ACORD 401 Instructions


Section Name Field Name Field and/or Section Description
The underwriting process for any Agriculture account begins with the submission of a completed application. This spreadsheet will provide assistance in completing ACORD 401, Agriculture Application – Applicant Information Section.
TITLE ACORD 401 (2007/09) Agriculture Application Applicant Information Section The Applicant Information Section is the foundation on which the ACORD Agriculture application program is built. This form contains information that is not duplicated on other ACORD agricultural application forms. The Applicant Information Section is a required part of every Agriculture submission, and no such application is complete without it.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Agency’s name and address
IDENTIFICATION SECTION Contact Name Indicate the name of the contact witihin the agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Agency’s telephone number.
IDENTIFICATION SECTION FAX Agency’s fax number.
IDENTIFICATION SECTION E-Mail Address Agency’s e-mail address.
Identification code assigned to your agency or brokerage firm by the insurance company
IDENTIFICATION SECTION Code receiving this form.
If your agency uses a sub-code identification system with the company, enter the
IDENTIFICATION SECTION Subcode appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
Name of the insurance company that will receive the application. Do not use group names,
use the actual name of the company within the group in which you wish to have the policy
IDENTIFICATION SECTION Carrier issued.
IDENTIFICATION SECTION NAIC Code Enter the NAIC code of the applicable insurance company.
IDENTIFICATION SECTION Company Policy or Program Name Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Program Code Show the program code assigned by the company, if applicable.
IDENTIFICATION SECTION Account No. Account number assigned by the applicable insurance company.
IDENTIFICATION SECTION New Indicate if the applicant is a risk that is new to the company.
IDENTIFICATION SECTION Renwl Indicate if the applicant is a risk that is a renewal of an expiring policy with the same company.
IDENTIFICATION SECTION Effective Date Date on which the terms and conditions of the policy will commence.
IDENTIFICATION SECTION Expiration Date Date on which the terms and conditions of the policy will terminate unless renewed.
IDENTIFICATION SECTION Direct Bill / Agency Bill Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.
IDENTIFICATION SECTION Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company’s specific designation for the plan where possible. Examples: * Prepaid * Annual * Semi-annual * Bi-monthly * 40-30-30
IDENTIFICATION SECTION Quote Indicate whether thecompany’s response to this application is expected to be a quote or an issued policy. If the risk is bound, list the date and time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes.
IDENTIFICATION SECTION Bound (Checkbox) Indicate whichcompany response to this application is expected. If the risk is bound, list the date and the time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes.
IDENTIFICATION SECTION Bound Date If the risk is bound, list the date and the time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes.
IDENTIFICATION SECTION Issue Policy (Checkbox) Indicate whether the company’s response to this application is expected to be a quote or an issued policy. If the risk is bound, list the date and time coverage began and attach a copy of the binder. If more than one option applies, check multiple boxes.
IDENTIFICATION SECTION Policy Type Indicate the type of policy.
IDENTIFICATION SECTION Est Total Premium Indicate the estimated total premium.
IDENTIFICATION SECTION Deposit Indicate the amount of any deposit paid.
IDENTIFICATION SECTION Balance Indicate the balance owed by the applicant.
IDENTIFICATION SECTION Indicate Sections Attached Check the applicable box(es).
IDENTIFICATION SECTION Agriculture Property Attach ACORD 402
IDENTIFICATION SECTION Agriculture Property Section Scheduled and Unscheduled Personal Property Attach ACORD 403
IDENTIFICATION SECTION Agriculture Liability Attach ACORD 404
IDENTIFICATION SECTION Agriculture Premises / Location Diagram Attach ACORD 405
IDENTIFICATION SECTION Agriculture Property Section Unscheduled Farm Personal Property Inventory Form Attach ACORD 406
IDENTIFICATION SECTION Livestock Mortality Section Attach ACORD 407
IDENTIFICATION SECTION Equine Liability Section Attach ACORD 408
IDENTIFICATION SECTION Commercial Auto Attach Business Auto, ACORD 127, or Truckers, ACORD 132
IDENTIFICATION SECTION CommercialGeneral Liability Attach ACORD 126
IDENTIFICATION SECTION Homeowners Attach ACORD 80
IDENTIFICATION SECTION Personal Auto Attach the ACORD 90 application for the state where the vehicles are located.
IDENTIFICATION SECTION Personal Inland Marine Attach ACORD 81
IDENTIFICATION SECTION Umbrella Attach Personal Umbrella, ACORD 83, or Commercial Umbrella, ACORD 131.
