ACORD 825 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 825 (2008/01) Professional / Specialty Insurance Application – For Use in Management, Executive & Professional Lines – Applicant Section The underwriting process for any commercial account begins with the submission of a completed application. The following instructions will provide assistance in the completion of the ACORD Professional / Specialty Insurance Application – For Use in Management, Executive & Professional Lines – Applicant Section. The Professional / Specialty Insurance – Applicant Section is the foundation on which the ACORD professional / specialty application program is built. The Professional / Specialty Insurance – Applicant Section is a required part of every professional / specialty lines submission and no professional / specialty lines application is complete without it.
IDENTIFICATION SECTION Date (MM/DD/YYYY) Month/day/year on which the form is completed. (MM/DD/YYYY)
Producer’s name and address. In Florida and Nebraska, also include the producer’s state
IDENTIFICATION SECTION Agency license number, and in Nebraska, add the agency state license number.
IDENTIFICATION SECTION Contact Name Indicate the name of the contact witihin the agency.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Producer’s telephone number.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Producer’s fax number.
IDENTIFICATION SECTION E-Mail Address Producer’s e-mail address.
Identification code assigned to the agency or brokerage firm by the insurance company
IDENTIFICATION SECTION Code receiving this form.
If the agency uses a sub-code identification system with the company, enter the
IDENTIFICATION SECTION Subcode appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
Name of the applicable insurance company. Do not use group names; use the actual
IDENTIFICATION SECTION Carrier name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code Individual company code assigned by the NAIC.
IDENTIFICATION SECTION Underwriter Use this field to direct the application to a specific company underwriter.
IDENTIFICATION SECTION Underwriter Off. Use this field to direct the application to a specific company underwriter’s office.
IDENTIFICATION SECTION Policies or Program Requested Use this field to request an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Policy Number Use this field to provide the policy number if a policy has already been issued.
IDENTIFICATION SECTION Indicate Sections Attached ACORD application sections that are attached to complete the submission. If there are any other additional forms attached enter the form number on the blank line under “Other”. Additional ACORD forms, such as state-specific forms, may also be filled in.
IDENTIFICATION SECTION D&O (Directors & Officers) Check this box if D&O (Directors & Officers) Liability Section, ACORD 807, is attached.
IDENTIFICATION SECTION E&O (Errors & Omissions) / MISCELLANEOUS PROFESSIONAL LIABILITY Check this box if E&O (Errors & Omissions) / Miscellaneous Professional Liability is attached.
IDENTIFICATION SECTION EPLI (Employment Practices Liability) Check this box if EPLI (Employment Practices Liability Section), ACORD 827, is attached.
IDENTIFICATION SECTION FIDUCIARY Check this box if Fiduciary is attached.
IDENTIFICATION SECTION CRIME Check this box if Crime is attached.
IDENTIFICATION SECTION KIDNAP / RANSOM Check this box if Kidnap / Ransom is attached.
IDENTIFICATION SECTION PROFESSIONAL LIABILITY Check this box if Professional Liability is attached.
IDENTIFICATION SECTION PROF LIAB – MEDIA PROFESSIONAL Check this box if Media Professional Liability is attached.
IDENTIFICATION SECTION PROF LIAB – ARCHITECTS PROFESSIONAL Check this box if Architects Professional Liability is attached. (including architects / engineers).
IDENTIFICATION SECTION PROF LIAB – LAWYERS PROFESSIONAL Check this box if Lawyers Professional Liability is attached. (including Employed Lawyers Professional)
IDENTIFICATION SECTION PROF LIAB – ACCOUNTANTS PROFESSIONAL Check this box if Accountants Professional Liability is attached.
IDENTIFICATION SECTION PROF LIAB –MEDICAL MALPRACTICE Check this box if Medical Malpractice Professional Liability is attached.
IDENTIFICATION SECTION PROF LIAB –INSURANCE AGENTS Check this box if Insurance Agents Professional Liability is attached.
IDENTIFICATION SECTION INTERNET LIABILITY Check this box if Internet Liability is attached.
IDENTIFICATION SECTION TECHNOLOGY Check this box if Technology Liability is attached.
IDENTIFICATION SECTION WORKPLACE VIOLENCE Check this box if Workplace Violence is attached.
IDENTIFICATION SECTION Blank Check Box This check box is provided for sections not stated above. Describe the section attached.
IDENTIFICATION SECTION Business Type Check the applicable box.
Indicate whichcompany response to this application is expected. If the risk is bound, list
the date and the time coverage began and attach a copy of the binder. If more than one
STATUS OF TRANSACTION option applies, check multiple boxes.
Use this section to indicate common effective and expiration dates or common billing and
POLICY INFORMATION payment plans for package policies.
Month/day/year on which the terms and conditions of the policy will commence.
