| Section Name |
Field Name |
Field and/or Section Description |
| TITLE ACORD 815 (2009/02) |
International Liability Exposure Supplement |
The title of the form. ACORD 815, International Liability Exposure Supplement, is used to provide information about any liability coverage to be provided with respect to business activities or exposures outside of the United States. This supplement gets attached to ACORD 126, CommercialGeneral Liability Section. |
| IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
| IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
| IDENTIFICATION SECTION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
| IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
| IDENTIFICATION SECTION |
First Named Insured |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, this is the first named insured. |
| 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 |
List Countries Where Applicant or Employees will Work, Travel to or Sell Products |
Enter text: The countries where applicant or employees will work, travel to or sell products. |
ACORD 815 (2009/02) rev. 02-27-2009 1 of 7
ACORD 815 (2009/02) rev. 02-27-2009 2 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| IDENTIFICATION SECTION |
Nature of Business / Description of Foreign Operations |
Enter text: The text description of the operations of this risk or insured. As used here, this section is designed to inform the underwriter of what business 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 (e.g., location #1 is a sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include number of leased and owned premises outside of the United States. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as “Metal Goods Mfg. N.O.C.” |
| IDENTIFICATION SECTION |
Does the Applicant have any Foreign Subsidiaries? Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does the applicant have any foreign subsidiaries?”. |
| LOSS HISTORY OUTSIDE OF THE US |
Chk here if none |
Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years. |
| LOSS HISTORY OUTSIDE OF THE US |
See attached loss summary |
Check the box (if applicable): Indicates that a loss summary report is attached to the policy. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Occurrence |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Line |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| LOSS HISTORY OUTSIDE OF THE US |
Type / Description of Occurrence or Claim |
Enter text: A brief description of the loss. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Claim |
Enter date: The date the claim was filed. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Paid |
Enter amount: The amount that has been paid on this claim to date. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Reserved |
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Open |
Check the box (if applicable): Indicates the claim is still open. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Closed |
Check the box (if applicable): Indicates the claim is closed. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Occurrence |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
ACORD 815 (2009/02) rev. 02-27-2009 3 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| LOSS HISTORY OUTSIDE OF THE US |
Line |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| LOSS HISTORY OUTSIDE OF THE US |
Type / Description of Occurrence or Claim |
Enter text: A brief description of the loss. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Claim |
Enter date: The date the claim was filed. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Paid |
Enter amount: The amount that has been paid on this claim to date. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Reserved |
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Open |
Check the box (if applicable): Indicates the claim is still open. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Closed |
Check the box (if applicable): Indicates the claim is closed. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Occurrence |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Line |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| LOSS HISTORY OUTSIDE OF THE US |
Type / Description of Occurrence or Claim |
Enter text: A brief description of the loss. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Claim |
Enter date: The date the claim was filed. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Paid |
Enter amount: The amount that has been paid on this claim to date. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Reserved |
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Open |
Check the box (if applicable): Indicates the claim is still open. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Closed |
Check the box (if applicable): Indicates the claim is closed. |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Occurrence |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Line |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
| LOSS HISTORY OUTSIDE OF THE US |
Type / Description of Occurrence or Claim |
Enter text: A brief description of the loss. |
ACORD 815 (2009/02) rev. 02-27-2009 4 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| LOSS HISTORY OUTSIDE OF THE US |
Date of Claim |