IDENTIFICATION SECTION Watercraft Attach ACORD 82
IDENTIFICATION SECTION Other If there are any other additional forms attached, enter the form name on the blank lines.
APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) Full name of the applicant as it should appear on the policy. (The first named insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first.) If joint ownership, the name used may include both names. (e.g., John and Mary Smith.) Wording such as “et al” or “As their interests may appear” is not acceptable as the name of the insured. These phrases do not designate legal entities.
APPLICANT INFORMATION Mailing Address Incl ZIP+4 (of First Named Insured) The physical address at which the first named insured is to receive all correspondence regarding the insurance. Include the phone number and email address at that address.
APPLICANT INFORMATION FEIN or Social Security Number (of First Named Insured): Show the federal employment identification number (FEIN).
APPLICANT INFORMATION Phone (A/C, No, Ext): The first named insured’s phone number. Include area code and extension, if applicable.
APPLICANT INFORMATION Number of Years Farming Experience by the Insured Indicate the number of years the insured has had experience in farming.
APPLICANT INFORMATION E-Mail Address(es) Indicate e-mail address (if applicable).
APPLICANT INFORMATION Website Address(es) Indicate website address (if applicable).
APPLICANT INFORMATION Individual Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide theform of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION Partnership Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION Corporation Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION Joint Venture Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION Subchapter “S” Corporation Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION Not For Profit Org Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION LLC Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, LLC or Other. If other, provide a description such as Professional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT INFORMATION No. of Members and Managers Identify the number of members and managers
APPLICANT INFORMATION CR Bureau Name The name of the credit bureau used for this risk.
APPLICANT INFORMATION ID Number Number assigned by the credit bureau for this risk.
APPLICANT INFORMATION Inspection Contact Name of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number.
APPLICANT INFORMATION Phone (A/C, No, Ext) Telephone number of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number.
APPLICANT INFORMATION E-Mail Address Indicate e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
APPLICANT INFORMATION Accounting Records Contact Name of the person to contact for accounting information. This should be an individual under the insured’s employment, not the insurance agent.
APPLICANT INFORMATION Phone (A/C, No, Ext) Telephone number of the person to contact for accounting information. This should be an individual under the insured’s employment, not the insurance agent’s name and number.
APPLICANT INFORMATION E-Mail Address Indicate e-mail address (if applicable) of the person to contact for accounting information. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
TYPE OF FARM/RANCH Check boxes Check the applicable box(es) and describe all that apply in the space provided.
TYPE OF FARM/RANCH Describe Farm/Ranch Operations This item is designated to inform the underwriter of what type of operation each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location. The section should be completed in enough detail to enable the underwriter to understand and classify each operation.
LOSS HISTORY Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type of Loss Indicate the line of business involved in the loss.
LOSS HISTORY Description of Occurrence Give a brief description of the loss.
LOSS HISTORY Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date. If the claim is still open, list the reserve amount the previous carrier is holding open for this claim.
PRIOR INSURANCE INFORMATION Prior Carrier Indicate the prior carrier(s).
PRIOR INSURANCE INFORMATION Type of Insurance Indicate the type of insurance.
PRIOR INSURANCE INFORMATION Policy # Indicate the policy number(s).
PRIOR INSURANCE INFORMATION Amount of Coverage Indicate the amount(s) of coverage.
OTHER RELATED POLICIES Insured Name Full name of the applicant as it appears on the policy.
OTHER RELATED POLICIES Type of Insurance Indicate the type of insurance.
OTHER RELATED POLICIES Policy # Indicate the policy number(s).
REMARKS Remarks Use this section to provide any additional information required for underwriting or rating. Attach additional sheets if more space is required.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
LOCATION/SUBLOCATION Provide premises information separately for each building. Indicate the location number (if
SCHEDULE Loc # a number has been assigned).
LOCATION/SUBLOCATION Provide premises information separately for each building/sublocation. Indicate a building
SCHEDULE Bldg/Sublocation # number if applicable.
LOCATION/SUBLOCATION
SCHEDULE Address Provide the address for each premises.
LOCATION/SUBLOCATION Indicate if the sublocation type is a dwelling, structure or other type. If other, identify in the
SCHEDULE Sublocation Type space provided.
LOCATION/SUBLOCATION
SCHEDULE Range Part of legal address description.
LOCATION/SUBLOCATION
SCHEDULE Latitude GPS Coordinates for location
LOCATION/SUBLOCATION
SCHEDULE Longitude GPS Coordinates for location
LOCATION/SUBLOCATION
SCHEDULE Sublocation Description Provide a complete description of the sublocation.
Provide premises information separately for each location. Indicate the location number (if
PREMISES INFORMATION Loc # a number has been assigned).
