ACORD 402 Instructions


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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 06/30/2009.
Section Name Field Name Field and/or Section Description
TITLE ACORD 402 (2009/03) Agriculture Property Section The title of the form. ACORD 402, Agriculture Property Section, is designed to handle the basic underwriting and rating needs for Agriculture property exposures. The Property Section accommodates five separate premises. This form was designed to be used in conjunction with the Agriculture Application -Applicant Information Section (ACORD 401). Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 401. Even though this data matches the data on ACORD 401, it is still importantto complete it. Many companies separate the applications by sub-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 Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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 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 Account Number Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number.
IDENTIFICATION SECTION New Check the box (if applicable): Indicates the response expected from the company is a new issued policy.
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Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Renewal Check the box (if applicable): Indicates the response expected from the company is a renewed policy.
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 Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
PREMISES INFORMATION Location # Enter number: The producer assigned number of the location.
PREMISES INFORMATION Building # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Building Description Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be “3 story blue structure on the left of the main building”.
PREMISES INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # One Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium One Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Two Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Two Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Three Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Three Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Coins % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Three Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Four Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Four Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.

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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Four Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Five Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Five Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Five Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Five Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Five Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Cause of Loss Five Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Five Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Five Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Total Value Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION Total Premium Enter amount: The premium for this property.
PREMISES INFORMATION Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION Rate Group Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION Diag# Enter identifier: The producer assigned identifier for the diagram of the location. As used here, show the number used on the diagram on ACORD 405.
PREMISES INFORMATION Const Type Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PREMISES INFORMATION YR Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION Heat Type Enter text: The description of the type of fuel used by the heating unit. As used here, if more than one type exists, document the secondary types in the remarks section. Use ACORD 101, Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION Roof Year Enter year: The year the roofing improvements took place.

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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Length Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Width Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Height Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL INFORMATION Are any wood or coal fired stoves used in any buildings? Yes/No Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any wood or coal fired stoves used?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
PREMISES GENERAL INFORMATION If there are any alarms on the premises, indicate the type of alarm and the floors protected. Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any burglar and / or fire alarms?”.
PREMISES GENERAL INFORMATION Burglary Alarm Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION Fire Alarm Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION 3. Are there any other protective devices? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any other protective devices?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
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Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Loss payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other checkbox Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other Field Enter text: The description of the type of interest in the item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Certificate Checkbox Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Name Enter text: The additional interest’s full name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address postal code.
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Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Interest in Item Number – Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
REMARKS Remarks Enter text: The general remarks associated with the farm policy. 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 Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Loc # Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Bldg # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
IDENTIFICATION SECTION Building Description Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be “3 story blue structure on the left of the main building”.
PREMISES INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # One Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium One Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Two Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Two Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Three Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Three Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Three Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Four Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Four Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Four Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Five Enter code: The code designating the subject of insurance or premium bearing option.
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Blkt # Five Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Five Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Five Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Five Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Five Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Five Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Five Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Total Value Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION Total Premium Enter amount: The premium for this property.
PREMISES INFORMATION Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION Rate Group Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION Diag# Enter identifier: The producer assigned identifier for the diagram of the location. As used here, show the number used on the diagram on ACORD 405.
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Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Const Type Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PREMISES INFORMATION YR Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION Heat Type Enter text: The description of the type of fuel used by the heating unit. As used here, if more than one type exists, document the secondary types in the remarks section. Use ACORD 101, Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION Roof Year Enter year: The year the roofing improvements took place.
PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Length Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Width Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Height Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL INFORMATION Are any wood or coal fired stoves used in any buildings? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any wood or coal fired stoves used?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
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Section Name Field Name Field and/or Section Description
PREMISES GENERAL INFORMATION If there are any alarms on the premises, indicate the type of alarm and the floors protected. Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any burglar and / or fire alarms?”.
PREMISES GENERAL INFORMATION Burglary Alarm Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION Fire Alarm Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION 3. Are there any other protective devices? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any other protective devices?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Loss payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other checkbox Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other Field Enter text: The description of the type of interest in the item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Certificate Checkbox Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Name Enter text: The additional interest’s full name.
ACORD 402 (2009/03) 16 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address postal code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Interest in Item Number – Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
PREMISES INFORMATION Location # Enter number: The producer assigned number of the location.
PREMISES INFORMATION Building # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
ACORD 402 (2009/03) 17 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Building Description Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be “3 story blue structure on the left of the main building”.
PREMISES INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # One Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium One Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Two Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Coins % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Two Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Three Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Three Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.

ACORD 402 (2009/03) 18 of 38

ACORD 402 (2009/03) 19 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Three Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Four Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Four Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
ACORD 402 (2009/03) 20 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Four Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Five Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Five Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Five Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Five Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Five Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Five Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Five Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Five Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Total Value Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION Total Premium Enter amount: The premium for this property.
ACORD 402 (2009/03) 21 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION Rate Group Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION Diag# Enter identifier: The producer assigned identifier for the diagram of the location. As used here, show the number used on the diagram on ACORD 405.
PREMISES INFORMATION Const Type Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PREMISES INFORMATION YR Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION Heat Type Enter text: The description of the type of fuel used by the heating unit. As used here, if more than one type exists, document the secondary types in the remarks section. Use ACORD 101, Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION Roof Year Enter year: The year the roofing improvements took place.
PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Length Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Width Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Height Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
ACORD 402 (2009/03) 22 of 38