Enter date: The date the claim was filed. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Paid |
Enter amount: The amount that has been paid on this claim to date. |
| LOSS HISTORY OUTSIDE OF THE US |
Amount Reserved |
Enter amount: The reserve amount the previous carrier is holding open for this claim. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Open |
Check the box (if applicable): Indicates the claim is still open. |
| LOSS HISTORY OUTSIDE OF THE US |
Claim Status – Closed |
Check the box (if applicable): Indicates the claim is closed. |
| LOSS HISTORY OUTSIDE OF THE US |
Remarks |
Enter text: The remarks associated with loss history information |
| PRIOR INTERNATIONAL COVERAGE |
Prior carrier and producer |
Enter text: The name of the previous insurer. |
| PRIOR INTERNATIONAL COVERAGE |
|
Enter text: The name of the previous producer. |
| PRIOR INTERNATIONAL COVERAGE |
# of Years with Company |
Enter number: The number of years with the previous insurer. |
| PRIOR INTERNATIONAL COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
| PRIOR INTERNATIONAL COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
| PRIOR INTERNATIONAL COVERAGE |
Premium |
Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. |
| COVERAGES / LIMITS |
Limits – Foreign Sales -Occurrence |
Enter limit: The commercial general liability international coverage, foreign sales each occurrence limit amount. |
| COVERAGES / LIMITS |
Limits – Foreign Sales – Aggregate |
Enter limit: The commercial general liability international coverage, foreign sales aggregate limit amount. |
| COVERAGES / LIMITS |
Limits – Foreign Sales – Excess |
Enter limit: The commercial general liability international coverage, foreign sales excess limit amount. |
| COVERAGES / LIMITS |
Limits – Contract Cost -Occurrence |
Enter limit: The commercial general liability international coverage, contract cost each occurrence limit amount. |
| COVERAGES / LIMITS |
Limits – Contract Cost – Aggregate |
Enter limit: The commercial general liability international coverage, contract cost aggregate limit amount. |
| COVERAGES / LIMITS |
Limits – Contract Cost – Excess |
Enter limit: The commercial general liability international coverage, contract cost excess limit amount. |
ACORD 815 (2009/02) rev. 02-27-2009 5 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| COVERAGES / LIMITS |
Coverages – Contingent Auto -Number of foreign owned autos: |
Enter number: The number of foreign owned vehicles. |
| COVERAGES / LIMITS |
Limits – Contingent Auto -Occurrence |
Enter limit: The commercial general liability international coverage, contingent auto each occurrence limit amount. |
| COVERAGES / LIMITS |
Limits – Contingent Auto – Excess |
Enter limit: The commercial general liability international coverage, contingent auto excess limit amount. |
| COVERAGES / LIMITS |
Limits – Employers Liability -Occurrence |
Enter limit: The commercial general liability international coverage, employers liability each occurrence limit amount. |
| COVERAGES / LIMITS |
Limits – Employers Liability -Excess |
Enter limit: The commercial general liability international coverage, employers liability excess limit amount. |
| OTHER COVERAGES |
Employers Responsibility – Limit |
Enter limit: The commercial general liability international coverage, employers responsibility limit amount. |
| OTHER COVERAGES |
Per Employee |
Check the box (if applicable): Indicates the employers responsibility limit is per employee. |
| OTHER COVERAGES |
Per Occurrence |
Check the box (if applicable): Indicates the employers responsibility limit is per occurrence. |
| OTHER COVERAGES |
Trip Purpose |
Enter text: The purpose of the trip. |
| OTHER COVERAGES |
Number of Trips |
Enter number: The number of trips. |
| OTHER COVERAGES |
Duration (Average Length of Stay) |
Enter text: The average length of stay per trip. |
| OTHER COVERAGES |
Days |
Check the box (if applicable): Indicates the trip duration count is in days. |
| OTHER COVERAGES |
Weeks |
Check the box (if applicable): Indicates the trip duration count is in weeks. |
| OTHER COVERAGES |
Months |
Check the box (if applicable): Indicates the trip duration count is in months. |
| OTHER COVERAGES |
Trip Purpose |
Enter text: The purpose of the trip. |
| OTHER COVERAGES |
Number of Trips |
Enter number: The number of trips. |
| OTHER COVERAGES |
Duration (Average Length of Stay) |
Enter text: The average length of stay per trip. |
| OTHER COVERAGES |
Days |
Check the box (if applicable): Indicates the trip duration count is in days. |
| OTHER COVERAGES |
Weeks |
Check the box (if applicable): Indicates the trip duration count is in weeks. |
| OTHER COVERAGES |
Months |
Check the box (if applicable): Indicates the trip duration count is in months. |
| OTHER COVERAGES |
Trip Purpose |
Enter text: The purpose of the trip. |
| OTHER COVERAGES |
Number of Trips |
Enter number: The number of trips. |
| OTHER COVERAGES |
Duration (Average Length of Stay) |
Enter text: The average length of stay per trip. |
| OTHER COVERAGES |
Days |
Check the box (if applicable): Indicates the trip duration count is in days. |
ACORD 815 (2009/02) rev. 02-27-2009 6 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| OTHER COVERAGES |
Weeks |
