ACORD Instruction Guide Richter Robb Pacific Insurance by jennyyingdi

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									                               ACORD Instruction Guide
This instruction guide was derived from The ACORD organization and is included in the desktop version of
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Professional Liability Supplement 187 (3/98)
Use this form to apply for professional liability coverage for any of the following classes:
Barbers and Beauticians
Funeral Directors
Optical and Hearing Aid Establishments
Printers
Veterinarians

This form is intended to be used as a supplement to the following forms:
ACORD 125 Commercial General Liability Section
ACORD 160 Business Owners Application
ACORD 165 Small Commercial Account Package App




Commercial Auto Driver Information Schedule 163 (11/2000)

Use this form with either ACORD 127, Business Auto Section, ACORD 128, Garage and Dealers Section, or ACORD 132,
Truckers/Motor Carriers Section, to record driver information when there is not enough space in ACORD 127, ACORD
128 or ACORD 132 to accommodate the number of drivers of the applicant's or the insured's vehicles.
INSTRUCTIONS
It is necessary to collect information on all drivers that will be covered under this account. The driver list should include
any family member that will be driving company vehicles and employees who regularly drive their own vehicles for
company business.
Driver #
Indicate driver number assigned by the agency/agency-vendor system used for tracking purposes.
Name
Enter driver's full name. If the company requires the address, enter it as well.
Sex
Enter F for female, M for male.
Mar Stat
Enter the marital status for each listed driver. Examples:

S=Single
M=Married
D=Divorced
SP=Separated
W=Widowed
Date of Birth
Enter driver's birth date.
Yrs Exp
Enter the number of years of driving experience for each driver.
Year Licensed
Enter year in which the driver was first licensed.
Driver's License Number/Soc. Sec. #
Enter complete driver's license number. If a license number is unavailable, enter the driver's social security number.
State Lic.
Enter the state in which the license was issued.
Date Hire
Enter the date of hire for each listed driver (MM/DD/YY).
Use Vehicle #
Enter the vehicle number that this driver primarily uses.
% Use
Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.




Restaurant/Tavern Supplement 185 (2/2001)

Use this form in conjunction with ACORD 125, Commercial Insurance
Application - Applicant Information Section.

This form is intended to be used as a supplement to the following forms, when insurance is desired for restaurants, diners,
banquet halls, taverns, night clubs, and other risks that provide food and/or beverage service:

ACORD 126, Commercial General Liability Section

ACORD 140, Property Section

ACORD 160, Business Owners Application

ACORD 165, Small Commercial Account Package Application

IDENTIFICATION SECTION

DATE
Month/day/year in which the form is completed.

PRODUCER
Producer's name, address, and telephone number.

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

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

AGENCY CUSTOMER ID
Customer's identification number assigned by the agency.

APPLICANT INFORMATION

APPLICANT
Full name of the applicant as it appears on ACORD 125.

LOCATION OF PROPERTY
Provide the street address as it appears on ACORD 125.

TYPE OF BUSINESS
Identify the type of business conducted. Also check the appropriate boxes to indicate if the business is franchised, not
franchised, seasonal or year round.

HOURS OF OPERATION
Provide the hours of operation.


GENERAL INFORMATION
This section is designed to inform the underwriter about the past financial condition of the owner or corporation, the type
of entertainment provided, if any, the original and subsequent use of the building, and the number of employees Also
indicate if the building owner is to be named as an additional insured on the policy.


BED & BREAKFAST INN ONLY
Complete this section if the risk is a bed & breakfast inn.


KITCHEN FIRE PROTECTION

This section is intended to provide sufficient information about the cooking equipment fire protection maintenance, and
installation to enable the underwriter to assess the risks involved. Use the Remarks section to explain "no" answers.

GENERAL LIABILITY

This section is intended to provide information related to the operation of this type of business that is not found in ACORD
126, General Liability.

LIQUOR LIABILITY

Complete this section if liquor liability coverage is to be provided. Use the Remarks section if more space is needed to
provide responses.

FINANCIAL INFORMATION

Use this section to provide information about the financial condition of the business during the most recent 12 month
period.

It is not necessary to complete this section if adequate financial statements are attached.




Contractors Supplement 186 (9/2001)

Use this form as a supplement to ACORD 126-S, Commercial General
Liability Section, ACORD 160, Business Owners Policy Application, or
ACORD 165, Small Commercial Account Package Application, when
applying for commercial insurance for the following contractor classes:
      •    Air Conditioning and Heating
      •    Cabinetmakers
      •    Carpentry
      •    Electrical Wiring
      •    Excavation and Grading of Land or Septic Installation
      •    Insulation
      •    Landscaping
      •    Masonry
      •    Painting
      •    Plumbing
      •    Roofing

IDENTIFICATION

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

Producer
Producer's name, address, telephone number and fax number.

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

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

Agency Customer ID
Customer's identification number assigned by the agency.

Applicant (First Named Insured)
First Named Insured as it appears on ACORD 126-S, ACORD 160, or ACORD 165.

Type of Contractor
Show the contractor class as described in ACORD 126-S, ACORD 160, or ACORD 165. Also provide the number of years
experience in this line of work.

Contractor's License Number
Show the state or local license number for the applicant, and indicate if the license holder is the owner, an officer, an
employee of the business, or other individual or entity.

Number of Employees, Percent of Work
Show the total number of full-time and part-time employees, the percent of work that is residential, commercial, new
construction and remodeling.

Gross Receipts, Payroll, Subcontracted Work
Show the total dollar amount of gross receipts, payroll, and subcontracted work for the past 12 months.

Minimum GL Limits
Show the minimum liability limits, per occurrence and aggregate that are required of subcontractors.

Indicate if any work is done in or around the following exposures.
Answer this question for all applicants regardless of risk class. Explain all "yes" responses.

General Information
Answer these questions for all applicants regardless of risk class. Explain all "yes" responses.

Specific Contractor Information
Answer only those questions that apply to the applicant's class of contractor.




Agriculture Application 401 (10/2001)

The underwriting process for any Agriculture account begins with the submission of a completed application. This guide
will provide assistance in completing the ACORD Agriculture Application - Applicant Information Section.

The Applicant Information Section is the foundation on which the ACORD Agriculture application program is built. This
form contains information that is not duplicated on other ACORD application forms. The Applicant Information Section is a
required part of every Agriculture submission, and no commercial application is complete without it.

IDENTIFICATION SECTION

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

Phone Fax (A/C, No, Ext)
Producer's telephone and fax numbers.

Producer
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 and its' NAIC code.. Do not use group names; use the actual name of the
company within the group in which you wish to have the policy issued.

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. Show the
program code assigned by the company, if applicable. Also show the account number assigned by the agency or by the
company, if applicable.
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. Also show the deposit premium amount.

Sections Attached
A checklist indicating the other ACORD application sections that are attached to complete the submission. If there are any
other additional forms attached, enter the form name on the blank lines. The form numbers associated with the listed
section names are:
     •    Agriculture Property Section - ACORD 402
     •    Agriculture Property Section, Scheduled and Unscheduled Personal Property -ACORD 403
     •    Agriculture Liability Section - ACORD 404
     •    Agriculture Application Premises Diagram- ACORD 405
     •    Commercial General Liability - ACORD 126-S
     •    Auto
     •    For personal auto, use the ACORD 90 application for the state where the vehicles are located. For commercial
          auto, use Business Auto, ACORD 127, or Truckers, ACORD 132.
     •    Umbrella
     •    Use Personal Umbrella, ACORD 83, or Commercial Umbrella, ACORD 131-S.
     •    Personal Inland Marine
     •    Use ACORD 81.
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.

Also show the Federal ID Number (FEIN), or the applicants social security number, if no FEIN..

Mailing and EMail Address (of First Named Insured)
The physical address at which the first named insured is to receive all correspondence regarding the insurance. Include
the phone number and email address at that address.

Form of Business Organization
Identify the applicant as an Individual, Partnership, Corporation, Joint Venture, or Other. If other, provide a description
such as an 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.
Date Business Began
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 and 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

For each separate premises, show 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. Show the gross receipts in
dollars. Indicate if the applicant has any other business,
whether or not this business has been transferred within the agency, and the date when the premises was last inspected
by the producer.

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

Indicate the prior carrier(s), type of insurance, policy number(s), and amount(s) of coverage. If any coverage was
cancelled or non renewed, explain the circumstances surrounding this situation. The questions cannot be asked in
Missouri.

GENERAL INFORMATION -PROPERTY

Answer guestions 1 through 6 if Property insurance is being requested.

GENERAL INFORMATION -LIABILITY.

Answer questions 1 through 28 iif 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.
Agriculture Property Section 402 (10/2001)

This guide provides the user with basic instructions for completing the ACORD Agriculture Property Section Application.
The Property Section has been designed to handle the basic underwriting and rating needs for Agriculture property
exposures.

The Property Section accommodates a single location.

This form was designed to be used in conjunction with the Agriculture
Application - Applicant Information Section (ACORD 401). Please
turn to the chapter on the ACORD 401 for information on that form.

IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the Applicant Information Section
of ACORD 401. Even though this data matches the data on ACORD 401, it is still important to complete it. Many
companies separate the applications by sub-line of business for rating purposes. Not completing this portion of the
application makes it difficult to keep track of the full account.

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

Producer
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.

Named Insured/Applicant's Name
Show the named insured or applicant exactly as shown on ACORD 401. .

Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date
Enter exactly as shown on ACORD 401.

PREMISES INFORMATION

Location #
Enter the location number used by the applicant, if applicable.

Farm Name
Enter the farm name used by the applicant, if applicable.

Address
Enter the address of the location to be insured. Use route number, distance and direction from nearest crossroads, and
section, township and/or range if applicable in your state. Also include the legal description of the farm, as it will appear on
the policy.

Fire District Name/Code Number
Enter the fire district name and corresponding five-character code number for the location.

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

COLUMN HEADINGS

Description of Property
The principal dwelling, household and personal property located in that dwelling and snowmobiles are pre-printed in this
column. For other property such as additional dwellings, barns, stables, outbuildings, provide a brief description. Show all
buildings or structures to be insured. Be sure to show contents separately, and indicate the occupancy of each building or
structure.

Bldg #
Show the building number if applicable.

Diag #
Show the number used on the diagram on ACORD 405.

Construction
Indicate the building's construction type: Fire Resistive (FR); Modified Fire Resistive (MFR); Masonry Non-Combustible
(MNC); Non-Combustible (NC); Joisted Masonry (JM); Frame (F).

Type of Heat
Type of heating device for the structure. If more than one type exists, indicate the primary and secondary types. Use the
Remarks section if necessary. Possible types include:
    •     Electric - Permanent/Portable Natural Gas
    •     Liquid Propane - Permanent/Portable, Oil
    •     Kerosene - Permanent/Portable
    •     Coal - Professionally/Non-Professionally Installed
    •     Wood
    •     Solar
    •     Other - Explain the heating system in Remarks section
Year Built
Show the year the building was completed.

Roof Improve Year
Show the year the roof was resurfaced, if applicable..

Square Feet
Enter the square footage of the structure.

RC/ACV
Indicate if replacement cost (RC) or Actual Cash Value (ACV) valuation is to apply.

Coins
Enter the coinsurance percentage that is to apply.

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.

Dist To Hyd
Show the distance in feet to the nearest hydrant.

Causes of Loss
Show the causes of loss (perils) that are to be covered.

Deductible
Deductible amount that is to apply.

Value
Show the current value of the structure or property.

Limit of Insurance
Show the limit of insurance that will apply.

Premium
Show the premium for each item.

Additional Coverages/Restrictions/Endorsements/Rating Information
Use this space to provide necessary information not provided elsewhere.

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

The back of the form contains a second PREMISES INFORMATION section that may be used to describe additional
premises.
Agriculture Property Section, Scheduled and Unscheduled Personal
Property 403 (5/2000)

This guide provides the user with basic instructions for completing the ACORD Agriculture Property Section, Scheduled
and Unscheduled Personal Property. This form has been designed to handle the basic underwriting needs for Agriculture
personal property exposures. The form was designed to be used in conjunction with Agriculture Application - Applicant
Information Section, ACORD 401. Please turn to the chapter on ACORD 401 for information on that form.
IDENTIFICATION SECTION
Much of the information for the Identification Section should match the data found within the Applicant Information Section
of ACORD 401. Even though this data matches the data on ACORD 401, it is still important to complete it. Many
companies separate the applications by subline of business for rating purposes. Not completing this portion of the
application makes it difficult to keep track of the full account.
Date
Month/Day/Year on which the form is completed.
Producer
Producer's name, address and telephone number.
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
Customers identification number assigned by the agency.