POLICY INFORMATION Proposed Eff. Date (MM/DD/YYYY)
Month/day/year on which the terms and conditions of the policy will terminate unless
POLICY INFORMATION Proposed Exp. Date renewed. (MM/DD/YYYY)
Indicate whether the agency or the company (direct) will bill the insured or other payor for
POLICY INFORMATION Billing Plan the policy.
The plan to be used to pay the company for the policy. Use the company’s specific
designation for the plan where possible. (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
POLICY INFORMATION Payment Plan 40-30-30.)
APPLICANT / FIRM 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 / FIRM
INFORMATION FEIN (of First Named Insured) Indicate the federal employment identification number (FEIN).
APPLICANT / FIRM
INFORMATION Soc Sec # (if no FEIN) Indicate the social security number, if the first named insured is an individual.
APPLICANT INFORMATION Primary Phone # Enter primary telephone number including area code.
APPLICANT INFORMATION Home Check if Secondary Phone is Home
APPLICANT INFORMATION Bus Check if Secondary Phone is Business
APPLICANT INFORMATION Cell Check if Secondary Phone is Cell
APPLICANT / FIRM
INFORMATION Secondary Phone # Enter secondary telephone number including area code.
APPLICANT INFORMATION Home Check if Secondary Phone is Home
APPLICANT INFORMATION Bus Check if Secondary Phone is Business
APPLICANT INFORMATION Cell Check if Secondary Phone is Cell
APPLICANT / FIRM
INFORMATION Fax No. (A/C, No) Enter the fax number
APPLICANT / FIRM
INFORMATION Website Addresses Indicate website address (if applicable).
APPLICANT / FIRM Mailing Address Incl ZIP+4 (of First The address at which the first named Insured / Firm representative is to receive all
INFORMATION Named Insured) correspondence regarding the insurance (include Zip + 4).
APPLICANT / FIRM
INFORMATION Applicant’s Title Indicate the title of the first named Insured / Firm representative
APPLICANT / FIRM
INFORMATION NAICS Code Indicate the North American Industry Classification System (NAICS) code for the firm.
APPLICANT / FIRM
INFORMATION SIC Code Indicate the Standard Industrial Classification (SIC) code for the firm.
APPLICANT / FIRM
INFORMATION CR Bureau Name The name of thecredit bureau used for this risk.
APPLICANT / FIRM
INFORMATION ID Number Number assigned by the credit bureau for this risk.
APPLICANT / FIRM
INFORMATION Primary E-Mail Address Indicate primary e-mail address (if applicable).
APPLICANT / FIRM INFORMATION Secondary E-Mail Address Indicate primary e-mail address (if applicable).
APPLICANT / FIRM INFORMATION Form of BusinessOrganization Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, Subchapter “S” Corporation, PC, LLC, GP/LLP or Other. If other, provide a description such asProfessional Association. If there is more than one named insured, provide the form of business organization for each. In the Remarks section list each named insured along with its form of organization. (e.g., The Green Thumb Co., a corporation; John Jones and Bill Smith, a partnership or a joint venture composed of ABC Contracting Inc. and XYZ Contracting Inc.)
APPLICANT / FIRM INFORMATION Operations Indicate if the business operations are based in the United States or outside of the United States (non-US).
APPLICANT / FIRM INFORMATION State of Incorporation If US based, indicate the state of incorporation.
APPLICANT / FIRM INFORMATION Date Business Started Provide the date the applicant began in business. This is important because it helps the underwriter determine the expertise and business success of the applicant.
APPLICANT / FIRM INFORMATION Total Employees – Full Time List the total number of full time employees.
APPLICANT / FIRM INFORMATION Total Employees – Part Time List the total number of part time employees.
APPLICANT / FIRM INFORMATION Total Payroll List the total payroll.
APPLICANT / FIRM INFORMATION Total Revenues Indicate the total revenue.
APPLICANT / FIRM INFORMATION Total Assets Indicate the total assets.
APPLICANT / FIRM INFORMATION Total Liabilities Indicate the total liabilities.
CONTACT INFORMATION Primary Contact Name of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number.
CONTACT INFORMATION Primary Phone # Enter primary telephone number including area code.
CONTACT INFORMATION Home Check if Secondary Phone is Home
CONTACT INFORMATION Bus Check if Secondary Phone is Business
CONTACT INFORMATION Cell Check if Secondary Phone is Cell
CONTACT INFORMATION Secondary Phone # Enter secondary telephone number including area code.
CONTACT INFORMATION Home Check if Secondary Phone is Home
CONTACT INFORMATION Bus Check if Secondary Phone is Business
CONTACT INFORMATION Cell Check if Secondary Phone is Cell
CONTACT INFORMATION Primary E-Mail Address Indicate primary e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
CONTACT INFORMATION Secondary E-Mail Address Indicate e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
CONTACT INFORMATION Contact Type Indicate the type of contact for other information (e.g., accounting).
