ACORD 410 Instructions


ACORD 410 – Small Farm/Ranch Application

As a general guideline, this form is intended to be used in lieu of ACORD 401 through 404, for small farm/ranch properties, not over three farm buildings and two residential buildings, and not over two different types of businesses (e.g., dairy, crops, livestock, etc.). Do not use if property is to be schedule or blanket rated.


IDENTIFICATION SECTION

Date

Month/day/year on which the form is completed.

Phone (A/C, No, Ext)

Producer’s telephone numbers. Include area code and extension, if applicable.

Fax (A/C, No, Ext)

Producer’s fax number, include area code.

Agency

Producer’s name and address.

Code

Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.

Subcode

If the agency uses a subcode identification system with the company, enter the appropriate code.

Agency Customer ID

Customer’s identification number assigned by the agency.

Company

Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued.

NAIC Code

Enter the NAIC code of the applicable insurance company.

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.

Program Code

Show the program code assigned by the company, if applicable.

Account No.

Account number assigned by the applicable insurance company.

New/Rnwl

Indicate if the applicant is a risk that is new to the company or a renewal of an expiring policy with the same company.

Effective Date

Date on which the terms and conditions of the policy will commence.

Expiration Date

Date on which the terms and conditions of the policy will terminate unless renewed.

Direct Bill/Agency Bill

Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.

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

Status of Submission

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.

Policy Type

Indicate the type of policy.

Deposit

Also show the deposit premium amount.

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 Relationship * * If more than one person is listed as the named insured, indicate the relationship to the first named insured.

Mailing Adress (of First Named Insured)

The physical address at which the first named insured is to receive all correspondence regarding the insurance.

Phone (A/C, No, Ext)

The first named insured’s phone number at the mailing address. Include area code and extension, if applicable.

E-Mail Address

The first named insured’s e-mail address.

Phone # on Premises

The first named insured’s phone number at the premises. Include area code and extension, if applicable.

Form of Business Organization

Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, or an option not listed . Use the blank space to provide a description such as an Association.

If there is more than one named insured, provide the form of businessorganization for each. In the Remarks section, list each named insured along with its form of organization.

Date Business Started

The date the applicant began in this business. This is important because it helps the underwriter determine the expertise and business success of the applicant.

SIC

Enter the Standard Industry Classification code that the applicant falls under.

Contact

Name of the person the carrier is 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

Phone (A/C, No, Ext)

Phone number of the person the carrier is 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.

TYPE OF FARM/RANCH

Indicate the primary nature of the applicant’s operation. Refer to your company for specific details, as they apply to the company’s individual programs.

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.

PREMISES INFORMATION

Provide premises information separately for each building. Indicate the location number (if a number has been assigned), and a building number if applicable.

For each separate building, show the applicable public protection class, the total acreage, number of acres cultivated or in pasture, and indicate whether the business is farmed by the owner of the property, a tenant, a manager, or another entity, and the gross receipts in dollars.

LOC #

Provide premises information separately for each building. Indicate the location number (if a number has been assigned).

BLD #

Provide premises information separately for each building. Indicate a building number if applicable.

Street, City, County, State, Zip

Provide the address for each premises.

Prot Class

For each separate building, show the applicable public protection class.

# Acres Total

For each separate building, show the total acreage.

# Acres Cultivated

For each separate building, show the number of acres cultivated.

# Acres in Pasture

For each separate building, show the number of acres in pasture.

Farmed By

For each separate building, indicate whether the business is farmed by the owner of the property, a tenant, a manager, or another entity.

Gross Receipts

For each separate building, show the gross receipts in dollars.

LOSS HISTORY

Whenever possible, attach a copy of the previous carrier’s loss run for each line of business. Loss reports should cover the previous five years of loss history.

Date of Occurrence

Date when the accident or incident occurred that resulted in the filing of a claim.

Type of Loss

Indicate the line of business involved in the loss.

Description

Give a brief description of the loss.

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).

Type of Insurance

Indicate the type of insurance.

Policy #

Indicate the policy number(s).

Amount of Coverage

Indicate the amount(s) of coverage.

ADDITIONAL INTERESTS-PROPERTY

Provide information about mortgage holders, loss payees, or other additional property interests, if applicable.