Named Insured / Applicant's Name
Show the named insured or applicant exactly as shown on ACORD 401.
Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date
Enter exactly as shown on ACORD 401.
GENERAL INFORMATION
1. Is any property kept on a location (s) other than an insured location?
If the answer to this question is yes, state where it is kept and indicate whether the storage is during the farming season
or off season.
2. What is the maximum value of equipment at any one location?
Provide maximum value in dollars, both during the farming season and in the off season.
3. Is any equipment loaned to/from others?
If yes, provide the value for borrowed or rented equipment.
4. What is the radius of operations of equipment?
If any insured equipment is used or travels off premises, indicate the radius in miles for each piece of equipment.
5. Is equipment well maintained?
Describe type of maintenance performed.
SCHEDULED FARM PERSONAL PROPERTY
Description
Provide a complete description of each item shown separately. Indicate premises location.
Causes of Loss
Show the causes of loss (perils) that are to be covered.
Coins
Enter the coinsurance percentage that is to apply.
Deductible
Deductible amount that is to apply.

Limit of Insurance
Show the individual limits of insurance that will apply.
Premium
Show the premium for each item.
Transit/Hay, Miscellaneous Machinery, Tools, Equipment
These items are preprinted on the form. Space is also provided to show scheduled hay located off premises, if applicable.
UNSCHEDULED FARM PERSONAL PROPERTY
This schedule is designed to collect information about:
Produce
Poultry
Livestock
Machining and Implements
Cultivating
Harvesting
Tools, Equipment and Supplies
Irrigation Equipment
Any other unscheduled Agriculture personal property

Enter the number of units, unit price, total value, applicable causes of loss (perils) to be insured against, applicable
coinsurance, deductible(s) and premium. If blanket coverage is desired and any personal property is to be excluded from
this method of coverage, list the specific items to be excluded in the section provided.



Agriculture Liability Section 404 (5/2000)

This guide provides the user with basic instructions for completing ACORD Agriculture Liability Section. This form was
designed to handle the basic underwriting needs for agriculture liability exposures. If the risk is to be provided with
commercial general liability rather than farm liability coverage, use ACORD 125, Commercial Insurance Application, and
ACORD 126-S, Commercial General Liability Section. For umbrella or excess liability coverage, use either ACORD 83,
Personal Umbrella Application, or ACORD 131-S, Umbrella Section. This form was designed to be used in conjunction
with Agriculture Application - Applicant Information Section, ACORD 401. Please turn to the chapter on ACORD 401 for
information on that form.
IDENTIFICATION SECTION
Much of the information for the Identification Section should match the data found within the Applicant Information Section
of ACORD 401; it is still important to complete it. Many companies separate the applications by subline of business for
rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
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
Customers identification number assigned by the agency.
Named Insured/Applicant's Name
Show the named insured or applicant exactly as shown on ACORD 401.
Company, Account Number, Policy Number, New/Renewal, Effective Date, Expiration Date
Enter exactly as shown on ACORD 401.
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. Show separate limits where applicable. Note
that different aggregate limits may apply to separate coverages or exposures. Consult your company manual for
applicable rules. If Commercial General Liability is to apply, use Acord 125-S, Commercial Insurance Application, and
ACORD 126-S, Commercial General Liability Section.
Code
Enter the applicable ISO, AAIS, or company code for each type of exposure. Descriptions of coverage have been
provided that track with ISO or AAIS rules. If company unique rules apply, use the blank spaces provided. Show
Increased Limit Factors, Basis Rates and Premium for applicable exposures.
GENERAL INFORMATION
1. Are independent contractors hired to perform any farming operations?
If yes, describe the operations and indicate if certificates of insurance are obtained.
2. Any part of the farm used or leased for organized recreational use?
If yes, describe the activities.
3. Does applicant build, repair or design machinery, equipment or systems for anyone at a charge or fee?
If yes, describe the operation(s) in detail.
4. Does applicant mix, process, slaughter, butcher or otherwise prepare any "end consumer" this or any other
grower's product?
If yes, describe in detail.
5. Does applicant handle any product, such as seed, fertilizer, sprays, etc. For resale?
If yes, describe the process in detail.
6. Are any contract or service operations performed for others such as, snow removal, tilling, excavating or
ditching?
If yes, describe the operation and indicate the time period when such operations are performed.
7. Are the farm premises open to the public for activities such as roadside stands, "U-Pick," Recreational, Rent -
A- Garden, Auction, Sales, Show, Food or Beverage Service, Animal Boarding, or Christmas tree sales uses?
If yes, describe in detail.
8. Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other
than farming?
If yes, provide the name(s) of the individuals or corporation and the use of the premises.
9. Is there any unusual hazard such as (but not admitted to) open dump pits, silage pits, sump holes, lakes or
reservoirs?
If yes, describe in detail. Also indicate if any safety measures are in place.
10. Is there an airstrip on the premises?
If yes, provide the length of the runway, and indicate the type and size of aircraft that use the air strip.
11. Are any "Hold Harmless" or "Indemnifying" agreements in effect?
If yes, provide a copy of the agreement.

12. If livestock is kept, are all areas adequately fenced?
If the areas are not adequately fenced, describe the measures taken to protect the livestock.
13. Are the described insured premises the only premises which the applicant or spouse owns, rents or operates
as a farm or ranch, or maintains as a residence, other than business property?
If no, explain.
14. Any non-owned horses on any insured premises?
If yes, indicate which premises and describe the operation. Include the number of horses.
15. Does insured board, race, breed, or rent horses?
If yes, describe. Include the number of horses.
16. Is any land held for real estate development or speculation?
If yes, indicate the area involved and the intended use of the land.
17. Does applicant maintain any vacation or seasonal premises?
If yes, indicate which premises and which structures are involved.
18. If dairy farm, is there any processing of milk?
If yes, describe the process and indicate how the milk is protected.
19. If dairy farm, is there any retail sales of milk products to public?
If yes, show the dollar amount of receipts.
20. Show the number of cows milked.

21. Any premises used for hunting purposes?
If yes, indicate whether the hunting is by the owner, or if the premises is rented to others. Show fees and receipts, if any.
22. Does applicant maintain a non-farm office or private school in an insured building?
If yes, describe.

23. Is there a swimming pool on premises?
If yes, indicate if there is a diving board, and if the pool is adequately fenced.
24. Does applicant serve on any boards for remuneration?
If yes, describe.
25. Is the applicant a subsidiary of another or does the applicant have subsidiaries?
If yes, describe.
26. Is a formal safety program in existence?
If yes, describe.

27. Does applicant have any potentially dangerous animals or exotic pets?
If yes, give the age, breed or other information about livestock or pets that may be dangerous to human beings. Also give
the history of biting or causing injury.
28. Is there a water craft or snowmobile exposure?
If yes, describe.




Mobile Home Application 85 (1/2002)

The underwriting process for any personal lines policy begins with the
submission of a completed application. This guide will provide assistance in completing the ACORD Mobile Home
Application.

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 mailing 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 the 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 the 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/YY). (E.g., March 7, 1944 should be 03/07/44.)

Social Security #
Social security number for each named applicant.

Questions relating to agent's knowledge of applicant and when property was inspected
Indicate how long the agent has known the applicant, and the date when the property was last inspected.

ADDITIONAL INTEREST

Provide the following information for each entity having an interest in the mobile home(s) to be insured: the interest
number or rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is
held), or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010)
and loan number.

COVERAGES/LIMITS OF LIABILITY

List the anticipated dollar limit amounts for each applicable coverage.

Deductible & Type
Enter the deductible amount and the type (Flat, Percentage,) The deductibles may vary from one amount for all perils to
different deductibles for various coverages..

Endorsements
Enter the name of each applicable endorsement, and the applicable limit of coverage, if any.

Premium
Enter the estimated total premium, the deposit paid by the applicant, and the balance due later.

Payment Plan

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 to be used for payment.

RATING UNDERWRITING INFORMATION

Year
The model year for the mobile home, not necessarily the year the unit was manufactured.

Make and Model
The name of the manufacturer.

ID Number
The unique identification number for this mobile home.

Length/Width
Mobile home's exterior length and width, expressed in feet.

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

New/Used
Check the box to indicate if the mobile home was purchased new by the applicant, or if it was purchased from a previous
owner.

Cooking Location
Check the appropriate box to show the location of the cooking equipment within the mobile home.

Tie Down
Check the appropriate box to indicate the type of tie down, if any, used to secure the mobile home from wind damage.

Terr Code
Location of the mobile home based on individual state bureau or company manual pages.

Fire Prem Group
The applicable premium group based upon the mobile home's location, construction and fire protection code. Some
companies require this data; others generate it.

EC Prem Group
Extended coverage, broad form and special form premium group number determined from the territory.

Pers Liab Terr Code
Provide the territory code determined by the dwelling's location if the company's rate structure requires separate rating
information for personal liability.

Protect Class
Four character fire protection class found in individual state manuals.

Distance to Hydrant
Distance (in ft.) from the nearest hydrant that supports the protection class used.
Distance to Fire Station
Distance in miles from the nearest fire station that supports the protection class used.

Fire District/Code Number
Fire district name and corresponding five character code number which can be found in the individual state manual pages.

Protection Device Type
For alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application.

Heat Type
Type of heating device for the residence. If the residence has no heat, check the box.

If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. If fuel
storage tanks are located on the premises, describe the type and indicate the location. Possible types include:
     •    Electric - Permanent/Portable
     •    Natural Gas
     •    Liquid Propane - Permanent/Portable
     •    Oil - Permanent/Portable
     •    Kerosene - Permanent/Portable
     •    Solar
     •    Coal - Professionally/Non-Professionally Installed
     •    Wood
     •    Other - Explain the heating system in Remarks section
     •    Central Heating


Housekeeping Condition
An evaluation of the interior upkeep of the mobile home.

Occupancy
Indicate by whom the mobile home is currently occupied: owner, tenant, no occupants, or the mobile home is vacant.

Use
Indicate if the mobile home is the applicant's primary or secondary residence, or if the use is seasonal, or rented to others.

Exterior Construction
Chech the appropriate box.

Foundation Construction
Check the box that most closely describes the type of foundation.

Utilities
Check the appropriate boxes to indicate which utilities are permanently connected to the structure.

Wiring
Check the appropriate box to indicate copper or aluminum wiring, and show the date the wiring was las inspected.

OTHER STRUCTURES

Describe any other structure(s) and coverage limits to be included in Coverage B - Other
Structures.

LOCATION INFORMATION

If the mobile home is located in a mobile home park, give Yes or No answers to the questions relating to park
management and access to the park.
If the mobile home is not located in a mobile home park, give Yes or No answers to the questions relating to visibility from
the road and road paving.

GENERAL INFORMATION QUESTIONS

Use the remarks section to provide additional information for any questions answered with a "Yes" response.

1. Any business conducted on premises?
Describe the business as well as where the business is conducted on the premises.

2. Any supplemental heating?
Describe any portable heating devices, such as electric, kerosene or LP gas heating units.
3. Any flooding, brush hazard, 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 detail the occupancy or use of the other residence. If no liability coverage is requested for this
residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property.

5. Has applicant had a foreclosure, repossession or bankruptcy during the past five years?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or
bankruptcy filing during the specified time period.

6. 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.

7. Is property located within two miles of tidal water?
Use the Remarks section to describe the coastal hazard, if applicable.

8. 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.

9. 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.

10. Has insurance been transferred within agency?
Indicate why this insurance has been moved from the last company.

11. Any coverage declined, cancelled, or non-renewed?
Explain the circumstances surrounding this situation. This question cannot be asked in certain states.

12. During the last five years (ten in RI), has any applicant been convicted of any degree of the crime of arson?
(In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a
sentence of up to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.

LOSS HISTORY

This section shows the losses this applicant has had in the past. List losses for the last three years unless the company
requires a different period of time.

PRIOR COVERAGE

Prior Carrier
Provide the prior insurance company's name.

Prior Policy Number
List the complete policy number including prefix and suffix.

Risk New to Agency
Indicate whether this is the first time this agency has written this line of business for this applicant.


Flood Insurance Application 301 (3/97)a
This form was developed at the request of the National Flood Insurance Program. It may be used to apply for flood
insurance. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more
information, call the NFIP at 1-800-720-1093.



Flood Insurance Cancellation / Nullification Form 304 (3/97)
This form was developed at the request of the National Flood Insurance Program. It may be used to request cancellation
of a flood insurance policy. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For
more information, call the NFIP at 1-800-720-1093.
Flood Insurance General Change Endorsement 302 (3/97)
This form was developed at the request of the National Flood Insurance Program. It may be used to request changes in
existing flood insurance policies. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual.
For more information, call the NFIP at 1-800-720-1093.




Flood Insurance Preferred Risk Policy Application 303 (6/98)
This form was developed at the request of the National Flood Insurance Program. It may be used to apply for a Preferred
Risk Policy. Instructions for completing this form are contained in the NFIP's Flood Insurance Manual. For more
information, call the NFIP at 1-800-720-1093.




Schedule of Insurance 159 (7/2000)

IDENTIFICATION SECTION

Date
Month/day/year on which the form is completed.
Producer
Producers name, address, phone and fax numbrs.
Code
Identification code assigned to the agency or the brokerage firm by the insurance company receiving this form.
Subcode
If the agency uses a subcode identification system with the company, use the apporpriate 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
The company code assigned by the National Association of Insurance Commissioners.
Page
If more than one ACORD 159form is required because of the number of properties to be included, indicate the page
number applicable and the total number of pages. (e. g., page 1 of 5, page 2 of 4.)
Insured/applicant
Show the name of the insured or applicant as it appears on the policy.
Effective Date
Enter the effective date of the policy.
Headquarters Address
Enter the principle address of the insured.
Coins %
Check the applicable coinsurance percentage, if applicable.
Applicable Cause of Loss
Indicate the cause of loss for the subject of insurance.
Class Code
Enter the ISO or company class codes, if applicable.
Location#/Bldg#/Decscription and Location of Property
For each building, enter the location number, building number and address shown on the application or change request
that was used when the building or the contents was first insured. Provide a description of the property where necessary.
Use more than one line if additional space is needed.
Subject
Enter the applicable Subject number for each item of insurance, as shown in the instructions at the bottom of the form (e.
g., B = building, S = stock.)
Limits of Insurance
Enter the limits of insurance for each separate item.




Premium Payment Supplement 610 (5/2000)

Use this form as a supplement to any ACORD application, to record pertinent information relating to premium payments
involving bank transfers, payroll deductions, credit card deductions, and similar transactions.
IDENTIFICATION SECTION

Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
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.
Applicant's Name and Mailing Address
First Named Insured as it appears on the basic application to which this supplement will be attached.

Company, Policy #
Name of the applicable insurance company and policy number of the policy involved in the payment transaction. Do not
use group names; use the actual name of the company within the group in which you wish
to have the policy issued.
Is the Premium Financed?
Check the applicable box.
Finance Company
Name of the finance company, if applicable.
Payment Interval
Check the applicable box.
Payment Due Date(s)
Indicate the dates on which the payment transactions should occur.
Payment Method
Select the applicable payment method and provide the required information to activate that method.




Agriculture Premises Diagram (5/2000)

Use this form as an attachment to ACORD 401, the basic agriculture insurance application to provide a diagram of the
premises to be insured.
Use a separate form for each premises.




Texas Windstorm Insurance Association Application for Windstorm and
Hail Insurance 64TX (2/2000)

Accounts Receivable/Valuable Papers 145 (11/94)

This chapter provides basic instructions for completing the ACORD Accounts Receivable/Valuable Papers section which
addresses the basic underwriting and rating needs for both Accounts Receivable and Valuable Paper coverages written
under an Inland Marine or Property policy. As much information as possible should be collected regarding receivables and
valuable papers to evaluate the particular risk. All questions regarding the particular risk must be completed. Attach a
separate sheet if necessary. Accounts Receivable is on the front side of the form and Valuable Papers on the reverse
side Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form.
IDENTIFICATION SECTION
Much of the information for the Identification Section should match the data found within the Applicant Information Section
of ACORD 125. However, it is still important to complete it. Many companies separate the applications for rating purposes
by line of business. Failure to complete this part of the application makes it difficult to keep track of the full account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Proposed Eff. Date
Effective date on which the terms and conditions of the policy will commence.
Proposed Exp. Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e. g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
Audit
Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code:
A         annual
S         semi-annual
Q         quarterly
M         monthly
O         other

ACCOUNTS RECEIVABLE
Building Construction
Construction of the premises location. Common construction classifications are:
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Sprinklers
Indicate if there are fire sprinklers on the premises.
Classification of Business
Indicate all classifications of business in which the applicant is involved by placing an "X" in all appropriate boxes. Specify
the percentage of the total accounts receivable each classification represents.
LOCATION OF RECORDS/PROTECTION
Complete this section in regard to the location and protection systems for the Accounts Receivable. Information on the
classification of safes, vaults and alarm systems can be found in the Crime Section of the ISO Classification and Rating
Manual.
Address or Location
Indicate the address where Accounts Receivable are kept. This might also appear in the Applicant Information Section
(ACORD 125). If so, indicate "per ACORD 125" and list the location number.
Section of Building
Specify the section of the building where records of Accounts Receivable are kept; e.g., warehouse vs. office (separate
fire rate) and floor have underwriting importance. If other than office, explain.
Fire Contents Rate
Indicate the 80 percent coinsurance (Basic Group I Personal Property Rate) for the section of the building where Accounts
Receivable are usually kept.
Safe/Vault/Receptacle Manufacturer
If records are kept in a safe, vault or other receptacle, enter the manufacturer's name.
Label
Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe
Manufacturers National Association (SMNA).
Class
Record the construction classification which represents the extent of fire protection for this safe or vault. Use the
classification from the Fire label and not the Burglary label located on the safe or vault. For industry definitions of the
classifications, refer to the Commercial Lines Manual.
Door Type
Indicate if the door is round or square.
Combination Locks
Identify the presence of combination locks as well and their placement on the safe/vault. Place an "X" in all boxes that
apply.
Door Thickness
Measurement in inches.
Wall Thickness
Measurement in inches.
Construction
Specify the construction of the safe, vault or other receptacle (e.g., 4-inch steel door, with 12-inch reinforced stone walls).
Duplicate Records
Indicate if duplicate Accounts Receivable records are kept by checking the appropriate box.

Percent of Records Duplicated
Indicate what percent of all Accounts Receivable have duplicate records.
Period Records Kept
Indicate the number of months all duplicate records will be maintained.
Location of Duplicate Records
Indicate the address of the location where duplicate records are kept and the precise storage location or section of the
building.
Alarm Type
Indicate the style of alarm(s) where the Accounts Receivable's are stored. Available options are:
Hold-Up - Manual or semiautomatic control which can transmit an alarm in the event of a hold-up.
Premises - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The
  Premises Extent must be completed for Premises Alarms.
Safe/Vault - System that protects the safe or vault and is connected to an outside central station, gong or siren. The
  Extent of Protection for Safe/Vault must be completed for all safes/vaults.
Alarm Description
Indicate any applicable features of the alarm.
Local Gong - Bell located outside the premises.
Central Station - Private security service which monitors the alarm system and may dispatch security officers in response
  to an alarm.
Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private
  control station.
With Keys - Indicate if security service or police have keys to respond to alarms.
Grade
Grade or class A, B, C, etc. which indicates the time required to respond to a signal from the alarm system. Refer to
manual.
Extent of Protection for Safe/Vault
Indicate the extent of the alarm protection for the safe or vault.
Partial - Alarm covers around door only.
Complete - Alarm covers sides, top walls, floor and ceiling.
Extent of Protection for Premises
Indicate the extent of the premises alarm as defined in the ISO Classification and Rating Manual.
Alarm Installed & Serviced By
Name of the company installing and servicing the alarm system. Alarm companies often install, maintain, and service the
system in addition to providing Central Station facilities.
# Guards
Number of guards within the premises or at its door while regularly open for business.
# Watchpersons
Number of watchpersons on the premises retained during non-office hours.
Watchpersons
Indicate the type of reporting the watchpersons do:
Rpt/Cent. St - Report to a central station on an hourly basis.
Clock Hrly - Register hourly with an approved watchpersons' clock (Detex Time Clock, etc.)
Don't Signal - Do not report or register in any way.
Certificate Number
Alarms approved by the Underwriters Laboratories (UL) have a certificate. Record the certificate number. (Note: UL
certification can apply to the entire system or to individual parts.)
Expiration Date
UL certificate expiration date.
Accessible Openings & Protection
Provide information regarding access to the premises. Indicate how many doors exist and if they are protected. Indicate
what type of locks are used, and if there is a gate or bars.
Other Protection
Describe any other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm, if
the building has skylights or if windows are visible from the street).
POLICY INFORMATION
Use this section to track policy limits and coverages.
Reporting/Non-Reporting
Indicate if Accounts Receivable insurance is requested on a reporting or non-reporting basis. Reporting coverage usually
requires monthly reports of the applicant's total Accounts Receivable and is subject to annual premium adjustment.
Your Premises - Limit
Insurance limit required for Accounts Receivable located on your premises, including branch locations.
Not at Your Premises - Limit
Insurance limit required for Accounts Receivable located off your premises.
In Transit - Limit
Insurance limit required for Accounts Receivable in transit.
All Covered Property at all Locations - Limit
Sum of all Accounts Receivable.
HISTORY OF RECEIVABLES
Amount of Receivables outstanding as of the last fiscal day of each month of the prior year immediately preceding the
date of this application. Specify the month and year for each entry.
Deferred Payment Percentage
Percentages of total monthly Accounts Receivable currently represented by deferred payment accounts.
Uncollected Accounts
Amount of uncollectable accounts for each of the past three years by entering the year and amount.
GENERAL INFORMATION
Use the Remarks section for additional information for any questions answered "Yes." The following overview lists
information that should be added to the remarks section for "Yes" responses.

1. Is "Cycle Billing" accounting system used?
Indicate if cycle billing is done and specify if original records are microfilmed. Fully describe the cycle billing procedure;
attach a separate sheet if necessary. This is similar to billing for credit cards.
2. Are billed and unbilled records kept separate?
Indicate location of each set of records.
3. Has there been flooding at any location?
Give date and location of flooding.

REMARKS
Use this section for any additional information required for underwriting or rating.
VALUABLE PAPERS
LOCATION
Building Construction
Construction of the premises location. Common construction classifications are:
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Sprinklers - Indicate if fire sprinklers are on the premises.
LOCATION OF RECORDS/PROTECTION
Complete this section as explained in the Accounts Receivable Section for Location of Records/Protection. (Note: This
section applies to Valuable Papers and not Accounts Receivable.)
POLICY INFORMATION
Your Premises - Limit
Insurance limit required for Valuable Papers located on your premises.
Not at Your Premises - Limit
Insurance limit required for Valuable Papers located off your premises.
Blanket/Specified Amount
If Blanket Coverage is requested, check the appropriate box and enter the blanket amount. If coverage is to be written on
a specified amount basis, an agreed amount per item should be entered in the Papers section along with a description of
the specified paper.
Occurrence Deductible
Deductible amount.
Can Papers Be Replaced?
Indicate if any papers can be replaced.
PAPERS
Complete this section only if specific insurance is desired on individual valuable papers.
#
Assign a number to each item listed.
Description of Papers
Describe the valuable papers to be insured including manuscripts, documents, rare printings, etc. Older items require
appraisals; architects' or engineers' plans should be described; deeds and contracts should be categorized. Valuable
papers do not include money and securities.
Amount
Specified amount for each item listed.
See Attached List
If a separate schedule of Valuable Papers is provided, place an "X" in the box for See Attached List and submit the
schedule with this application.
REMARKS
Use this section for additional information required for underwriting or rating.




Additional Interest 45 (3/93)

The Additional Interest form is used in multiple situations to expand upon the additional interest sections within line of
business applications. This form may be used for both personal and commercial accounts. The form is used to secure
information on additional interests and certificate holders.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Phone (A / C, No, Ext)
Producer's telephone number.
Code
Identification code assigned to the agency or brokerage firm by the Insurance Company receiving this form.
Agency Customer ID
Customer's identification number assigned by the agency.
Applicant (First Named Insured)
First Named Insured as it appears on the line of business form to which this form will be attached.
Phone (A / C, No, Ext)
Applicants telephone number.
Effective Date
Month/day/year on which the terms and conditions of the policy will commence.
Expiration Date
Month/day/year on which the terms and conditions of the policy will terminate unless renewed.
Co/Plan
Name of the insurance company 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 (Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that
company.
Policy Number
Number assigned by the insurance company for the policy.

Account Number
Account number to be used for billing purposes. This is the Billing Number assigned by the billing entity. If agency bill, the
agency assigns; if direct bill the company assigns.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS
Use this section for information on any additional interests, employees who should be listed as additional insureds, and
others who require Certificates of Insurance.
Interest
Indicate all appropriate options for the individual named.
Rank
Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee.
Name and Address
List the additional interests name and address.
Reference #
Indicate the additional interests reference number for this applicant such as the loan or mortgage number.
Certificate Required
If a Certificate of Insurance is required check this box.
Interest in Item Number
List the item number corresponding with the application for the item of interest for this additional insured.
Item Description
If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a
scheduled item list the description, such as 3 carat diamond in six point setting.




Automobile Loss Notice 2 (3/2001)

Use the ACORD Automobile Loss Notice (ACORD 2) for the reporting of both commercial and personal lines automobile
losses.
IDENTIFICATION SECTION

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

Phone (A/C, No, Ext)
Producer's telephone number.

FAX
Producer's fax number.

Producer
Producer's name and address.

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

Subcode
If your agency uses a sub-code 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 and its' NAIC code. Do not use group names, use the actual name of the
company within the group to which you are sending the loss notice.

Miscellaneous Info
Use this field to list site and location codes for large accounts. It may also be used to enter the claim number on a phone-
in report.

Policy Number
Number assigned by the insurance company for the policy.

Policy Type
Provide the type of policy issued to the insured. E. g., personal auto, truckers, garage liability.

Reference Number
Insured's claim number or other reference number to identify this notice.

CAT #
If a catastrophe number has been assigned by the Property Claim Service or other industry organization, enter it here.
This is the number assigned to the event that caused the loss being described.

Effective Date
Date on which the terms and conditions of the policy commenced.

Expiration Date
Date on which the terms and conditions of the policy will or have expire(d).

Date of Accident and Time
Enter the date and approximate time the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g,
01/11/94 - 12:15 A.M.).

Previously Reported
Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If not, list
in the remarks section when other report(s) have been made.

INSURED

Name & Address
Name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if applicable,) of the
insured as found on the declarations page of the policy.

Residence Phone (A/C, No)
For an individual, the home telephone number, including area code, at which the insured may be reached.

Business Phone (A/C, No, Ext)
Business telephone number, including area code and extension, of the insured.
CONTACT

Contact Insured
If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address
and phone numbers.

Name and Address
Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business
relating to this incident. No entry is necessary if the "Contact Insured" option is checked.

Residence Phone
Enter the home phone number including area code of the contact named above. If it is the insured, leave this field blank.

Business Phone
Enter the business telephone number, including area code and extension of the contact. If it is the insured, leave this field
blank.

Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).

When
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).

LOSS

Location of Accident (Include city and state)
Indicate street or intersection, mile marker, or a description (e.g., On Route 83 five miles north of the Smallville
intersection with Route 59).

Authority Contacted
Enter the name of the police department or other authority to which the accident was reported, including any precinct or
station number, if available.

Report #
If a case or file number has been assigned, be sure to include that number as well. Usually the report number is the
number of the vehicle incident report filed by the police after an automobile accident.

Violations/Citations
Provide the type of violation/citation and identify the driver who received the citation using driver number.

Description of Accident
Explain how the accident occurred.

POLICY INFORMATION

Use this section to list the policy limits and deductibles for the insured as shown on the declarations page.

Bodily Injury (Per Person)
Used for split limit policies. Enter the Bodily Injury Per Person Limit.

Bodily Injury (Per Accident)
Used for split limit policies. Enter the Bodily Injury Per Accident Limit.

Property Damage
Used for split limit policies. Enter the Property Damage Per Accident limit.

Single Limit
For combined single limit policies, enter the liability limit in this field.

Medical Payment
Indicate the limit (if any) provided for Medical Payments.

OTC Ded.
Other Than Collision (OTC) Deductible. If physical damage coverage other than collision is provided, enter the deductible
amount. If there is no deductible, enter ACV (Actual Cash Value) or other basis. If no coverage is provided, enter N/A.

Other Coverage & Deductibles
Describe any additional coverages and deductibles provided on the policy (e.g., No-Fault, Towing, Full Coverage Glass).
Loss Payee
Enter the name of any Loss Payee for the auto involved in the loss. If none, enter N/A.

Collision Ded.
Collision Deductible. If Collision coverage is provided, enter the deductible amount. If no coverage is provided, enter N/A.

Umbrella/Excess
Indicate if such a policy is in force by checking the appropriate box. Also list the carrier. Enter the umbrella or excess
policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the applicable self insured
retention or deductible.

INSURED VEHICLE

Use this section to describe the insured's vehicle and the driver involved in the loss. Information entered should correlate
to the insured's declarations page whenever possible.

Veh. No.
Vehicle Number. Indicate the number assigned to the vehicle as it appears on the policy declarations page.

Year
Model year of the vehicle.

Make
Vehicle's manufacturer (e.g., Buick).

Model
Manufacturer's model name (e.g., Regal).

Body Type
Vehicle's body type (e.g., two-door sedan).

V.I.N.
Enter the full Vehicle Identification Number.

Plate No.
Indicate the license plate number.

State
State of issuance for the license plate.

Owner's Name & Address
Enter the name and address of the owner of the vehicle. If it is the insured, enter "insured."

Residence Phone
Enter the vehicle owner's telephone number with the area code.

Business Phone (A/C, No, Ext)
Enter the vehicle owner's business phone number with area code and extension.

Driver's Name & Address
If this is the owner, check the available box. Otherwise, provide the driver's name and address.

Residence Phone
Enter the driver's home telephone number with area code.

Business Phone
Enter the driver's business telephone number, including area code and extension.

Relation to Insured
Indicate the relationship between the driver and the insured (e.g., Insured, wife, child).

Date of Birth
Indicate the driver's birth date.

Driver's License Number
Enter the driver's license number.

State
State of issuance of the driver's license.
Purpose of Use
Enter a short description of the purpose of the trip during which the accident occurred (e.g., trip to store or commuting to
work).

Used With Permission?
Indicate if the vehicle was used with the permission of the owner by placing an "X" in the appropriate box. Explain a "no"
response in the Remarks section of the form.

Describe Damage
Describe any damage to the insured's vehicle (e.g., right front fender crushed).

Estimate Amount
If known, give an estimate for the cost of repairing the vehicle.

Where Can Vehicle Be Seen?
Indicate where the adjuster can inspect the vehicle. If other than at the insured's address, include the address.

When
Indicate the time period the vehicle is available for inspection.

Other Insurance On Vehicle
Provide the company name and policy number on any other applicable insurance. Enter "N/A" if none.

PROPERTY DAMAGED

Use this section to describe any property other than the insured vehicle (buildings, other vehicles) damaged in relation to
this loss. Check the appropriate box to indicate whether or not the damaged property is a vehicle.

Describe Property
Give a brief description of the type of property damaged, such as home or fence. If a vehicle, list the year, make, model
and plate number.

Other Veh./Prop. Ins?
Indicate if the damaged property (or vehicle) is insured or not.

Company or Agency Name
Enter the name of the insurance company or agency covering this property (or vehicle).

Policy #
Enter the policy number for this property (or vehicle).

Owner's Name & Address
Enter the name and address of the owner of the property (or vehicle).

Residence Phone
Enter the home phone number, including area code, of the property owner.

Business Phone
Enter the business telephone number, including the area code and extension, of the property owner.

Other Driver's Name & Address
If the property damaged is another vehicle, enter the name and address of the driver of the other vehicle. Check the box if
it is the same as the owner's name and address.

Residence Phone
Enter the home telephone number of the driver, including area code.

Business Phone
Enter the business telephone number of the driver, including area code and extension.

Describe Damage
Describe the extent of the property damaged (e.g., porch pillar broken, right front fender crushed).

Estimate Amount
If known, give an estimate of the cost of repair.

Where Can Damage Be Seen?
Indicate where the damaged property is located, including address, so that an adjuster can inspect it.

INJURED
Use this section to collect information on all injured parties.

Name & Address
Enter the name(s) and address(es) of any people injured in the accident.

Phone
Enter the home telephone number, including area code of any injured party.

PED
Indicate if the injured party was a pedestrian by an "X" in this box.

Ins. Veh.
Indicate if the injured party was in the insured's vehicle by an "X" in this box.

Other Veh.
Indicate if the injured party was in a vehicle other than the insured's by an "X" in this box.

Age
Enter the age of the injured party.

Extent of Injury
Briefly describe the injury to the injured party (e.g., broken left leg).

WITNESSES OR PASSENGERS

Use this section to describe any additional parties involved in or witnessing the accident.

Name & Address
Enter the name(s) and address(es) of any witnesses or uninjured passengers.

Phone
Enter the home telephone number, including area code, of any witness or passenger.

Ins. Veh.
Indicate if the witness or passenger was in the insured's vehicle by an "X' in this box.

Other Veh.
Indicate if the witness or passenger was in a vehicle other than the insured's by an "X" in this box.

Other
Describe any other witnesses. If they were not in the insured's vehicle or other involved vehicle, include the location from
which they witnessed the incident.

Remarks
List any other additional information that will assist in properly reporting and settling this claim. Include the adjuster's name
if known.

Reported By
Indicate the name of the individual who reported the loss.

Reported To
Indicate the name of the individual within the agency or company to whom this loss was reported.

Signatures of Producer and Insured
This form should be signed by the producer and the insured.

Note: Important state information is on the second side of this form.




Boiler and Machinery Section 155 (11/2000)

This chapter provides basic instructions for completing the ACORD Boiler & Machinery Section (ACORD 155). This form
has been designed to address basic underwriting and rating needs for the issuance of Boiler and Machinery policies
Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form.
IDENTIFICATION SECTION
Most information for the Identification Section should match the data found within the Applicant Information Section of
ACORD 125. however it is still important to complete the section. Many companies, for rating purposes, separate the
applications by line of business. Not completing this portion of the application impedes tracking the full account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Proposed Eff. Date
Effective date on which the terms and conditions of the policy will commence.
Proposed Exp. Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
SMALL BUSINESS POLICY (Limit Rated)
Use section for submissions in conjunction with a business owner's policy (BOP) or to companies issuing Boiler and
Machinery policies based on limited rating criteria.
Coverage
Mark an "X" in the appropriate box for the Coverage desired.
Basic Coverage Form
Boilers and Vessels are automatically included. Indicate if the basic form includes air conditioners/compressor units or
excludes air conditioners/compressor units.
Broad Coverage Form
Comprehensive coverage that includes boilers, pressure vessels, mechanical and electrical equipment, but excludes
production machinery.
Other
Many companies have independently filed Boiler and Machinery products. Refer to the companies for information needed
to rate the product.
Spoilage (Consequential Damage)
Mark an "X" in the appropriate box for the desired limit. Spoilage is the loss of perishable goods due to lack of power,
light, heat, steam or refrigeration.
Deductible
Mark an "X" in the appropriate box for the desired deductible.
General Information
Mark an "X" in the appropriate box. Indicate whether Heating (hot water or steam only) or Process Boilers are located on
any locations to be covered. If the answer varies by location, use the Additional Information area to note the information.
Additional Information
List any additional information that would be useful in the underwriting of this account (e.g., age of boiler, building
construction).
STANDARD POLICY
Covered Equipment
Mark an "X" in the appropriate box(es) by equipment type box for coverage(s) desired.
PD       Property Damage
BII      Business Interruption Insurance

Comprehensive
Coverage includes Boilers, Pressure Vessels and Mechanical and Electrical Equipment. It may include or exclude
coverage for production machines (equipment used specifically for manufacturing or processing of products). If
comprehensive coverage is chosen, do not choose any of the "All" categories or complete any "Other" item.
All Boilers - Pressure Vessels
Indicate which coverage is desired for this type of equipment.
All Air Conditioning & Refrigeration Equipment
Indicate which coverage is desired for this type of equipment.
All Electrical Equipment
Indicate which coverage is desired for this type of equipment.
All Mechanical Equipment
Indicate which coverage is desired for this type of equipment.

Other Object Groups
This area may be used to select particular types of Objects that fall within the "All" categories (e.g., Transformers would
be one group within the All Electrical Equipment category). Consult with your insurer for more information about object
group descriptions.
Coverages
Refer to the ISO Commercial Lines Manual for standard values, limits, deductibles and other items.
Property Damage Limit of Insurance
Insurance limit for property damage coverage. This amount should be $100,000 or greater.
Property Damage Deductible
Property Damage deductible (minimum $250).
Extra Expense Limit of Loss
Indicate the limit of loss desired for Extra Expense coverage.
Extra Expense Period of Restoration
Period of restoration percentage for Extra Expense coverage (e.g., an entry of 100 percent would allow the applicant to
collect the entire Limit of Loss during the first 30 days after the loss; 40-80-100 would provide up to 40 percent of the limit
during the first month, up to 80 percent of the limit the second month, and the remainder the third month. Any limit not
used within the 100 percent time frame is collectible for as long as the extra expense continues).
Extra Expense Deductible
Desired Extra Expense deductible.
Business Interruption
Choose between Actual Loss Sustained or Valued Form per location.
Actual Loss Sustained
Complete this section for Actual Loss Sustained.
Limit of Loss
Percentage of Annual Value to be used for the limit (applies at all locations).
Annual Value
Annual value for each location.
Deductible
Desired deductible.
Ordinary Payroll
Number of days for which ordinary payroll is to be included within the actual loss sustained.
Valued Form
Complete this section for Valued Form.
Daily Limit
Desired daily limit.
Number of Days
Mark "X" in the appropriate box indicating the desired number of days for which the coverage is to apply.

Deductible
Desired Valued Form deductible.
Consequential Damage
An indirect loss resulting from loss of use of the property over a period of time.
Limit of Loss
Desired limit of loss.
Coins % (Coinsurance Percentage)
Enter the percentage of the total value of the product that corresponds with the selected limit.
Deductible
Desired deductible.
Specified Property
Describe the product being insured.
In Storage/In Process
Mark an "X" in the appropriate box. In Storage means coverage applies to specified property only while in storage. In
Process means coverage applies to specified property while being processed or while in storage.
ADDITIONAL INFORMATION
Provide any additional information required for underwriting or rating.
PREMISES INFORMATION
Use section to collect underwriting, rating and contact information on the applicant. Complete one section per each
premises location of the risk.
Premises Number
List the premises location number as stated in the Applicant Information Section (ACORD 125).
Machinery and Equipment Values
If available, indicate the total (100%) machinery and equipment values for the specified location. If these values are not
available, list the Contents value and indicate that the number shown represents a value for Contents at 100 percent.
Building Values
List the building value (100%) for each location.
Inspection Contact
Name of an individual for each location who can be contacted for physical inspection of the premises.
Phone Number
Telephone number for the listed individual.
ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS
Use section to collect information on any additional interest or receiver of Certificates of Insurance.
Prem #
Premises location number as stated in the Applicant Information Section (ACORD 125).
Name and Address
List the Additional Interest's name and mailing address.
Certificate Required
If a Certificate of Insurance is required, check this box.
Interest
List the type of interest of the additional interest. Examples:
Mortgagee
Loss Payee
Additional Insured
REMARKS
Provide any additional information required for underwriting or rating.




Business Auto Section 127 (8/2001)

The Business Auto Section of the ACORD Commercial Insurance
Application series contains basic policy information as well as essential underwriting information for commercial auto
accounts. Through the effective use of the Business Auto Section, specific needs of an individual account can be
addressed. Space is provided to enter driver information for up to ten drivers. For additional drivers, ACORD 163, Driver
Information Schedule, can be attached. Space is also provided to enter descriptions of up to eight vehicles. If the fleet
should exceed this number, the ACORD Vehicle Schedule (ACORD 129), which contains space for 7 additional vehicles,
can be attached.

Insurance coverages,"no fault" and uninsured/underinsured motorists coverages in particular, vary widely from state to
state. In addition, there are numerous state-specific requirements that apply to Business Auto applications. ACORD 127
cannot address these various unique specifications. Therefore, state-specific forms, ACORD 137, have been developed
to respond to these requirements. Use the ACORD 137 for your state to provide coverages/ limits information, as well as
the required disclosure and other data unique to the state. See the State Forms section of this Guide for more information.

This form was also designed to be used in conjunction with the Commercial Insurance Application - Applicant Information
Section (ACORD 125). Please turn to the chapter on the ACORD 125 for
information on that form.
Many states require supplements to all auto applications, to provide specific coverage explanation or to allow applicants to
accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In
others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the
necessary supplements in all states. Refer to the State Forms section of this Guide.


IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the Applicant Information Section
of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of
business for rating purposes. Not completing
this portion of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address and telephone number.

Phone (A/C, No, Ext)/FAX No
Producer's telephone and fax numbers.

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.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

Effective Date
Month/day/year on which the terms and conditions of the policy will commence.

Expiration Date
Month/day/year on which the terms and conditions of the policy will terminate unless renewed.

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

Payment Plan
Plan 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, 40-30-30).

Audit
The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code:

A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . .other

COVERAGES/LIMITS

Covered Auto Symbols
The Business Auto Policy uses numeric symbols on the policy declarations to indicate the type(s) of vehicles for which
coverage is in effect. Be sure to place an "X" in the appropriate box for each type of coverage. Only those symbols
specified for a coverage may be used.
Symbols 1 through 6 provide fleet automatic coverage. Symbol 1 includes Hired and Non-Owned auto coverage. If symbol
1 is not used and Hired auto (symbol 8) or Non-Owned auto (symbol 9) coverage is desired, those symbols must be
checked.

The symbols indicate coverage for each applicable automobile. The symbols "trigger" coverage. Please refer to the
company's policy declarations page for exact policy definitions of the symbols.
Symbol 1 - Any Auto
Symbol 1 can only be used for liability insurance. This includes coverage for owned, non-owned, and hired autos.
Provides automatic coverage for autos the insured newly acquires. Not to be used for No-Fault, Medical Payments,
Uninsured or Underinsured Motorists, or
Physical Damage coverages.

Symbol 2 - All Owned Autos
Applies only to autos owned by the insured, and for liability coverage on any non-owned trailers while attached to power
units the insured owns. This provides automatic coverage for autos the insured newly acquires. Used for Liability, Medical
Payments, Uninsured and Underinsured Motorists, or Physical Damage coverages, except Towing and Labor.

Symbol 3 - Owned Private Passenger Autos
Provides automatic coverage for private passenger autos the insured newly acquires. Used for Liability, Medical
Payments, Uninsured and Underinsured Motorists, Physical Damage, or Towing.

Symbol 4 - Owned Autos Other Than Private Passenger
Provides automatic coverage for autos other than private passenger the insured newly acquires. Used for Liability,
Medical Payments, Uninsured and Underinsured Motorists, and Physical Damage except Towing.

Symbol 5 - All Owned Autos Which Require No-Fault Coverage
Provides automatic coverage for autos the insured newly acquires where no-fault is required by law. Used only for P.I.P.
and Additional P.I.P.

Symbol 6 - Owned Autos Subject To Compulsory U.M. Law
Provides automatic coverage for autos the insured newly acquires where rejection of U.M. is not permitted by law.

Symbol 7 - Autos Specified On Schedule
Applies only to those autos described on the schedule for which a premium charge is shown, and for liability coverage on
any non-owned trailers while attached to power units the insured owns. Provides no automatic coverage for autos the
insured newly acquires. The
company must be notified of newly acquired autos within 30 days. Used for all coverages.

Symbol 8 - Hired Autos
Applies only to those autos leased, hired, rented or borrowed by the insured. This does not include any auto leased, hired,
rented or borrowed from any of the insured's employees or members of their households. Can be used for all coverages
except no-fault, towing, and labor. For medical payments, this symbol applies only to funeral directors.

Symbol 9 - Non-Owned Autos
Applies only to those autos not owned, leased, or hired by the insured which are used in connection with the insured's
business. Used only for liability coverage. Coverages / Limits - Use ACORD 137 for your state.

DRIVER INFORMATION

This section is used to collect information on all the drivers that will be covered under this account. The driver list should
include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for
company business.

Driver #
Indicate the driver number assigned by the agency/agency-vendor system used for tracking purposes.

Name
Enter driver's full name. If the company requires the address, enter it as well.

Sex
Enter F for female, M for male.

Marital Stat

Enter the marital status for each driver. Examples:

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

Date of Birth
Enter the driver's birth date.

Yrs Exp
Enter the number of years of driving experience for each driver.

Year Licensed
Enter the year in which the driver was first licensed.

Driver's License Number/Soc. Sec. #
Enter the complete driver's license number. If a license number is unavailable, enter the driver's social security number.

State Lic.
Enter the state in which the license was issued.

Date Hire
Enter the date of hire for each driver.

Broadened No Fault
Certain states "no fault" liability laws permit broadened no fault coverage to be written for specific drivers. If
such specific coverage is to apply, indicate "yes" here for each driver that is to be covered.

DOC
Enter Y in this column for any driver specifically covered by Drive Other Car coverage.

Use Vehicle #
Enter the vehicle number that this driver primarily uses.

% Use
Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The
overview below lists the expected information that should be added to the remarks section for "Yes" responses.

1. With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?
Indicate if any of the vehicles described in the application are not owned by or registered to the applicant.

2. Do over 50% of the employees use their autos in the business?
Indicate if more than 50% of applicant's employees use their vehicles in the applicant's business.

3. Is there a vehicle maintenance program in operation?
Explain the type of program and if there are maintenance records kept on file.

4. Are any vehicles leased to others?
Indicate if autos are leased on a short term or long term basis. Are certificates of insurance required from lessees? List
who the vehicles are leased to.

5. Are any vehicles customized, altered or have special equipment?
Provide the details on such alterations/customizations. List customized item and estimated value of customization.

6. Are ICC, PUC or other filings required?
If Interstate Commerce Commission or Public Utilities Commission filings are required, describe the insured operations
and trip frequency.

7. Do operations involve transporting hazardous material?
List the materials hauled, safety measures taken and if the applicant is subject to the Federal Motor Carrier Act
Requirements.

8. Any Hold Harmless Agreements?
If any hold harmless agreements are in force, describe any in which the applicant indemnifies others. Attach a copy of the
agreement.

9. Any vehicles used by family members?
Provide details regarding which vehicles are used and how often. Make sure the driver is included in the Driver
Information section.

10. Does the applicant obtain MVR verifications?
Indicate if applicant reviews MVRs on all assigned drivers. How often? Upon hiring only? If No, provide explanation of why
MVRs are not reviewed.

11. Does the applicant have a specific driver recruiting method?
Describe the recruiting method. Are written and/or road tests conducted?
12. Are any drivers not covered by Workers Compensation?
Provide the names of all drivers not covered.

13. Any vehicles owned but not scheduled on this application?
List vehicles not to be covered and explain why. Indicate where coverage is placed for these vehicles.

14. Any drivers with moving traffic violations?
Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in
accordance with the company's and state's requirements.

15. Has agent inspected vehicles?
Describe any damage to vehicles, including any missing safety devices.

Maximum Dollar Value Subject to Loss
List the highest value that the insurer would be subject to if a major automobile loss occurred on the insured premises.

Description of Garage/Storage Locations
Provide a brief description of all garage or storage locations for the vehicles (e.g., Fenced in secured lot or Closed
secured garage).

ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS

Use this section for information on any additional interests, employees who should be listed as additional insureds, and
others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an
ACORD 45.

Interest
Indicate all appropriate options for the individual named.

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

Name and Address
List the additional interest's name and address.

Reference #
Indicate the additional interest's reference number for this applicant such as the loan or mortgage number.

Certificate Required
If a Certificate of Insurance is required, check this box.

Interest in Item Number
List the item number corresponding with the application for the item of interest for this additional insured.

Item Description
If needed, further clarify the item of interest in this field. For a vehicle, list the make, model and VIN number. For a
scheduled item, list the description, such as three carat diamond in six point setting.

Cert
Indicate by "yes" or "no" whether a Certificate of Insurance needs to be issued to the additional interest.

VEHICLE DESCRIPTION

This section is used to collect pertinent information on the vehicles that are to be insured, what they are, how they are
used and what coverage applies to them. If there are more than eight vehicles associated with this risk, place additional
vehicles on the ACORD 129 Vehicle Schedule.

Veh #
Number assigned by the agent to this vehicle for purposes of tracking in the application process.

Year
Vehicle's model year.

Make
Vehicle's manufacturer (e.g., Buick).

Model
Manufacturer's model name (e.g., Regal).
Body Type
Vehicle's body type (e.g., 4 door sedan).

V.I.N.
Full vehicle identification number assigned by the manufacturer.

City, State, Zip where garaged
List the location where this vehicle is normally garaged.

Lic State
Enter the state where the vehicle is licensed.

Terr
Enter the rating territory in which the vehicle is principally garaged.

GVW/GCW
These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly.

GVW
Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer.

GCW
Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which
the truck-tractor is designed as specified by the manufacturer.

Class
This is the primary industry classification code found in rating manuals for commercial vehicles as determined by:
     •     If this is a fleet or non-fleet policy
     •     Commercial autos by size, business use, radius of operation and whether truck or trailer type
     •     Public autos by type of vehicle, radius or seating capacity


S.I.C.
This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating
manuals.

Factor
This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you
are not rating this application.

Seating Capacity
Used for public vehicles and livery vehicles. Enter the number of passenger seats available.

Sym/Age
Enter the age of the vehicle in years, as follows:
     •    1-Current model year
     •    2-First preceding model year
     •    3-Second preceding model year
     •    4-Third preceding model year
     •    5-Fourth preceding model year
     •    6-All other autos

Cost New
If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and
equipment.

Radius
Enter the appropriate radius code as follows:

L - Local
Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging.

I -Intermediate
Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging.

LD - Long Distance
Regularly and frequently operated beyond a radius of 200 miles.

Farthest Term
For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of
this vehicle, that this vehicle travels to.

Drive to Work/School
If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are:
       •    Drive to Work or School under 15 miles one way
       •    Drive to Work or School 15 miles or over one way

Use
Check the appropriate box for the primary use of this vehicle. Options are:
    •    Pleasure - Private passenger vehicles or pickups/vans not used for business purposes
    •    Farm - Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch
    •    Retail - Pick up or delivery of property to individual households
    •    Service - Transportation of personnel, tools, equipment or supplies to or from a job site
    •    Commercial - The transportation of property in vehicles other than those defined as retail or service

Check Coverages
Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the
symbols indicated in the coverage section of ACORD 137. Abbreviations are:
Liab . . . . . . . . . . . . . . . . . . . . .Liability
No-Fault . . . . . . . . . . . . . . . . "No-Fault" coverage, if applicableP
Add'l No-Fault . . . . . . . . . . . Additional "No-Fault" Protection, if applicable
Med Pay . . . . . . . . . . . . . . . . Medical Payments
Unins. Mot . . . . . . . . . . . . . . . Uninsured Motorist
Underins Mot . . . . . . . . . . . . Underinsured Motorist
Towing & Labor . . . . . . . . . .Towing and Labor
Spec C of L . . . . . . . . . . . . . . Specified Cause of Loss
F. . . . . . . . . . . . . . . . . . . . . . . . .Specified Cause of Loss by Fire
F & T. . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss by Fire and Theft
F, T, & W . . . . . . . . . . . . . . . . .Specified Causes of Loss by Fire, Theft and Windstorm
LSP . . . . . . . . . . . . . . . . . . . . . . Limited Specified Perils
Comp. . . . . . . . . . . . . . . . . . . . .Comprehensive Coverage
Coll. . . . . . . . . . . . . . . . . . . . . . .Collision Coverage

Deductibles
Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt - Stated Amount basis
by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit.

Indicate if the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the
collision deductible in the space provided.

Net Veh Dr/Cr
Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide
under Remarks a description of each debit or credit used in the calculation of the net rating factor.

Tot Prem
Enter the total premium for the vehicle.

REMARKS

Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments
such as hold harmless agreements, or pictures of vehicles are being sent.




Business Owner's Policy 160 (8/2000)

This application is designed to be used with most business owners and small business policies. The form collects
information for coverage for property, liability and additional coverages, such as accounts receivables, boiler and
machinery, crime, glass, signs and valuable papers. Space is provided for company-specific additional coverages as well.
The form can accommodate specialty programs, such as apartment, condominiums or restaurants.
Individual carriers should be contacted for unique underwriting and any other information required by specific companies.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address, telephone, FAX and E-Mail numbers.
Code
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
Subcode
If your agency uses a sub-code identification system with the company, enter the appropriate code.
Agency Customer ID
Customers identification number assigned by the agency.
Company
Name of the applicable insurance company and its NAIC number. Do not use group names; use the actual name of the
company within the group in which you wish to have the policy issued.
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 indicate an ISO or other rating organization policy type, or to name the subsidiary
company where the line of business will be placed.
Program Code
The code assigned by the company for the program.
New/Renwl
Indicate if the applicant is new to the company or a renewal of an expiring policy with the same company.
Effective Date
Enter the Effective date on which the terms and conditions of the policy will commence.
Expiration Date
Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
Quote/Bound/Issue Policy
Indicate whether the company's response to this application is expected to be a quote or an issued policy. If the risk is
bound, so indicate and include the date coverage began and attach a copy of the binder. If more than one option applies,
check off multiple boxes.
Policy Type
Include identifying information as requested by company policy.
Deposit
Enter the dollar amount of the deposit, if any.
APPLICANT INFORMATION
Name (First Named Insured)
Enter the 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
are not legal entities.
Mailing Address
Address at which the First Named Insured is to receive all correspondence regarding their insurance.
Address should include:
Street number, if any
Pre-direction, if any (example: 150 N Central Ave)
Street name, if any
Street type (examples: st, rd, ave)
Post-direction, if any (example: 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 address if required by
mortgagee.
Individual, etc.
Identify the applicant as an Individual, Partnership, Limited Corporation, Corporation,
Joint Venture or Other. If other, provide a description such as Professional 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.).
GL Code
Enter the General Liability Code, if applicable.
SIC
Enter the Standard Industry Classification code that the applicant falls under.
Federal ID #
Enter the Federal Employer ID number assigned by the IRS, or, if an individual, their social
security number.
Contact
Name and 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.
NATURE OF BUSINESS
Indicate the primary nature of the applicant's operation. Options available are:
Office
Apartments
Service
Condominiums
Retail
Contractors
Wholesale
Restaurant
Contractor
Other (describe)
Enter the number of years the applicant has been in business, ISO or Company Class Code,
Rate # and Rate Group, if applicable. Refer to your company for specific details with respect
to definitions of these elements, as they apply to the company's individual program.
DESCRIPTION OF OPERATIONS/OCCUPANCY
This section is designed to tell the underwriter what business each applicant performs and the way
it is conducted by premises, the number of employees at this premises, and the hours of operation.
Operations which may not be apparent in a general description of operations may be segmented by
premises.
Annual Sales/ Receipts
List the projected sales over the last 12 months.
Total Payroll
List the projected sales over the last 12 months.
The section should be completed in enough detail to enable the underwriter to understand
and classify each operation. Do not use the classification phraseology from the Commercial
Lines Manual or Workers Compensation Manual; this does not provide adequate detail.
PREMISES INFORMATION
Address, Street, City, state, County, Zip
Enter the physical street address (not P.O. Box) where the applicant is located. Include
premises numbers and building numbers, if applicable. Indicate if the primary location is at
this address.
Interest
Indicate the interest the applicant has at this location.
Year Built
Enter the year the building was originally constructed.
Area Occup.
Enter the percentage of the building the applicant occupies.
Sq. Ft.
Enter the square footage of the building.
Surrounding Exposures and Other Occupancies
Describe the buildings, structures, activities conducted, or use of property adjacent to the
insured premises and provide the distance from the insured premises. Also include any other
occupancies not operated by the insured within the building where the insured is located.
Any Area Leased?
Indicate if any area of the premises is leased to others by the applicant.
Prot. Cl.
Enter the fire rating protection class for this location.
Rate Terr.
Enter the ISO or company rating territory for this location.
Fire District / Code No.
Enter the name of the fire district within which the property is located, and the
corresponding five character code number, and indicate whether or not the property is
inside city limits.
PROPERTY
For each building, and separately for personal property within each building, list the following (use
a separate form for each building):
Limit
The limit of insurance that will apply.
% Coins
Show the coinsurance percentage, if applicable. If coinsurance does not apply, enter
"None."
Valuation
Replacement Cost (RC), Full Value Replacement Cost (FVRC), or Actual Cash Value
(ACV). If other, add name next to available box.
INFL%
The Inflation Guard percentage that is to apply.
Deductible
The deductible amount that is to apply. If more than one deductible applies, show all
deductibles in the Remarks section.
Construction Type
Indicate the building's construction type: Fire Resistive (FR); Modified Fire Resistive
(MFR); Masonry Non-Combustible (MNC); Non-Combustible (NC); Joisted Masonry
(JM); Frame (F).
Total Square Foot Area
For building coverage, indicate the total square foot area of the building; for personal
property, indicate the area in square feet that the applicant occupies.
# Apt Units
The number of rental units if this is an apartment building or a condominium.
# Stories
Indicate the height of the building in stories, not including basement.
% Sprink
The percentage of the building that is protected by a sprinkler system.
Basement
Indicate if there is a basement and if it has been finished.
Building Improvements
If wiring, roofing, plumbing or heating have been partially or completely replaced, provide
the year updated.
Roof Type
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
Bldg. Code Grade
Enter the ISO Building Code Grade, if applicable.
Tax Code
Enter the city, county or state tax code if required.
Wind Class
Check the applicable wind class.
LIABILITY
Limits
List all limits as they will appear in the policy. Show limits in whole dollars.
Several formats are included here for the collection of liability limits. Complete only those
items that match the format of the program you are using to write the policy.
Deductible
Indicate dollar amount or percentage, and coverages to which the deductible is to apply.
Classification, Class Code, Premium Basis/Basis Code
Use this section only if the Liability portion of the policy is independently rated. Enter the
necessary information as instructed by the company.
PRIOR POLICY(IES) / LOSS HISTORY
Previous Carrier
Name of the insurance company that wrote the previous policy.
Policy Number
Identification number assigned by the insurance company to identify the policy.
Exp. Date
Expiration date of the previous policy.
# Losses Last 3 Yrs.
Give the total number of losses.
Total Losses
Show the total amount, in dollars, of all losses in the last 3 years.
Description of Losses
Describe any losses, give loss dates and amounts paid.
ADDITIONAL COVERAGES
Enter the necessary total limits of insurance and applicable deductibles for each additional coverage
to be provided for. Options are:
Extra expense *
Loss of income *
Valuable papers
Accounts receivable
Sign
Employee dishonesty
Burglary and robbery, stock
Burglary and robbery, money
Boiler and machinery, basic
Boiler and machinery, broad
Boiler and machinery spoilage
Glass **
Money and Securities - Inside
Money and Securities - Outside
Spoilage
Computers
Ordinance or Law
ERISA (Employee Dishonesty)
Flood
Earthquake
* If extra expense or loss of income coverages are provided on a 12 month basis
rather than with dollar limits, show "12 months" in the Amount column.
** For glass coverage by ground floor and/or above ground floor panes, include
the following:
# Panes
The number of like size panes
Area
The total area per pane
Length
The horizontal measurement per pane in linear feet
Interior, Tenants Exterior
Check if glass is inside the building or outside a tenant area.
Type
The type of pane, such as window, jalousie, etc.
Value
The cost per pane
Deductible
The deductible for glass coverage
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes"
response. The overview below lists the expected information that should be added to the remarks
section for "Yes" responses.
1. Do/have past, present or discontinued operations involving storing,
treating, discharging, applying, disposing, or transporting of hazardous
material?
If so, indicate how they are or were controlled, stored or disposed of. Indicate if the
applicant owns or operates any landfills or fuel tanks.
2. Are athletic teams sponsored?
Indicate if the teams are composed of employees or others such as Little League.
3. Are Certificates of Insurance required from sub contractors?
Indicate who checks them, and if coverages are equal or greater than the applicants.
4. During the last ten years, has any applicant been convicted of any degree
of the crime of arson? (In Rhode Island, failure to disclose the existence of
an arson conviction is a misdemeanor punishable by a sentence of up to one
year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this
question.
5. Any coverage declined, cancelled, non-renewed?
If any policy had this action taken, provide the reasons and circumstances. This question
cannot be asked in Missouri.
6. Do you lease to or from other employers?
If yes, describe the extent of leasing.
7. Is any workers compensation carried?
If yes, give company and policy number.
8. Do you own or operate any other business?
If yes, provide description of operations.
9. Is there a swimming pool on the premises?
If yes, describe the fencing and access. Describe any diving board or water slide. Note if
there is a lifeguard on duty when the pool is open.
10. Any other insurance with this company?
If yes, provide the policy numbers under Remarks.
11. Are you involved in manufacturing mixing, relabeling or repackaging of
products?
If yes, describe the process.
12. Do you rent or loan equipment to others?
Describe the types of equipment.
13. For retail stores, does installation, service or repair work account for
more than 15% of receipts?
If yes, give percentage and describe the operation.
Describe any location/business interest owned or operated by insured but not listed
List any location or risk that is not to be covered within this package policy.
SPECIALTY PROGRAMS
APARTMENT AND CONDOMINIUMS
Is there a playground on premises?
Describe the equipment at the playground (e.g., slides, swings, etc.).
Is aluminum wiring used?
Indicate the date when wiring was done, and indicate if there is also copper wiring.
Number of Units Per Building or Fire Division
Enter the number of residences that are in the fire division, including the insured's. Also
indicate the percent of the building that is owner-occupied.
Indicate where coverage applies to: bare walls, finished walls.
If the building is a condominium, indicate if the building coverage is to include bare or
finished walls; this information can be found in the condominium association agreement.
Smoke Detectors
If the building and/or apartment units are equipped with smoke detectors, check the
appropriate box.
Attach copy of condo association bylaws if Directors and Officers coverage is requested.
Also indicate if the developer or contractor is a board member, and if a property manager is
employed.
RESTAURANTS
Attach ACORD 185 for each restaurant location.
CONTRACTORS
Attach ACORD 186.
PROFESSIONAL LIABILITY
Attach ACORD 187 for barber and beauty shops, funeral homes, optical and hearing aid
establishments, printers or veterinarians.
CRIME
Complete this section in regards to the location and protection systems for this risk. Information on
the classification of safes, vaults and alarm systems can be found in the Crime Section of the ISO
Commercial Lines Manual.
Alarm Type
Indicate the style of alarm(s) protecting this premises, safe or vault. Available options are:
Hold-Up The presence of a manual or semiautomatic control which can
transmit an alarm in the event of a hold-up
Premises - A sensing device installed on premises which transmits an alarm in
the event of unauthorized entry. The Premises Extent needs to be completed for
Premises Alarms
Safe/Vault - An alarm system that protects the safe or vault and is connected to
outside central station, gong or siren. The Extent of Protection for Safe/Vault
needs to be completed for all safes/vaults
Alarm Description
Indicate any applicable features of the alarm.
Local Gong - A bell located outside the premises
Central Station - A private security service which monitors the alarm system
and may dispatch security officers in response to an alarm
Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to
Police Headquarters rather than to a private control station
Grade
Enter the GRADE or class A, B, C, etc. This indicates the time required to respond to a
signal from the alarm system. Please refer to manual.
Extent of Protection for Safe/Vault
Indicate the extent of the alarm protection for the safe or vault.
Partial - Alarm covers around door only
Complete - Alarm covers sides, top walls, floor, and ceiling
Extent of Protection for Premises
Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual.
Certificate #/Expiration Date
Alarms which are approved by the Underwriters Laboratories (UL), or other nationally
recognized testing laboratories, are evidenced by a certificate. Record the certificate number
and its expiration date.
Safe/Vault/Receptacle Manufacturers Name
List the manufacturer's name of the applicant's safe, vault or other secured receptacle.
Label
Check the appropriate box to indicate if the rating is based on the Underwriters
Laboratories, Inc. (U.L.) or the Safe Manufacturers National Association (SMNA).
Class
Record the construction classification which represents the extent of burglary protection for
this safe or vault. Be sure to use the classification from the Burglary label and not the Fire
label located on the safe or vault. For industry definitions of the classifications refer to the
Commercial Lines Manual.
Maximum Cash on Premises
Indicate the maximum amount of cash kept on the premises during normal business hours.
Maximum Cash With Messenger
Indicate the maximum amount of cash messengers are allowed to carry for the applicant.
Money on Premises Overnight
Indicate the maximum amount of cash left on the premises overnight.
Frequency of Deposits
Indicate the frequency with which deposits are made to the bank. Examples: daily, twice a
week.
Dbl. Cyl. Door Locks
Indicate if all doors leading into and out of the applicant's premises have double cylinder
door locks.
Other Protection
List any other protection device that the applicant uses.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS
Use this section for information on any additional interests, employees who should be listed as
additional insureds, and others who require Certificates of Insurance. For additional names, attach
an ACORD 45.
Interest
Indicate all appropriate options for the individual named.
Rank
Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee.
Name and Address
List the additional interests name and address.
Reference #
Indicate the additional interests reference number for this applicant such as the loan or
mortgage number.
Certificate Required
If a Certificate of Insurance is required check this box.
Interest in Item Number
List the item number corresponding with the application for the item of interest for this
additional insured.
Item Description
If needed, further clarify the item of interest in this field. For a scheduled item list the
description, such as 3 carat diamond in six point setting.
REMARKS
Use this section to provide any additional information required for underwriting or rating.
If necessary, use additional sheets of paper.




Business Owner's Supplemental App 161 (11/98)

This form is designed to collect information about two additional premises to be insured under a businessowners or small
business policy.
Use ACORD 160, Business Owners Application, for the first premises and ACORD 161 for any other premises.
All of the premises information sections on this form are identical to sections in ACORD 160. Please refer to the chapter
on ACORD 160 for specific element descriptions.




CA Offer of Earthquake Coverage 66CA (2/98)
This form complies with California law, which requires that the named insured for each policy of residential property
insurance be offered earthquake coverage as provided by the law. Use ACORD 66 CA with ACORD 80 and ACORD 84.




CA Residential Property Insurance Disclosure 67CA (11/94)

This form complies with California law, which requires that the named insured for each policy of residential property
insurance be provided a copy of the California Residential Property Insurance disclosure statement contained in the law.
Use ACORD 67 CA with ACORD 80 and ACORD 84.




Cancellation Request/Policy Release 35 (1/97)

This guide provides basic instructions for completing the ACORD Cancellation Request/Policy Release form. It explains
information the company needs to process the transaction.

This form is used as tangible evidence of the insured's instruction to cancel a contract. It can be used for either Personal
or Commercial Lines, or as an enclosure to the returned original contract, when available.

Method of cancellation and all calculations should be confirmed with the company before final settlement of the account
with the insured. Caution should be exercised to ensure proper signature specifications are followed, as required by the
company.
Insured entities must have an authorized signature and title where applicable. Individual companies may have specific
requirements for additional information particularly in situations of "Policy Rewritten" or "Pro Rata" cancellations.

Verify that cancellation notice rights have not been extended to additional parties. Premium financed policies should be
discreetly handled to ensure proper transmittal of premium and information.
INFORMATION SECTION
Date
Month/day/year on which the form was completed.
Producer
Name and address of the producer of record whose policy is being cancelled or released.
Phone (A/C, No, Ext)
Producer's telephone number.
Code
Identifying code assigned to your agency or brokerage firm by the insurance company receiving this form.
Subcode
If your 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 and Address
Issuing company's name, NAIC code, and address shown on the policy being cancelled or released. Do not use group or
trade name.
Policy Type
Specific type of insurance (e.g., Automobile Policy, Workers Compensation, Homeowners, etc.).
Insured Name and Address
Name, mailing address and ZIP code of the insured as it appears on the policy. If the policy is issued to multiple named
insureds, and the space is not adequate to list them all, enter only the first named insured followed by "et al."
CANCELED POLICY INFORMATION
Policy Number
Policy Number exactly as it appears on the policy, including both prefix and suffix symbols.
Effective Date and Hour of Cancellation
List the effective date of the policy cancellation in month/day/year format. Enter the time including, AM or PM, that the
policy cancellation takes effect.
Policy Term
List the full term effective and expiration dates as listed on the policy.
CANCELLATION REQUEST (Policy Attached)
If this form is being used to notify the carrier of policy cancellation and the insured's original copy of the policy is attached,
check this box and return both this form and original policy to the company.
POLICY RELEASE (Complete Statement Section below)
Policy Release
Mark "X" in this block only if this document is used as a Policy Release (policy not attached).
Witness
When this document is used as a Policy Release, an insured should have a witness sign and date the form before
returning it to the agent.
Signature of Named Insured
First named insured must sign and date this form when used as either a Cancellation Request or Policy Release.
Additional Interest
Provide the name and address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking "X" in the
appropriate box.
The signature and title of an authorized representative of any additional interest indicated in the contract must be obtained
if the document is used as a Policy Release. Space is provided for the corresponding signature date.
FOR AGENCY/COMPANY USE
Reason for Cancellation
Mark "X" in the appropriate block to indicate the reason for cancellation of the policy. Available options are:
Not Taken
Request of Insured
Rewritten (complete below)
Other (Identify)

If Rewritten is indicated, enter the new Company, Policy Number, and Inception Date in the spaces provided. If Other is
indicated, identify the reason in the space provided.
Company
The name of the company that the rewritten policy has been placed with.
Policy Number
The new policy number for the rewritten policy.
Effective Date
The effective date of the rewritten policy.
Method of Cancellation
Mark "X" in the appropriate box indicating method of cancellation. Available options are:
Flat
Short Rate
Pro Rata
Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten
or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before
final settlement of the account with the insured.
Full Term Premium
Premium for the full term (six months, annual, etc.) of the policy, including endorsements.
Unearned Factor
Unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to
date of policy expiration.
Return Premium
Gross return premium equals the unearned factor multiplied by the full term premium.
REMARKS
List any additional comments regarding the cancellation. Explanations should be made regarding back-dated
cancellations or why premium is listed as being pro-rated instead of short-rated.
NAME AND ADDRESS - Request/ Release Distribution
Use these sections to list any additional distributions for this form, including the new agent of record, if any. Check the
appropriate box for the corresponding address. The line within the name and address field is a margin setting used for
window envelopes.
PRODUCER'S SIGNATURE
This form should be signed by the agent completing it.




Certificate of Liability Insurance 25-N (1/95)

ACORD 25-N is used for risks containing commercial liability coverages not using the ISO policy simplification format. All
other risks should use ACORD 25-S. The instructions within this chapter contain information for completing data within
the Coverages section that differs from that on ACORD 25-S. For instructions on the additional sections of this form and
general information on using ACORD Certificate of Liability Insurance, refer to the chapter on ACORD 25-S.
COVERAGES
All limits are to be listed as whole dollar amounts.
GENERAL LIABILITY
Complete this section if you are certifying general liability coverage.
Type of Insurance Indicators
Check the appropriate box for the coverages listed on the insured's policy. Available coverage options are:
Form
Premises Operations
Underground, Explosion & Collapse
Products & Completed Operations
Contractual
Independent Contractors
Broad Form Property Damage
Personal Injury
Limits
All limits should be listed as whole dollar amounts. Enter the limits as they appear on the policy declarations page. For
split limits, use the Bodily Injury Occurrence, Bodily Injury Aggregate, Property Damage Occurrence, and Property
Damage Aggregate fields. For combined limits use the BI & PD Occurrence and BI & PD Aggregate fields.
See the chapter on ACORD 25-S for other coverage sections and general information on completing Certificates of
Liability Insurance.




Certificate of Liability Insurance 25-S (8/2001)


The Certificate of Insurance ACORD 25 is "issued as a matter of information only, and confers no rights upon the
certificate holder. This certificate does not amend, extend, or alter the coverage afforded by policies".

The above information is included in the opening statement of the form.

If the receiver of the form wants to verify that liability coverage exists on a policy and has no direct interest in the policy,
use the certificate of insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as
an additional insured, the liability policy must be amended by endorsement, to provide the appropriate coverage for the
interested party prior to issuing a certificate of insurance (since the certificate confers no rights upon the holder and does
not amend the policy).

ACORD 25 was designed to collect policy limit information based on the ISO commercial lines program . It addresses
both Claims Made and Occurrence policies.

Purpose of the Certificate of Liability Insurance

The purpose of the Certificate of Liability has been the topic of frequent discussions throughout the industry. Attention
centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder.

In 1974, the Court of Appeals, Fifth District ruled that a certificate is not a contract between the holder and the insurer. It
only provides information to an interested third party that insurance is in force at the time of issuance. The court also
stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any
consideration." Although many companies provide notice of cancellation to certificate holders, they are not obliged to do
so, since the holder is not a party to the contract. Agents or brokers should not change any provision on this form without
prior consent of the issuing company.

The Certificate of Kiability Insurance is used for most casualty situations in which the insured has requested certification to
a third party of issued casualty coverages.. The uses of the Certificate can include large and small contracting or
manufacturing risks, lessor/lessee agreements, or other areas of liability certification.