CONTACT INFORMATION Name Name of the person to contact for other information. This should be an individual under the insured’s employment, not the insurance agent.
CONTACT INFORMATION Primary Phone # Enter primary telephone number including area code.
CONTACT INFORMATION Home Check if Secondary Phone is Home
CONTACT INFORMATION Bus Check if Secondary Phone is Business
CONTACT INFORMATION Cell Check if Secondary Phone is Cell
CONTACT INFORMATION Secondary Phone # Enter secondary telephone number including area code.
CONTACT INFORMATION Home Check if Secondary Phone is Home
CONTACT INFORMATION Bus Check if Secondary Phone is Business
CONTACT INFORMATION Cell Check if Secondary Phone is Cell
CONTACT INFORMATION Primary E-Mail Address Indicate primary e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
CONTACT INFORMATION Secondary E-Mail Address Indicate e-mail address (if applicable) of the person to contact to arrange for a premises inspection. This should be an individual under the insured’s employment, not the insurance agent’s name and number..
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISES 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 the general offices, location #2 is the warehouse). 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.”
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISES If the applicant is a manufacturer, describe the: * Raw materials used * Processes or work performed * Products manufactured, who uses them and how they are used If the applicant is a contractor, describe the: * Type of contractor * Work performed * Specialized equipment used * Nature of sub-contracts If the applicant is a merchant, describe the: * Type of operation, wholesale or retail (if both, give the percentage of each) * Merchandise sold, indicate if domestic or foreign manufacture * Services provided, whether or not the applicant delivers If the applicant is a service organization, describe the: * Type of service performed * Location where services are performed * Applicant’s clients (e.g., general public, dentists, banks)
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
Use the space provided below each question to provide additional information for any
questions answered with a “Yes” response. Use the Remarks section below the questions
GENERAL INFORMATION Explain all “Yes” Responses if more space is required.
1a. Is the applicant a subsidiary of If the applicant is a subsidiary of another organization, identify the parent company and
GENERAL INFORMATION another entity? describe the relationship including the percentage owned by the parent.
1b. Does the applicant have any If the applicant has any subsidiaries, provide a list and describe each relationship and the
GENERAL INFORMATION subsidiaries? percentage owned by the applicant.
2. Any other insurance with this Indicate if other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section
GENERAL INFORMATION company or being submitted? along with any policy numbers available.
GENERAL INFORMATION 3. Has any policy or coverage being applied for been declined, cancelled or non-renewed? Provide an explanation of how this situation occurred. This question may not be asked in Missouri.
4. Any bankruptcies, tax or credit
liens against the applicant in the
GENERAL INFORMATION past five (5) years? If yes, Describe in detail.
5. Has business been placed in a
GENERAL INFORMATION trust? If yes, provide the name of the trust.
6. Are there any predecessor
GENERAL INFORMATION firms? Please advise if there are any predecessor firms.
REMARKS Remarks Use this space for any additional remarks or comments.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
Space is provided to enter up to five years of information for each line of business. This
information, along with the loss history below, is required to experience rate the risk. The
PRIOR CARRIER completeness and accuracy of this information can affect the underwriter’s pricing
INFORMATION decisions.
D&O LIABILITY Carrier Name of the insurance company that wrote the policy.
D&O LIABILITY Policy Number Reference identification assigned by the insurance company to identify the policy.
D&O LIABILITY Policy Type Indicate whether the policy was issued on a Claims Made or Occurrence basis.
D&O LIABILITY Eff.- Exp. Date Show the effective and expiration date of the policy.
If the policy was issued on a Claims Made basis and there was a retroactive date, list the
D&O LIABILITY Retro Date date. If there was no date enter “none”.
D&O LIABILITY Continuity Date Please indicate the continuity date.
D&O LIABILITY Limit Per Claim Please indicate the limit per claim.
D&O LIABILITY Retention Please indicate the retention.
D&O LIABILITY Deductible Please indicate the deductible.
D&O LIABILITY Additional Layers Please indicate the additional layers.
The annual modified premium charged (not including taxes or service charges) for the
D&O LIABILITY Total Premium specified line of business.
E P L I Carrier Name of the insurance company that wrote the policy.
E P L I Policy Number Reference identification assigned by the insurance company to identify the policy.
E P L I Policy Type Indicate whether the policy was issued on a Claims Made or Occurrence basis.
E P L I Eff.- Exp. Date Show the effective and expiration date of the policy.
If the policy was issued on a Claims Made basis and there was a retroactive date, list the
E P L I Retro Date date. If there was no date enter “none”.
E P L I Continuity Date Please indicate the continuity date.
