ACORD 84 Instructions


ACORD 84 (2004/12) – Dwelling Fire Application

The underwriting process for any personal lines policy begins with the submission of a completed application. These instructions will assist in the completion of ACORD 84, Dwelling Fire Application.


IDENTIFICATION SECTION

Date

Month/day/year (MM/DD/YYYY) on which the form is completed.


Agency

Producer’s name and address.

Phone No.

Producer’s telephone number. (Include area code and extension if applicable)

Fax No.

Producer’s fax number. (Include area code)

Code

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

Subcode

If the agency or brokerage uses a sub-code identification system with the company, enter the appropriate code.

Agency Customer ID

Customer’s identification number assigned by the agency or brokerage.

Applicant’s Name and Mailing Address

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 and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail.


Address should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.: 150 Central Ave N); City; County; State; ZIP code


If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal description if required by the mortgage holder.

NAIC Code

The identification code assigned to the company by the NAIC.

Facility Code

The identification code used by assigned risk plans, FAIR plans and other associations (only applicable in a few states). When using this field, also enter the name of the facility in the CO/PLAN field.

Policy #

The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time.

Date at Curr Res

Indicate the date applicant moved into current residence.

CO/Plan

Name of the insurance company (or residual market plan) that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. Also, if applicable, indicate the type of plan or policy program (example: Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company.

Home Phone #

Home telephone number at which the applicant may be reached. Include area code.

Effective Date

Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.

Expiration Date

Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless renewed.

Business Phone #

Business telephone number at which the applicant may be reached. Include area code and extension, if applicable.

APPLICANT INFORMATION

Previous Address

Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.


Location of Property if Diff From Above

Enter the physical address of the property to be insured only if it is different from the address listed above.

Applicant’s/Co-applicant’s Occupation

Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of business if self-employed.

Applicant’s/Co-Applicant’s

Employer Name and Address Name and address of the organization that employs the applicant(s) named in the identification section.

Yrs in Curr. Occ.

Number of years in current occupation or business.

Yrs w/Curr. Empl.

Number of years with present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section.

Yrs w/Prior Empl.

Number of years with the prior employer.

Mar Stat

Marital status of each named applicant. Codes:


S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Married
D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced
SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated
W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed

Date of Birth

Birth date of each named applicant (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.)

Social Security #

Social security number for each named applicant.

How long have you known the applicant?

Indicate how long the applicant is known to the agent.

Date Agent last inspected property

Indicate when the property was last inspected by the agent.

COVERAGES/LIMITS OF LIABILITY

Enter the anticipated dollar limit amounts for each applicable coverage.

Policy Type

Show the policy form, form number or company form designation for the type of policy/coverage desired.

PREMIUM

Premium

Enter the estimated total premium calculated by the insurance agency, as well as the applicant’s deposit and balance, if any owed.

DED

Deductibles

Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.)

ENDORSEMENTS

Endorsements

Enter the applicable endorsements. Check the appropriate box for replacement cost dwelling and/or replacement cost contents.

PAYMENT PLAN

Account #

Indicate the account number.

Billing

Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan for payment. Indicate the account number.

Mail Policy to:

Indicate to whom the policy should be mailed.

RATING/UNDERWRITING

Provide the information below for each dwelling.


Construction Type

Check the primary type of building material used to construct the dwelling. Also indicate the siding type.
Examples of siding types not shown on the form include stucco, log, asbestos, and synthetic stucco/ EIFS (Exterior Insulation Finishing System).


Synthetic stucco is an artificial stucco used for exterior insulation and finishing systems (EIFS). It is created by affixing a styrofoam panel to the wall sheathing. The styrofoam is covered with reinforcing mesh, followed by a base coat and a finish coat. Both the base coat and the finish coats include an acrylic resin. The resin is water soluble in its liquid form, but once applied and dried, it becomes waterproof. Typically, this type of surface is less than a half-inch thick. It is relatively light, and sounds hollow when tapped. Real stucco is relatively heavy and feels and sounds solid when tapped. It is a much harder material than synthetic stucco, and is more resistant to injury by a blow or impact.


NOTE: you must advise the insurer if synthetic stucco (EIFS) siding is present.

Yr Built

Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alternations in the Remarks section. Also complete the Renovation Update section.

Sq Ft

Dwelling’s total square footage of living area.

# Rooms

Total number of rooms in a residence, including full and half rooms (bath).

# Apts

Complete only for tenant or condominium policies. Enter the number of apartments (residences) in the building.

Market Value

Estimated total dollar amount for which the dwelling could be sold under current market conditions.

Replacement Cost

Estimated total dollar amount required to rebuild the dwelling without depreciation.

