ACORD 862LA Instructions


ACORD 862 LA (2009/06) 1 of 9

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 862 LA (2009/06) Louisiana Property Supplement -Louisiana Hurricane Loss Mitigation SurveyForm The title of the form. ACORD 862 LA, Louisiana Property Supplement – Louisiana Hurricane Loss Mitigation Survey Form, complies with LA Regulation 94. Buildings eligible for hurricane loss mitigation credits must be inspected by a qualified professional. In accordance with the regulation, thebuilding inspector must use this form.
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 Agent Enter text: The name of theauthorized representative of the producer, agency and/or broker that signed the form.
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 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 Policy Type Enter text: The description of the type of policy issued to the insured.
SECTION I: INSURED INFORMATION Applicant(s) / Insured’s Name(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SECTION I: INSURED INFORMATION Applicant / Insured’s Phone Number Enter number: The named insured’s primary phone number.
SECTION I: INSURED INFORMATION Check box – Home Check the box (if applicable): Indicates the primary phone number is for ahome phone.
SECTION I: INSURED INFORMATION Check box – Business Check the box (if applicable): Indicates the primary phone number is for abusiness phone.
ACORD 862 LA (2009/06) 2 of 9

Section Name Field Name Field and/or Section Description
SECTION I: INSURED INFORMATION Location Address Enter text: The first address line of the physical location.
SECTION I: INSURED INFORMATION Enter text: The second address line of the physical location.
SECTION I: INSURED INFORMATION Enter text: The city of the physical location.
SECTION I: INSURED INFORMATION Enter text: The county of the location.
SECTION I: INSURED INFORMATION Enter code: The state or province of the physical location.
SECTION I: INSURED INFORMATION Enter code: The postal code of the physical location.
SECTION II: INSPECTION SURVEY Building Code – A) Louisiana State Uniform Construction Code Check the box (if applicable): Indicates the building or residential code the dwelling constructed to is the State Uniform Code.
SECTION II: INSPECTION SURVEY Building Code – B) Certified by IBHS as a Fortified for Safer Living structure Check the box (if applicable): Indicates the building or residential code the dwelling constructed to is IBHS Certified.
SECTION II: INSPECTION SURVEY Building Code -C) Neither of the above; built to another code (specify) Check the box (if applicable): Indicates the building or residential code the dwelling constructed to is other than those listed.
SECTION II: INSPECTION SURVEY Building Code -Another Code Enter text: The description of the building or residential code the dwelling constructed to.
SECTION II: INSPECTION SURVEY Building Code – D) Unknown, unidentified, or no code Check the box (if applicable): Indicates the building or residential code the dwelling constructed to is unknown, unidentified, or no code.
SECTION II: INSPECTION SURVEY Basic Design Wind Speed – A) Less than or equal to 90-mph (3second gust) Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is less than or equal to 90 mph (if in fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION SURVEY Basic Design Wind Speed -B) Greater than 90-mph and less than or equal to 100-mph (3-second gust) Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 90 mph and less than or equal to 100 mph (if in fastest mile speed, convert to 3-second gust).
SECTION II: INSPECTION SURVEY Basic Design Wind Speed -C) Greater than 100-mph and less than or equal to 110-mph (3second gust) Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 100 mph and less than or equal to 110 mph (if in fastest mile speed, convert to 3-second gust).
ACORD 862 LA (2009/06) 3 of 9