Section Name Field Name Field and/or Section Description
PREMISES GENERAL INFORMATION Are any wood or coal fired stoves used in any buildings? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any wood or coal fired stoves used?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
PREMISES GENERAL INFORMATION If there are any alarms on the premises, indicate the type of alarm and the floors protected. Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any burglar and / or fire alarms?”.
PREMISES GENERAL INFORMATION Burglary Alarm Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION Fire Alarm Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION 3. Are there any other protective devices? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any other protective devices?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Loss payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other checkbox Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other Field Enter text: The description of the type of interest in the item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ACORD 402 (2009/03) 23 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Certificate Checkbox Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Name Enter text: The additional interest’s full name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address postal code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Interest in Item Number – Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ACORD 402 (2009/03) 24 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
PREMISES INFORMATION Location # Enter number: The producer assigned number of the location.
PREMISES INFORMATION Building # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Building Description Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be “3 story blue structure on the left of the main building”.
PREMISES INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # One Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
ACORD 402 (2009/03) 25 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Premium One Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Two Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Two Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Three Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Three Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Coins % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Three Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Four Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Four Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.

ACORD 402 (2009/03) 26 of 38

ACORD 402 (2009/03) 27 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Four Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Five Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Five Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Five Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Five Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Five Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Cause of Loss Five Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Five Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Five Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Total Value Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION Total Premium Enter amount: The premium for this property.
PREMISES INFORMATION Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION Rate Group Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION Diag# Enter identifier: The producer assigned identifier for the diagram of the location. As used here, show the number used on the diagram on ACORD 405.
PREMISES INFORMATION Const Type Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PREMISES INFORMATION YR Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION Heat Type Enter text: The description of the type of fuel used by the heating unit. As used here, if more than one type exists, document the secondary types in the remarks section. Use ACORD 101, Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION Roof Year Enter year: The year the roofing improvements took place.

ACORD 402 (2009/03) 28 of 38

ACORD 402 (2009/03) 29 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Length Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Width Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Height Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL INFORMATION Are any wood or coal fired stoves used in any buildings? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any wood or coal fired stoves used?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
PREMISES GENERAL INFORMATION If there are any alarms on the premises, indicate the type of alarm and the floors protected. Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any burglar and / or fire alarms?”.
PREMISES GENERAL INFORMATION Burglary Alarm Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION Fire Alarm Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION 3. Are there any other protective devices? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any other protective devices?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
ACORD 402 (2009/03) 30 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Loss payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other checkbox Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other Field Enter text: The description of the type of interest in the item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Certificate Checkbox Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Name Enter text: The additional interest’s full name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address postal code.
ACORD 402 (2009/03) 31 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Interest in Item Number – Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
PREMISES INFORMATION Location # Enter number: The producer assigned number of the location.
PREMISES INFORMATION Building # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Building Description Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be “3 story blue structure on the left of the main building”.
PREMISES INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # One Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
ACORD 402 (2009/03) 32 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium One Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Two Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
ACORD 402 (2009/03) 33 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Two Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Three Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Three Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Three Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Four Enter code: The code designating the subject of insurance or premium bearing option.
ACORD 402 (2009/03) 34 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Blkt # Four Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PREMISES INFORMATION Valuation Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Four Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Subject of Insurance Five Enter code: The code designating the subject of insurance or premium bearing option.
PREMISES INFORMATION Blkt # Five Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION Limit of Insurance Five Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PREMISES INFORMATION Coins % Five Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
ACORD 402 (2009/03) 35 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Valuation Five Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PREMISES INFORMATION Cause of Loss Five Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PREMISES INFORMATION Deductible Five Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION Premium Five Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION Total Value Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION Total Premium Enter amount: The premium for this property.
PREMISES INFORMATION Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION Rate Group Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION Diag# Enter identifier: The producer assigned identifier for the diagram of the location. As used here, show the number used on the diagram on ACORD 405.
PREMISES INFORMATION Const Type Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PREMISES INFORMATION YR Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION Heat Type Enter text: The description of the type of fuel used by the heating unit. As used here, if more than one type exists, document the secondary types in the remarks section. Use ACORD 101, Additional Remarks Schedule if more space is needed.
ACORD 402 (2009/03) 36 of 38

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Roof Year Enter year: The year the roofing improvements took place.
PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Length Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Width Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Height Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL INFORMATION Are any wood or coal fired stoves used in any buildings? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are any wood or coal fired stoves used?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
PREMISES GENERAL INFORMATION If there are any alarms on the premises, indicate the type of alarm and the floors protected. Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any burglar and / or fire alarms?”.
PREMISES GENERAL INFORMATION Burglary Alarm Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION Fire Alarm Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL INFORMATION Type of Alarm, indicate floors protected by the alarm Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PREMISES GENERAL INFORMATION 3. Are there any other protective devices? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Are there any other protective devices?”.
PREMISES GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
ACORD 402 (2009/03) 37 of 38

Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Loss payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other checkbox Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Other Field Enter text: The description of the type of interest in the item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Certificate Checkbox Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Name Enter text: The additional interest’s full name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Enter code: The additional interest’s mailing address postal code.
Section Name Field Name Field and/or Section Description
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Interest in Item Number – Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).