Structure Type

Indicate the residence type. The full meaning of each abbreviation is:


* DWELLING – Dwelling, intended to be a free standing, up to 4 family building.
* APART – Apartment.
* CONDO – Condominium.
* TOWNHOUSE – Townhouse.
* ROWHOUSE – Rowhouse.
* CO-OP – Co-operative.

Usage Type

Applicant’s use for the dwelling within the guidelines listed. (“COC” refers to dwellings in the “course of construction.”)

# Families

Number of separate family units in the dwelling. Not required for HO-4 or HO-6.

# Hsehold Res

Number of residents in the household.

Purchase Date/Price

Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format.

# of Fire Div/ # of Units in Fire Div

Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of residences that are in the same fire division with the insured residence (including the insured’s residence). A fire division is the number of units within the building or within approved firewalls.

Terr Code

Dwelling location based on individual state bureau or company homeowners manual pages.

Prem Group

Premium group codes are found in individual state homeowner manuals. Some companies may require this data, others will generate it. Premium Group is a combination of Protection Class, Territory Code and Construction Type Code used to determine the applicable rate based upon the dwelling’s location, construction and fire protection code.

Protect Class

Dwelling’s four-character fire protection grade found in individual state homeowners manuals.

Distance to Hydrant

Distance in feet from the nearest hydrant to support the protection class used.

Distance to Fire Station

Distance in miles from the nearest fire station to support the protection class used.

Fire/EC Rate

Complete if residence is specifically rated. Refer to the company rate manual.

Fire District/Code Number

Residence’s fire district name and corresponding code number, which can be found in the individual state manual pages.

Protection Device Type

For temperature, smoke and burglar alarms to qualify for credit, a copy of the manufacturer’s specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies.

Heat Type

Type of heating device for the residence. If there is more than one type, indicate the primary and secondary types. Use the Remarks section if necessary. Some possible types are:

* Electric – Permanent/Portable
* Liquid Propane – Permanent/Portable
* Natural Gas
* Kerosene – Permanent/Portable
* Coal -Professionally/Non-Professionally Installed
* Oil
* Wood
* Solar
* Other – Explain the heating system in Remarks

Housekeeping Condition

Enter the evaluation of the interior upkeep of the dwelling.

Renovation Type

If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year.

Date Heating System Last Serviced

Indicate the date (MM/DD/YYYY) heating system was last serviced.

Num of Amps (Elec. Syst)

Indicate the number of amps in the electrical system.

Circuit Breakers

Check the applicable box.

Fuses

Check the applicable box.

Knob & Tube or Aluminum Wiring

Check the applicable box.

Plumbing System Condition

Indicate condition of the plumbing system.

Plumbing System & Any Known Leaks

Indicate if there are any known leaks in the plumbing system.

Foundation

Check the applicable box.

Dwelling Location

Location of the dwelling within the guidelines listed. Complete only if applicable.

Occupancy

Indicate if the dwelling is occupied by the owner or a tenant, unoccupied or vacant.

Deadbolt

If all entry (exterior) doors are fitted with deadbolt locks, check the box.

Fire Extinguisher

If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space.

Visible to Neighbors

If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box.

Oil Storage Tank Location

If the fuel type is oil, provide the location of the fuel oil storage tank. Options are:


* Indoors above ground on masonry floor
* Indoors above ground not on a masonry floor
* Outdoors above ground
* Outdoors below ground


Also show the distance from the dwelling, if the storage tank is outdoors.

Swimming Pool

If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board, slide or approved fence.

Windstorm Loss Mitigation Features

Describe the construction features which may qualify for credit under the rules in the company manual. General categories of construction features are:

* Roof Covering
* Roof Deck Attachment
* Roof/Wall Connection
* Window Protection
* Door Type
* Roof Geometry


Use an additional sheet if more space is required.

Bldg Code Grade

Enter the ISO Building Code Grade, if applicable. Also check the appropriate box to indicate whether or not the building was inspected.

Tax Code

Enter the city, county or state tax code, if required.

Rating

Check the applicable box.

Occupied Daily

Check the applicable box.

# Weeks Rented

Number of weeks the dwelling is rented by the insured to others.

Wind Class

Check the applicable box.

Roof Material

Enter the material used to construct the roof. Examples:

* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
*Wood Shake/Shingle
* Other If used, explain in Remarks

Condition of Roof

Indicate the condition of the roof.

If Replacement Cost coverage applies

Check the appropriate box if an ACORD replacement cost worksheet has been used (i.e., ACORD 42.)

Basement

Indicate the number of square feet in the basement. Leave this field blank if there is no basement.

Garage

Indicate the number of square feet in the garage. Leave this field blank if there is no garage.

Breezeway

Indicate the number of square feet in the breezeway. Leave this field blank if there is no breezeway.

Rating Credits

Check the applicable box(es) if any rating credits apply.

Sprinkler

If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system.

Fireplaces

Enter the number in the applicable box(es) to describe the fireplace(s.)

PRIOR COVERAGE

Prior Carrier

Provide the prior insurance company’s name.

Prior Policy

Number /Expiration Date List the complete policy number including prefix and suffix, and the policy’s expiration date.

GENERAL INFORMATION QUESTIONS

Use the Remarks section to provide additional information for any questions answered with a “Yes” response. (Except questions 15, 16 and 17.)

1. Any farming or other business conducted on premises?

Describe the business, where the business is conducted on the premises, and if applicable, whether corporal punishment coverage is to be provided. If “Yes”, provide amount of gross receipts.

2. Any residence employees?

Describe the number and type of full and part time employees.

3. Any flooding, brush, forest fire hazard, landslide, etc.?

Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph.

4. Any other residence owned, occupied or rented?

Use the Remarks section to describe the occupancy or use of the other residence. If no liability coverage is requested for this residence and this policy will provide liability coverage, detail where the coverage for the other residence is provided.

5. Any other insurance with this company?

Indicate whether 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 along with any policy numbers available.

6. Has insurance been transferred within agency?

Indicate why this insurance has been moved from the last company.

7. Any coverage declined, cancelled, or non-renewed?

Explain the circumstances surrounding this situation. Indicate the reason for the cancellation, etc. This question cannot be asked in Missouri.

8. Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years?

Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, bankruptcy filing, judgment or lien during the specified time period.

9. Are there any animals or exotic pets kept on the premises?

Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also, give any history of biting or causing injury to others or to other animals.

10. Is property located within two miles of tidal water?

Use the Remarks section to describe the coastal hazard, if applicable.

11. Is property situated on more than five acres?

Use the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose.

12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)?

Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description.

13. Is Building retrofitted for earthquake?

Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest “earthquake resistant” technology and building codes.

14. During the last five (5) years [ten (10) in Rhode Island], has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or other arson-related crime in connection with this or any other property ?

(In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.) Rhode Island law requires that all applicants for property insurance must answer this question.

15. There is a manager on the premises.

This question should be answered by applicants who reside in condos or are renters only.

16. A security attendant.

This question should be answered by applicants who reside in condos or are renters only.

17. The building entrance is locked.

This question should be answered by applicants who reside in condos or are renters only.

18. Any uncorrected code violations?

Describe any violations of applicable building codes that have not been corrected.

19. Is building undergoing renovation or reconstruction?

Describe the type and scope of renovation or reconstruction of any part of the building.

20. Is the house for sale?

Provide the length of time the house has been for sale, and the expected sale date if known.

21. Is property within 300 ft. of a commercial or non-residential property?

Describe the occupancy of any commercial or non-residential property.

22. Is there a trampoline on the premises?

Describe the device.

23. Was the structure originally built for other than a private residence and then converted?

Describe what the structure was originally built for.

24. Any lead paint hazard?

Describe the location and extent of the hazard.


25. If a fuel oil tank is on premises, has other insurance been obtained for the tank?

Give the First Party to the insurance and the applicable limit, and the Third Party and the applicable limit.


26. If building is under construction, is the applicant the general contractor?

Check the appropriate box if the applicant is the general contractor.

LOSS HISTORY

This section shows the losses this applicant has had in the past. List losses for the time period required by the company. Provision is made for the applicant to initial this section.

Date

Date of Loss (MM/DD/YYYY)

Type

Identify the type of loss.

Description of Loss

Describe the loss in detail.

CAT#

CAT# refers to a Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events.

Amount

Indicate the amount of the loss.

ADDITIONAL INTEREST

INT#

Provide the interest number or rank (1st, 2nd)


Check boxes

Identify whether the additional interest is the mortgage holder (i.e., bank in which the mortgage is held), or other interest

Name and Address

Provide the address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) for each entity having an interest in the dwelling(s) to be insured.

Loan Number

Provide the loan number.

BINDER/SIGNATURE

This section is to be used by producers with the permission of the company underwriter or when the producer has binding authority for this line of business. If the coverage is bound, complete the Insurance Binder section. If coverage is not bound, check the box.

Effective Date

Month/day/year (MM/DD/YYYY) on which the insurance applied for is bound. This insurance is subject to the terms, conditions, and limitations of the company.

Expiration Date

Month/day/year (MM/DD/YYYY) on which the binder terminates.

Time

Time the provisions of the binder become effective.

12:01/ Noon

Indicate the time on which the binder terminates.

Notice of Information Practices

Check this box if a copy of the Notice of Information Practices has been given to the applicant.

Applicant’s Signature

The applicant should read and understand the Fair Credit Reporting Act, the Privacy Act (where applicable), the Applicant’s Statement, and any other disclosure information on the form before personally signing the application.

Date

Date the form was signed.

Producer’s Signature

The producer should sign the application. This is required in most states.

National Producer Number

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