Section Name Field Name Field and/or Section Description
Basic Design Wind Speed -D)
SECTION II: INSPECTION Greater than 110-mph and less than or equal to 120-mph (3 Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 110 mph and less than or equal to 120 mph (if in
SURVEY second gust) fastest mile speed, convert to 3-second gust).
Basic Design Wind Speed -E)
SECTION II: INSPECTION Greater than 120-mph and less than or equal to 130-mph (3 Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 120 mph and less than or equal to 130 mph (if in
SURVEY second gust) fastest mile speed, convert to 3-second gust).
Basic Design Wind Speed -F)
SECTION II: INSPECTION Greater than 130-mph and less than or equal to 140-mph (3 Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 130 mph and less than or equal to 140 mph (if in
SURVEY second gust) fastest mile speed, convert to 3-second gust).
Basic Design Wind Speed -G)
SECTION II: INSPECTION Greater than 140-mph and less than or equal to 150-mph (3 Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and construct the dwelling is greater than 140 mph and less than or equal to 150 mph (if in
SURVEY second gust) fastest mile speed, convert to 3-second gust).
Basic Design Wind Speed -H) Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
SECTION II: INSPECTION Greater than or equal to 150-mph construct the dwelling is greater than or equal to 150 mph (if in fastest mile speed, convert
SURVEY (3-second gust) to 3-second gust).
Basic Design Wind Speed -I)
SECTION II: INSPECTION Unknown, unidentified, or no Check the box (if applicable): Indicates the Basic Design Wind Speed used to design and
SURVEY Basic Wind speed construct the dwelling is unknown, unidentified, or no basic wind speed.
SECTION II: INSPECTION SURVEY Exposure – A) Check the box (if applicable): Indicates the Exposure Category A, as defined by ASCE 7, was used to design and construct the dwelling.
SECTION II: INSPECTION SURVEY Exposure – B) Check the box (if applicable): Indicates the Exposure Category B, as defined by ASCE 7, was used to design and construct the dwelling.
SECTION II: INSPECTION SURVEY Exposure – C) Check the box (if applicable): Indicates the Exposure Category C, as defined by ASCE 7, was used to design and construct the dwelling.
SECTION II: INSPECTION SURVEY Exposure -D) Check the box (if applicable): Indicates the Exposure Category D, as defined by ASCE 7, was used to design and construct the dwelling.
SECTION II: INSPECTION Exposure – Unknown, unidentified, Check the box (if applicable): Indicates the Exposure Category, as defined by ASCE 7,
SURVEY or no Exposure Category used to design and construct the dwelling is unknown or unidentified.
SECTION II: INSPECTION Secondary Roof Water Intrusion Check the box (if applicable): Indicates there is a secondary roof water intrusion system
SURVEY System-Y) Yes, on all roof areas installed over all dwelling roof areas.
ACORD 862 LA (2009/06) 4 of 9

Section Name Field Name Field and/or Section Description
SECTION II: INSPECTION SURVEY Secondary Roof Water Intrusion System-N) No Check the box (if applicable): Indicates there no secondary roof water intrusion system installed over all dwelling roof areas.
SECTION II: INSPECTION SURVEY Secondary Roof Water Intrusion System-U) Unknown or Unidentified Check the box (if applicable): Indicates the existence of a secondary roof water intrusion system is unknown or unidentified.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- A) All Openings – All building envelope openings with and without glass / glazing, including garage doors Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is All Openings – All building envelope openings with and without glass / glazing, including garage doors, if garage doors exist on dwelling or if no garage door exists on dwelling, have wind borne debris protection. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- B) All Openings (except garage doors) – All building envelope openings with and without glass / glazing, excluding garage doors Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is All Openings (except garage doors) – All building envelope openings with and without glass / glazing, excluding garage doors, if garage doors exist on dwelling, have wind borne debris protection. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- C) All Glass / Glazed Openings and Some Openings without Glazing Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is All Glass / Glazed Openings and Some Openings without Glazing – All building envelope openings with glass / glazing and some building openings without glass / glazing, excluding garage doors have wind borne debris protection. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- D) Only Glass / Glazed Openings – All building envelope openings with glass / glazing have wind borne debris protection. Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is D – Only Glass / Glazed Openings – All building envelope openings with glass / glazing have wind borne debris protection. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
ACORD 862 LA (2009/06) 5 of 9

Section Name Field Name Field and/or Section Description
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- E) Some Glass / Glazed Openings – Some building envelope openings with glass / glazing have wind borne debris protection, but not all. Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is E – Some Glass / Glazed Openings – Some building envelope openings with glass / glazing have wind borne debris protection. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- F) No wind borne debris protection is provided on any glass / glazed building envelope openings Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is F – No wind borne debris protection is provided on any glass / glazed building envelope openings Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
SECTION II: INSPECTION SURVEY Extent of Windborne Debris Protection- U) Unknown or Unidentified Check the box (if applicable): Indicates the extent the building envelope openings have wind-borne debris protection – either protected with external protection devices or deemed impact-resistant through building code approved impact testing is U) Unknown or Unidentified. Building envelope openings include, but are not limited to windows, swinging doors, sliding doors, garage doors, skylights, and door sidelights.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
SECTION II: INSPECTION SURVEY (continued) Type of Wind Borne Debris Protection- A) Building envelope opening products: Have passed the following cyclic loading and windborne debris impact tests listed Check the box (if applicable): Indicates the weakest type of wind-borne debris protection used on the structure is Building envelope opening products: Have passed the following cyclic loading and wind-borne debris impact tests – [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or {Miami-Dade TAS 201 and TAS 203] or {ANSI/DASMA 115 for garage doors only]; and are approved by and included in the State of Florida Product Approval System or the Miami-Dade Code Compliance Office Product Approval System; or Are protected with an external protection device that has passed the following cyclic loading and wind-borne debris impact tests 0 [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or [Miami-Dade TAS 201 and TAS 203]; and are approved by and included in the State of Florida Product Approval System or the Miami-Dade Code Compliance Office Product Approval System.
ACORD 862 LA (2009/06) 6 of 9

Section Name Field Name Field and/or Section Description
SECTION II: INSPECTION SURVEY (continued) Type of Wind Borne Debris Protection- B) External protection devices that cannot be identified as meeting the requirements in Answer A Check the box (if applicable): Indicates the weakest type of wind-borne debris protection used on the structure is External Protection Devices that have not passed the following wind-borne debris impact test: 0 [ASTM E 1886 and ASTM E 1996 (Missiles D or E)] or [Miami-Dade TAS 201 and TAS 203]; or are not approved by and included in the State of Florida Product Approval System or the Miami-Dade Code Compliance Office Product Approval System..
Type of Wind Borne Debris
SECTION II: INSPECTION Protection- C) Wood structural Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
SURVEY (continued) panels (plywood or OSB) used on the structure is Wood Structural Panels (plywood or OSB).
Type of Wind Borne Debris
SECTION II: INSPECTION Protection- U) Unknown or Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
SURVEY (continued) Unidentified used on the structure is unknown or unidentified.
Type of Wind Borne Debris
Protection- X) Not applicable
SECTION II: INSPECTION because there is no wind borne Check the box (if applicable): Indicates the weakest type of wind-borne debris protection
SURVEY (continued) debris protection. used on the structure is not applicable because there is no wind-borne debris protection.
Check the box (if applicable): Indicates the shape of the roof is a total hip roof – hip roof
SECTION II: INSPECTION Roof Geometry- A) Total Hip roof – covering the entire structure (porches or carports that are not structurally connected to the
SURVEY (continued) Hip roof covering entire structure main roof system are not considered in the roof geometry determination).
SECTION II: INSPECTION SURVEY (continued) Roof Geometry- B) Partial Hip roof – Hip roof with no other roof shapes greater than 50% of any major wall length Check the box (if applicable): Indicates the shape of the roof is a partial hip roof – hip roof with no other roof shapes greater than 50% of any major wall length (porches or carports that are not structurally connected to the main roof system are not considered in the roof geometry determination).
SECTION II: INSPECTION SURVEY (continued) Roof Geometry- O) Other – Any other roof shape or combination of roof shapes including hip, gable, flat gambrel, mansard, and other roof shapes Check the box (if applicable): Indicates the shape of the roof is other than those listed (porches or carports that are not structurally connected to the main roof system are not considered in the roof geometry determination). This may include hip, gable, flat gambrel, mansard, and other roof shapes.
SECTION II: INSPECTION SURVEY (continued) Roof Covering System- Y) Yes Check the box (if applicable): Indicates the predominant roof covering on the dwelling is asphalt shingles that have passed either ASTM D3161 (Class F) or ASTM D7158 (Class G or H).
ACORD 862 LA (2009/06) 7 of 9

Section Name Field Name Field and/or Section Description
SECTION II: INSPECTION SURVEY (continued) Roof Covering System- N) No Check the box (if applicable): Indicates the predominant roof covering on the dwelling is not asphalt shingles that have passed either ASTM D3161 (Class F) or ASTM D7158 (Class G or H).
SECTION II: INSPECTION SURVEY (continued) Roof Covering System- U) Unknown or Unidentified Check the box (if applicable): Indicates the predominant roof covering on the dwelling is asphalt shingles but the status of the ASTM 3161 (Class F) or ASTM D7158 (Class G or H) tests are unknown or unidentified.
Roof Covering System-X) Not
applicable because predominant
SECTION II: INSPECTION roof covering is not asphalt Check the box (if applicable): Indicates the predominant roof covering on the dwelling is
SURVEY (continued) shingles not asphalt shingles.
SECTION II: INSPECTION SURVEY (continued) Age of Roof Covering- A) Check the box (if applicable): Indicates the year the roof covering system was installed is known.
SECTION II: INSPECTION SURVEY (continued) Age of Roof Covering- Year Enter year: The year the roof covering system was installed.
SECTION II: INSPECTION SURVEY (continued) Age of Roof Covering- U) Unknown Check the box (if applicable): Indicates the year the roof covering system was installed is unknown.
SECTION II: INSPECTION SURVEY (continued) Type of Roof Deck: Enter text: The predominant roof deck material.
SECTION II: INSPECTION SURVEY (continued) Size and Type of Fastener: Enter text: The size and type of fastener used for the roof deck.
SECTION II: INSPECTION SURVEY (continued) Spacing of Fasteners: Enter text: The spacing of the roof deck fasteners.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-A) Double Wraps Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on the dwelling are double wraps.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-B) Single Wraps Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on the dwelling are single wraps.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-C) Clips Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on the dwelling are clips.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-D) Toenails Check the box (if applicable): Indicates the weakest form of roof-wall connectors used on the dwelling are toenails.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-E) None Check the box (if applicable): Indicates none was selected as the weakest form of roof-wall connectors used on the dwelling.
ACORD 862 LA (2009/06) 8 of 9

Section Name Field Name Field and/or Section Description
SECTION II: INSPECTION SURVEY (continued) Roof Wall-X) Not applicable as roof deck is metal roof deck (pan type), precast concrete panels, or poured-in-place concrete Check the box (if applicable): Indicates the weakest form of roof-wall connectors is not applicable as the roof deck is metal (pan type), precast concrete panels, or poured-inplace concrete.
SECTION II: INSPECTION SURVEY (continued) Roof Wall-U) Unknown or Unidentified Check the box (if applicable): Indicates the weakest form of roof-wall connectors is unknown or unidentified.
SECTION II: INSPECTION SURVEY (continued) Gable Roof Bracing- Y) Yes Check the box (if applicable): Indicates the gable roof structure bracing members and system is designed and installed in accordance to the State Uniform Construction Code.
SECTION II: INSPECTION SURVEY (continued) Gable Roof Bracing-N) No Check the box (if applicable): Indicates the gable roof structure bracing members and system is not designed and installed in accordance to the State Uniform Construction Code.
SECTION II: INSPECTION SURVEY (continued) Gable Roof Bracing- X) Does not apply because there are no gable or gambrel roof shapes Check the box (if applicable): Indicates the question is not applicable because there are no gable or gambrel roof shapes.
SECTION II: INSPECTION SURVEY (continued) Gable Roof Bracing- U) Unknown or Unidentified Check the box (if applicable): Indicates it is unknown or unidentified if the gable roof structure bracing members and system is designed and installed in accordance to the State Uniform Construction Code.
SECTION II: INSPECTION SURVEY (continued) Foundation Restraint- Y) Yes Check the box (if applicable): Indicates there are floor-to-foundation connections designed and installed in accordance with the State Uniform Construction Code.
SECTION II: INSPECTION SURVEY (continued) Foundation Restraint- N) No Check the box (if applicable): Indicates there are not floor-to-foundation connections designed and installed in accordance with the State Uniform Construction Code.
SECTION II: INSPECTION SURVEY (continued) Foundation Restraint- U) Unknown or Unidentified Check the box (if applicable): Indicates it is unknown or unidentified if there are floor-tofoundation connections designed and installed in accordance with the State Uniform Construction Code.
SECTION III: Name (Please Type or Print) Enter text: The full name of the individual conducting the inspection.
SECTION III: Firm Name Enter text: The name of the firm of the individual conducting the inspection.
SECTION III: Title (Vendor, Owner, Officer, or Partner Enter text: The title of the individual conducting the inspection.
SECTION III: State of Louisiana License Number Enter identifier: The state license number of the individual conducting the inspection.
SECTION III: Signature Sign here: The signature of the inspector.
SECTION III: Date Enter date: The date the form was signed by the inspector.
SECTION III: Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SECTION III: Date Enter date: The date the form was signed by the named insured.
Section Name Field Name Field and/or Section Description
SECTION III: Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SECTION III: Date Enter date: The date the form was signed by the named insured.
SECTION III: Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SECTION III: Date Enter date: The date the form was signed by the named insured.
SECTION III: Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SECTION III: 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).