E P L I Limit Per Claim – Occurrence Please indicate the limit per claim – Occurrence.
E P L I Limit Per Claim – Aggregate Please indicate the limit per claim – Aggregate.
E P L I Retention Please indicate the retention.
E P L I Deductible Please indicate the deductible.
E P L I Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business.
PROFESSIONAL LIABILITY Carrier Name of the insurance company that wrote the policy.
PROFESSIONAL LIABILITY Policy Number Reference identification assigned by the insurance company to identify the policy.
PROFESSIONAL LIABILITY Policy Type Indicate whether the policy was issued on a Claims Made or Occurrence basis.
PROFESSIONAL LIABILITY Eff.- Exp. Date Show the effective and expiration date of the policy.
PROFESSIONAL LIABILITY Retro Date If the policy was issued on a Claims Made basis and there was a retroactive date, list the date. If there was no date enter “none”.
PROFESSIONAL LIABILITY Continuity Date Please indicate the continuity date.
PROFESSIONAL LIABILITY Limit Per Claim – Occurrence Please indicate the limit per claim – Occurrence.
PROFESSIONAL LIABILITY Limit Per Claim – Aggregate Please indicate the limit per claim – Aggregate.
PROFESSIONAL LIABILITY Retention Please indicate the retention.
PROFESSIONAL LIABILITY Deductible Please indicate the deductible.
PROFESSIONAL LIABILITY Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business.
CRIME Carrier Name of the insurance company that wrote the policy.
CRIME Policy Number Reference identification assigned by the insurance company to identify the policy.
CRIME Policy Type The coverage form that the previous policy was issued on. (e.g., Special excluding Theft.)
CRIME Eff.- Exp. Date Show the effective and expiration date of the policy.
CRIME Limit Please indicate the limit.
CRIME Deductible Please indicate the deductible.
CRIME Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business.
FIDUCIARY Carrier Name of the insurance company that wrote the policy.
FIDUCIARY Policy Number Reference identification assigned by the insurance company to identify the policy.
FIDUCIARY Policy Type The coverage form that the previous policy was issued on. (e.g., Special excluding Theft.)
FIDUCIARY Eff.- Exp. Date Show the effective and expiration date of the policy.
FIDUCIARY Limit List the limits as they appear on the policy declarations page.
FIDUCIARY Deductible Please indicate the deductible.
FIDUCIARY Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business.
OTHER Complete this section for policy history on other lines of business.
OTHER Carrier Name of the insurance company that wrote the policy.
OTHER Policy Number Reference identification assigned by the insurance company to identify the policy.
OTHER Policy Type The coverage form that the previous policy was issued on. (e.g., Special excluding Theft.)
OTHER Eff.- Exp. Date Show the effective and expiration date of the policy.
OTHER Limit List the limits as they appear on the policy declarations page.
OTHER Deductible Please indicate the deductible.
OTHER Total Premium The annual modified premium charged (not including taxes or service charges) for the specified line of business.
ATTACHMENTS Financials Check the applicable box.
ATTACHMENTS Carrier Loss Runs Check the applicable box.
ATTACHMENTS Carrier Supplement(s) Check the applicable box.
ATTACHMENTS Blank Blank rows have been provided for any additional attachments not previously defined. Describe. Check the applicable box.
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, except in Kansas and New York, which limit the recording of loss history to three years. If loss reports are attached check the “See Attached Loss Summary” box instead of completing this section.
LOSS HISTORY Check Here if None Check this box if there are no known losses and no occurrences that may lead to losses over the past five years for all lines of business being submitted.
LOSS HISTORY See Attached Loss Summary Check this box if a loss summary report is being sent with the application.
LOSS HISTORY Date of Occurrence Date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line of Business Line of business involved in the loss (e.g., D&O, Professional Liability, Crime, EPLI, etc.).
LOSS HISTORY Type/Description of Occurrence or Claim A brief description of the loss.
LOSS HISTORY Date of Claim The date on which the loss or occurrence occurred.
LOSS HISTORY Amount Paid If the previous carrier has made any payments on this claim, enter the total amount paid to date.
LOSS HISTORY Amount Reserved If the claim is still open, list the reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Claim Status Indicate if this claim is open or closed.
REMARKS Remarks Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures of this risk.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
SIGNATURE SECTION Notice of Information Practices Check this box if a copy of the Notice of Information Practices (Privacy) has been given to the Applicant.
SIGNATURE SECTION Applicant’s Signature Upon completion of the full commercial lines application series, the insured should review the applications and sign this form in the available space.
SIGNATURE SECTION Date Date the application was signed.
SIGNATURE SECTION Producer’s Signature Upon completion of the full commercial lines application series, the producer should review the applications and sign this form in the available space. The National Producer Number should also be provided.
SIGNATURE SECTION National Producer Number Number assigned to the producer by the NAIC.