Check the box (if applicable): Indicates the trip duration count is in weeks. |
| OTHER COVERAGES |
Months |
Check the box (if applicable): Indicates the trip duration count is in months. |
| OTHER COVERAGES |
Employees Abroad – Job Functions performed |
Enter text: The description of the job functions performed. |
| OTHER COVERAGES |
Number of U.S. Nationals |
Enter number: The number of United States nationals on the payroll. |
| OTHER COVERAGES |
Payroll – U.S. Nationals |
Enter amount: The total annual payroll of United States nationals outside of the United States. |
| OTHER COVERAGES |
Number of Third Country Nationals |
Enter number: The number of third country nationals on the payroll. |
| OTHER COVERAGES |
Payroll – Third Country Nationals |
Enter amount: The total annual payroll of third country nationals outside of the United States. |
| OTHER COVERAGES |
Number of Local Nationals |
Enter number: The number of local nationals on the payroll. |
| OTHER COVERAGES |
Payroll – Local Nationals |
Enter amount: The total annual payroll of local nationals outside of the United States. |
| OTHER COVERAGES |
Employees Abroad – Job Functions performed |
Enter text: The description of the job functions performed. |
| OTHER COVERAGES |
Number of U.S. Nationals |
Enter number: The number of United States nationals on the payroll. |
| OTHER COVERAGES |
Payroll – U.S. Nationals |
Enter amount: The total annual payroll of United States nationals outside of the United States. |
| OTHER COVERAGES |
Number of Third Country Nationals |
Enter number: The number of third country nationals on the payroll. |
| OTHER COVERAGES |
Payroll – Third Country Nationals |
Enter amount: The total annual payroll of third country nationals outside of the United States. |
| OTHER COVERAGES |
Number of Local Nationals |
Enter number: The number of local nationals on the payroll. |
| OTHER COVERAGES |
Payroll – Local Nationals |
Enter amount: The total annual payroll of local nationals outside of the United States. |
| OTHER COVERAGES |
Employees Abroad – Job Functions performed |
Enter text: The description of the job functions performed. |
| OTHER COVERAGES |
Number of U.S. Nationals |
Enter number: The number of United States nationals on the payroll. |
| OTHER COVERAGES |
Payroll – U.S. Nationals |
Enter amount: The total annual payroll of United States nationals outside of the United States. |
| OTHER COVERAGES |
Number of Third Country Nationals |
Enter number: The number of third country nationals on the payroll. |
| OTHER COVERAGES |
Payroll – Third Country Nationals |
Enter amount: The total annual payroll of third country nationals outside of the United States. |
| OTHER COVERAGES |
Number of Local Nationals |
Enter number: The number of local nationals on the payroll. |
ACORD 815 (2009/02) rev. 02-27-2009 7 of 7
| Section Name |
Field Name |
Field and/or Section Description |
| OTHER COVERAGES |
Payroll – Local Nationals |
Enter amount: The total annual payroll of local nationals outside of the United States. |
| OTHER COVERAGES |
Medical $ |
Enter limit: The commercial general liability international coverage, employers medical and accidental death and dismemberment, medical limit amount. |
| OTHER COVERAGES |
AD&D $ |
Enter limit: The commercial general liability international coverage, employers medical and accidental death and dismemberment, accidental death and dismemberment limit amount. |
| OTHER COVERAGES |
Number of Employees |
Enter number: The number of employees. |
| OTHER COVERAGES |
Number of Trips |
Enter number: The number of trips. |
| OTHER COVERAGES |
Duration (Average Length of Stay) |
Enter text: The average length of stay per trip. |
| OTHER COVERAGES |
Days |
Check the box (if applicable): Indicates the employers medical and AD&D trip duration count is in days. |
| OTHER COVERAGES |
Weeks |
Check the box (if applicable): Indicates the employers medical and AD&D trip duration count is in weeks. |
| OTHER COVERAGES |
Months |
Check the box (if applicable): Indicates the employers medical and AD&D trip duration count is in months. |
| OTHER COVERAGES |
Separate Applications required for: Kidnap and Extortion |
Check the box (if applicable): Indicates the Kidnap/Ransom section is attached to this policy. |
| OTHER COVERAGES |
Separate Applications required for: Property |
Check the box (if applicable): Indicates the Property section is attached to this policy. |
| OTHER COVERAGES |
Separate Applications required for: Defense Base Act |
Check the box (if applicable): Indicates the Defense Base Act section is attached to this policy. |
| OTHER COVERAGES |
Separate Applications required for: Other |
Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy. |
| OTHER COVERAGES |
Separate Applications required for: Other Description |
Enter text: The type of section being attached to the policy. |
| OTHER COVERAGES |
Remarks |
Enter text: The remarks associated with the general liability line of business. |
| SIGNATURE |
Applicant’s Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
| SIGNATURE |
Applicant’s Title |
Enter text: The title of the individual in the organization or his relationship to the organization. |
| SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
| EDITION |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |