government order to vacate or destroy the building, or has the building been classified as uninhabitable or structurally unsafe? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is there a government order to vacate or destroy the building, or has the building been classified as uninhabitable or structurally unsafe?”.
(F) VACANCY / UNOCCUPANCY Are any utilities out of service? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any utilities out of service?”.
(F) VACANCY / UNOCCUPANCY Explain Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
(F) VACANCY / UNOCCUPANCY Is there unrepaired damage or have items been stripped from building? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is there unrepaired damage or have items been stripped from building?”.
(F) VACANCY / UNOCCUPANCY Describe Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
(F) VACANCY / UNOCCUPANCY Is the building up for sale? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is the building up for sale?”.
(F) VACANCY / UNOCCUPANCY Date Listed For Sale (MM/DD/YYYY) Enter date: The date the building was listed for sale.
(G) OTHER INSURANCE Other Insurance Status One Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE Other Insurance Effective Date One Enter date: The date on which the terms and conditions of the other policy commence.
(G) OTHER INSURANCE Other Insurance Expiration Date One Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE Other Insurance Amount of Insurance One Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE Other Insurance Carrier One Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE Other Insurance Policy Number One Enter identifier: The policy number on any other applicable insurance.
(G) OTHER INSURANCE Other Insurance Status Two Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE Other Insurance Effective Date Two Enter date: The date on which the terms and conditions of the other policy commence.
(G) OTHER INSURANCE Other Insurance Expiration Date Two Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE Other Insurance Amount of Insurance Two Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE Other Insurance Carrier Two Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE Other Insurance Policy Number Two Enter identifier: The policy number on any other applicable insurance.
(G) OTHER INSURANCE Other Insurance Status Three Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE Other Insurance Effective Date Three Enter date: The date on which the terms and conditions of the other policy commence.
(G) OTHER INSURANCE Other Insurance Expiration Date Three Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE Other Insurance Amount of Insurance Three Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE Other Insurance Carrier Three Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE Other Insurance Policy Number Three Enter identifier: The policy number on any other applicable insurance.
(H) REAL ESTATE TRANSACTIONS Date One Enter date: The date of the real estate transaction. As used here, list all real estate transactions over the past three years.
(H) REAL ESTATE TRANSACTIONS Name of Seller One Enter text: The name of seller of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Selling Price One Enter amount: The selling price of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Mortgage Amount One Enter amount: The mortgage amount of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Mortgagee One Enter Text: The mortgagee of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Date Two Enter date: The date of the real estate transaction. As used here, list all real estate transactions over the past three years.
(H) REAL ESTATE TRANSACTIONS Name of Seller Two Enter text: The name of seller of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Selling Price Two Enter amount: The selling price of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Mortgage Amount Two Enter amount: The mortgage amount of the real estate transaction.
(H) REAL ESTATE TRANSACTIONS Mortgagee Two Enter Text: The mortgagee of the real estate transaction.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).