Prem No / Bldg No

Enter the premises number and the building number of the property.

Name and Address

List the additional interest’s name and mailing address.

Interest

Check all appropriate boxes that apply to the additional interest. If the interest is other than the listed options, check the last box and list the interest type after it.

Evidence

Check the appropriate box to indicate whether a certificate or a copy of the policy is to be provided to the additional insured.

ADDITIONAL INTERESTS-LIABILITY

Provide information about mortgage holders, loss payees, or other additional property interests, if applicable.

Rank

Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee.

Interest

Check all appropriate boxes that apply to the additional interest. If the interest is other than the listed options, check the last box and list the interest type after it.

Name and Address

List the additional interest’s name and mailing address.

Evidence

Check the appropriate box to indicate whether a certificate or a copy of the policy is to be provided to the additional insured.

PROPERTY COVERAGE

Location #

Enter Location Number as shown in PREMISES INFORMATION section on page 1.

Fire District Name

Enter the name of the fire district.

Distance to Hydrant

Enter the distance in feet.

Distance to Fire Station

Enter the distance to the nearest mile.

Bldg Type

Describe the occupancy of the building. For dwellings only, enter the number of families.

Construction

Enter the construction type in accordance with the state manual.

Type of Heat

Enter the heat source (e.g., natural gas) and the type of heating unit.

Age of Bldg

Enter the age in years.

Age of Roof

Enter the age in years.

Square Feet

Enter the total square foot area for each building.

RC/ACV

Indicate if replacement cost (RC) or actual cash value (ACV) applies.

Conisurance %

Enter the coinsurance percentage applicable to the coverage.

Prot Class

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 protection class of the community to apply.

Cause of Loss

Perils that are to be covered

Deductible

Enter the deductible, if any.

Value

Enter the market value, if known.

Limit of Insurance

Enter the applicable limit in dollars.

Premium

Enter the premium for each building and personal property, if applicable.

Additional Coverages, Restrictions, Endorsements and Rating Information

Indicate any Additional Coverages, Restrictions, Endorsements and Rating Information

LIABILITY COVERAGE

Coverages

Provision is made for recording Bodily Injury and Property Damage Liability, Personal and Advertising Injury Liability Medical Payments, Fire Damage Coverage, Damage to Property of Others, and Personal Liability Coverage (AAIS), if applicable. For other combinations of liability coverage, use the blank lines.
Consult your company manual for applicable rules.

If Commercial General Liability is to apply, use Acord 125, Commercial Insurance Application, and ACORD 126, Commercial General Liability Section.


Limits of Liability

Show separate limits where applicable. Note that different aggregate limits may apply to separate coverages or exposures.

Code

Enter the applicable ISO, AAIS, or company code for each type of exposure.

LOC #

Show location number if applicable.

Coverage

Descriptions of coverage have been provided that track with ISO or AAIS rules. If company unique rules apply, use the blank spaces provided.

INCR Limits Factor

Show Increased Limit Factors for applicable exposures.

Basis/Rate

Show Basis Rates for applicable exposures.

Premium

Show Premium for applicable exposures.

GENERAL INFORMATION

Question 1

Indicate if there is a year-round water source available for fire protection and check the applicable boxes.

Question 2

Indicate if wood or coal fired stoves are used. Explain their use, including locations within the buildings

Question 3

If there are any alarms on the premises, indicate the type of alarm and the floors protected. This question cannot be asked in Missouri.

Question 4

Indicate if the applicant performs equipment maintenance, and if yes, describe.

Question 5

Indicate whether or not the entire premises is occupied year round. If not, explain.

Question 6-35

Answer questions 6 through 35 if Liability insurance is being requested. Explain all “yes” responses under remarks. If necessary, use additional sheets of paper.

REMARKS

Use this section to provide any additional information required for underwriting or rating. If necessary, use additional sheets of paper.

ATTACHMENTS

Check the appropriate box.

SIGNATURE SECTION

Applicant’s Signature

Applicant must sign form.

Producer’s Signature

Date applicant signed form.

National Producer Number

The National Producer Number assigned by the NAIC should be shown.