PREMISES INFORMATION County Indicate the county in which this location number resides.
PREMISES INFORMATION Section Part of legal address description and is in XML this way.
PREMISES INFORMATION Township Indicate the township in which this location number resides which is part of legal address.
PREMISES INFORMATION Farm Name Enter the farm name used by the applicant, if applicable.
PREMISES INFORMATION # Acres For each separate location, show the total acreage.
Is there a year-round water supply
usable for fire protection? Check the applicable box(es). If “YES”, indicate the Source and the Quantity.
Enter the protection class that applies to the structure. Note that some structures may be
located too far from the nearest hydrant, or too far from the nearest fire station, for the
PREMISES INFORMATION Prot Class protection class of the community to apply.
PREMISES INFORMATION Fire District Code Enter the fire district code number for the location.
PREMISES INFORMATION Fire District Name Enter the fire district name for the location.
For each separate location, indicate whether the business is farmed by the owner of the
property, a tenant, a manager, or another entity. If another entity, identify in the space
PREMISES INFORMATION Operated By provided.
PREMISES INFORMATION Owned By Applicant For each separate location, indicate whether the business is owned by the applicant.
PREMISES INFORMATION Distance To Public Hydrant Ft Show the distance in feet to the nearest fire hydrant.
PREMISES INFORMATION Distance To Fire Stat Mi Show the distance in miles to the nearest fire station.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
GENERAL INFORMATION 1. Does applicant have any other business or other non-farm activities on or off premises, such as dude ranch, bed & breakfast or resort facility? If so, include receipts: $ If “YES” (Y), list receipts in $ area and provide details
GENERAL INFORMATION 2. Is farming the primary source of the insured’s income? If “YES” (Y), provide any details
GENERAL INFORMATION 3. Is this business new to the agency? If “YES” (Y), provide any details
GENERAL INFORMATION 4. Has any policy been cancelled or non-renewed in the past 5 years? (Not applicable in MO) This question may not be asked in Missouri.
GENERAL INFORMATION 5. Have you inspected this property in the last twelve (12) months? If “YES” (Y), provide any details
GENERAL INFORMATION 6. During the last five years (ten in RI), has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question.
GENERAL INFORMATION 7. Are independent contractors hired to perform any farming operations? If “YES” (Y), are Certificates of Insurance required?
GENERAL INFORMATION 8. Is any part of the farm rented or leased for recreations use? If “YES” (Y), indicate which part of farm
GENERAL INFORMATION 9. Are the farm premises open to the public for activities such as roadside stands, “U-Pick”, recreational, camping, “Rent-a-Garden”, auction, sales, shows, rodeos, hay rides, fishing, kennels, animal boarding, or Christmas tree sales? If “YES” (Y), indicate the activities, when open and any receipts
GENERAL INFORMATION 10. Are any portions of the farm or structures rented or leased or used by any other individual, corporation or interest for other than farming? If “YES” (Y), indicate the portion that are rented or leased
GENERAL INFORMATION 11. Does the applicant or spouse own, rent or operate as a farm, ranch or residence any premises other than those described in the premises information section. If “YES” (Y), provide location and details of coverage as well as type of operation
GENERAL INFORMATION 12. Is any land held for real estate development or speculation? If “YES” (Y), indicate the land information
GENERAL INFORMATION 13. Does applicant maintain any vacation or seasonal premises? If “YES” (Y), list address
GENERAL INFORMATION 14. Is the applicant a subsidiary of another? If “YES” (Y), list the subsidiary
GENERAL INFORMATION 15. Does the applicant have subsidiaries? If “YES” (Y), list the subsidiaries
GENERAL INFORMATION 16. Does the insured plan any construction or renovation work to be done on the premises in the next 12 months? If “YES” (Y), indicate what type of construction or renovation is planned with details
GENERAL INFORMATION 17. Is a formal safety program in existence? If “YES” (Y), provide details of the program
GENERAL INFORMATION 18. Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years? If “YES” (Y), provide specific details surrounding the circumstances involved in the foreclosure, repossession, bankruptcy, judgement or lien and whether or not it has been satisfied.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
REMARKS Remarks Use this section to provide any additional information required for underwriting or rating. If necessary, use additional sheets of paper.
ATTACHMENTS Attachments Check the applicable box(es). Blank space has been provided for other options.
SIGNATURE SECTION Applicant’s Signature Applicant must sign form.
SIGNATURE SECTION Date Date the form was signed
SIGNATURE SECTION Producer’s Signature Producer must sign form.
SIGNATURE SECTION National Producer Number The National Producer Number assigned by the NAIC should be shown.