The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the
Certificate NOT be used in the following situations:
     •     To waive rights
     •     To provide information to the owner of a leased motor vehicle or the lender about both liability and physical
           damage coverages applying to the vehicle (ACORD 23, Leased Auto Certificate of Insurance, should be used
           for this)
     •     To quote wording from a contract
     •     To attach to an endorsement
     •     To quote any wording which amends a policy unless the policy itself has been amended

IMPORTANT

Kentucky, Minnesota, North Carolina and Wisconsin require the filing of certificate of insurance forms. ACORD has filed
all of its certificates in these states.

In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the
respective state Department of Insurance.

Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a
policy unless the revised certificate is filed and approved.


IDENTIFICATION SECTION

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


INSURERS AFFORDING COVERAGE

Insurer Letter A through E
This section is designed for use in certifying coverage issued by many as five companies. Enter only full legal company
name(s) as found in the file copy of the policy. Do not enter group or trade names.

NAIC No.
Enter the NAIC number for each insurer affording coverage.

COVERAGES

Insr Ltr
Enter the Insurer Letter, as identified in the Insurers Affording Coverage section, next to the appropriate coverage(s).

Add'l Insrd
Use this column if the certificate holder has been named as an additional insured for any of the coverages
described in the certificate. Place a check mark next to each coverage where an additional insured endorsement
has been issued.

Policy Number
Show the number exactly as it appears on the policy, including prefix and suffix symbols for each "Type of Insurance".

Policy Effective Date
Date on which the terms of the policy commenced.

Policy Expiration Date
Date on which the terms and conditions of the policy expire.

Limits
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations
page.

Abbreviations:

Med. Exp. . . . . . . . . . . . . . . . Medical Expense
Personal & Adv. Injury . . . . . . . Personal and Advertising Injury
Products-Comp/Op Agg . . . . . . Products and Completed Operations Aggregate

General Liability
Complete this section if you are certifying general liability coverage.

Commercial General Liability
Check this box for Commercial General Liability (CGL) and one of the corresponding boxes to designate the type of policy
issued, Claims Made, or Occurrence (Occur) of CGL policy.

Other General Liability Coverages
The two open option boxes available allow listing of liability coverages not found on this form. List the coverage type next
to the available box. An example of this would be issuing a certificate for Comprehensive Personal Liability. The first box
would be checked and "Comprehensive Personal Liability" would be inserted on the line after the box.

General Aggregate Limit Applies Per
Check the appropriate box to indicate if the general aggregate limit applies per policy, per project, or per location.

Automobile Liability
Complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the
covered auto symbols found on the policy declarations page.

The last available option box allows listing an automobile liability coverage not found on this form. List the coverage type
next to this optional box.

If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Leased
Auto Certificate of Insurance.

Garage Liability
Complete this section only if you are certifying garage liability. Use the available lines or the "Any Auto" option to indicate
coverage specifics.

Excess/Umbrella Liability
Complete this section only if you are certifying some type of excess or umbrella liability policy. Check the appropriate box
to indicate whether the "coverage trigger" is on a claims-made or an occurrence basis. Also show any deductible or
retention amount.

Workers Compensation and Employers' Liability
If workers compensation coverage is based on statutory limits, check the appropriate box within the limit section. If other
limits apply, check the appropriate box and show the limits in the "Other" section. If Employer's Liability is to be certified,
show the limits applicable to "Each Accident", "Disease-Each Employee" and "Disease-Policy Limit".

Other
This section certifies other coverages that are not listed on the form. The type of insurance, policy number, policy effective
date, policy expiration date and limits sections should be completed.

Description of Operations/Locations/Vehicles/Exclusions Added by Endorsement/Special Provisions
Record information necessary to identify the operations, locations or vehicles for which the certificate was issued. Any
exclusion endorsement or special policy conditions should also be indicated.
     Information about additional insureds should also be shown here. However, if it is necessary to show several
     additional insureds for liability coverages (e.g., mortgagees, vendors, landlords, etc.), and there is not enough room
     on the form, use the Descriptions box to indicate "see Additional Interest form, ACORD 45, attached" and use
     ACORD 45 to show the information pertinent to the additional insureds.
Certificate Holder
Name and mailing address of the individual or entity for whom the certificate is being prepared. The line within this field is
a margin setting for window envelopes.

Cancellation
Number of days in which the company will endeavor to mail a written cancellation notice. This amount is subject to
approval by the company(ies).

Authorized Representative
Form must be signed by an agent, broker, or other representative authorized by all companies to issue Certificates.




Certificate of Property Insurance 24 (1/95)

Certificate of Property Insurance vs. Evidence of Property Insurance
An important distinction exists between the Certificate of Property Insurance (ACORD 24) and the Evidence of Property
Insurance (ACORD 27). This distinction is outlined in the opening statements of each form.
Certificate of Property Insurance
This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. It does not
amend, extend, or alter the coverage afforded by the policies below.
Evidence of Property Insurance
This is evidence that insurance as identified below has been issued, is in force, and conveys all the rights and privileges
afforded under the policy.
If the receiver of the form wants to verify that property insurance coverage exists on a policy and has no direct interest in
the policy, use the Certificate of Property Insurance. However, if the receiver of the form does have a verifiable interest in
the policy, such as a mortgagee or additional insured, use the Evidence of Property Insurance.
Purpose of the Certificate of Insurance
The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention
centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder. This is particularly
important when the difference between a certificate holder and lien holder, loss payee, or mortgagee is considered.
In 1974, the Court of Appeals, Fifth District ruled that a certificate is not a contract between the holder and the insurer. It
only provides information to an interested third party that insurance is in force at the time of issuance. The court also
stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any
consideration." Although most companies provide notice of cancellation to certificate holders, they are not obliged to do
so, since the holder is not a party to the contract. Agents or brokers should not change any provisions on this form without
prior consent of the issuing company.
The Certificate of Property Insurance is used for most property situations in which the insured has requested certification
of issued property coverages to a third party. The uses of this Certificate can include parties involved in condominium
association agreements, lessor/lessee agreements, or other areas of certification. The ACORD Certificate should be
issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the
following situations:
To satisfy a mortgagee or lienholder (the Evidence of Property Insurance (ACORD 27) should be used for this)
To quote wording from a contract
To waive rights
To attach to an endorsement
To quote any wording which amends a policy unless the policy itself has been amended.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.
Producer
Name, address and phone number of the producer or broker issuing this form.
Insured
Insured's name and address as they appear on the policy declarations page. The line within this field is a margin setting
for window envelopes.
COMPANIES AFFORDING COVERAGE
Company Letter A Through D
This section is designed for use in certifying coverage issued by as many as four companies. Enter only full legal
company name(s) as found on the file copy of the policy. Do not enter group or trade names.
COVERAGES
Co Ltr
Enter the Company Letter of the company, as identified in the Companies Affording Coverage section, next to the
appropriate coverage(s).
Type of Insurance
Check the appropriate box(es) to indicate the coverage afforded by the policy. For Inland Marine, describe the type of
policy (e.g., Equipment Floater, EDP, etc.). Also, check the appropriate box to indicate if "Named Perils" or "Other"
causes of loss apply. If necessary, describe under "Special Conditions/Other Coverages". If crime coverage applies,
describe the type of policy (e.g., Forgery, Money and Securities, Premises Safe, etc.).
Policy Number
Show the number exactly as it appears on the policy, including prefix and suffix symbols for each "Type of Insurance".
Policy Effective Date
Date on which the terms and conditions of the policy commenced.
Policy Expiration Date
Date on which the terms and conditions of the policy expire.
Covered Property
Describe the property covered.
Limits
All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations
page.
LOCATION OF PREMISES
Location/Description
For buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave,
Endicott - Grocery Store with Apartments, or Route 66, five miles south of intersection with I99 - Tobacco Barn).
For other property items, such as inland marine equipment (for lessor information), describe the item along with any
available vehicle identification number or serial number (e.g., 82 Case Backhoe Model H-15, Ser # G5963a57).
SPECIAL CONDITIONS/OTHER COVERAGES
Record any special policy conditions or coverages not fully explained in the Coverages section.
Certificate Holder
Name and mailing address of the individual or entity for whom the certificate is being prepared. The line within this field is
a margin setting for window envelopes.
Cancellation
Number of days in which the company will endeavor to mail a written cancellation notice. This amount is subject to
approval by the company(ies).
Authorized Representative
Form must be signed by an agent, broker, or other representative authorized by all companies to issue Certificates.




Commercial Auto 137

Alabama Commercial Auto, Coverages/Limits Section ACORD 137 AL (6/2001)
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

Alaska Commercial Auto, Coverages/Limits Section ACORD 137 AK (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132 Truckers/Motor Carrier Section.

This following are the specific differences in this state:
     •     Personal Injury Protection coverage does not apply; this is not a "no-fault" state.
     •     A required statement has been added to the back of the form with respect to the offer of Rental Vehicle
           Damage coverage if Comprehensive and/or Collision coverage has been rejected by the applicant.
Arizona Commercial Auto, Coverages/Limits Section ACORD 137 AZ (7/2001)
Use this form to collect the coverage, limits and premium information necessary to write
Business Auto, Truckers or Motor Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section or ACORD 132, Truckers /Motor
Carrier Section.

The following are the specific differences in this state:
               •    Personal Injury Protection coverage is not available; this is not a "no-fault"
               •    state.
               •    Uninsured and Underinsured Motorists Property Damage coverages are not
               •    available.
               •    Statement added to the back of the form, referencing the Arizona Supplement,
               •    ACORD 61 AZ, which must be signed by the applicant.


Arkansas Commercial Auto, Coverages/Limits Section ACORD 137 AR (10/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. The following are the specific differences in this state.
Personal Injury Protection coverages are revised to reflect unique Arkansas coverages and options. Refer to your state
  manual.
Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorist Property Damage is not
  available.
An additional statement is added, referencing the Arkansas Supplement, ACORD 61 AR, which must be used if the
  applicant chooses Uninsured or Underinsured Motorists Bodily Injury coverages less than the limits of the policy's basic
  Bodily Injury Liability limits.
A statement is added to the back of the form allowing the applicant to reflect any or all of the Personal Injury Protection
coverages.
California Commercial Auto, Coverages/Limits Section ACORD 137 CA (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write
Business Auto, Truckers or Motor Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section.

The following are the specific differences in this state.
Personal Injury Protection coverage does not apply. This is not a "no-fault"
state.
               •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
               •    Reference to "Waiver of Collision Deductible" is added.
               •    Statement added referring to the offer of Uninsured Motorists coverage up to
               •    the Bodily Injury Liability coverage in the policy, and the applicant's right to
               •    select lower limits, reject coverage for certain drivers, or reject UM coverage
               •    entirely. If the applicant chooses any option other than limits equal to the
               •    policy's BI limits, the California Auto Supplement, ACORD 61 CA, must be
               •    signed.
               •    Statement added referring to the offering of a Waiver of the Collision deductible.
               •    The fraud statement is revised to comply with California law.
               •    A statement is added to the back of the form as required by California law,
               •    advising the applicant of his or her rights with respect to "good driver" policies.


Colorado Commercial Auto, Coverages/Limits Section ACORD 137 CO (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    Personal Injury Protection coverages are replaced with Colorado's unique coverages and options. Refer to your
          state manual.
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
     •    The fraud warning is specific to the state.
     •    Statement added referring to the explanation and offer to the applicant of Uninsured Motorists coverage, and
          the right of the applicant to select/reject coverage. If Uninsured Motorists Bodily Injury coverage is rejected
          entirely, the applicant must initial the statement.

Connecticut Commercial Auto, Coverages/Limits Section ACORD 137 CT (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
               •    Personal Injury Protection coverages reflects the optional coverages available.
               •    Uninsured Motorists and Underinsured Motorists coverages are combined.
               •    Uninsured Motorists Conversion coverage is added. This coverage can be purchased instead of
                    Uninsured/Underinsured Motorists coverage.

Delaware Commercial Auto, Coverages/Limits Section ACORD 137 DE (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance inthis state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

Following are the specific differences in this state.
     •    Personal Injury Protection coverages are revised to reflect Delaware's unique coverages and options. Refer to
          your state manual.
     •    Underinsured Motorists Bodily Injury coverage is included in Uninsured Motorists coverage; Property Damage
          coverage is not available.
     •    Statement added to the back of the form, referencing the auto supplement, ACORD 61 DE, which must be used
          whenever the applicant chooses Uninsured Motorists Bodily Injury coverage less than the limits of the policy's
          basic Bodily Injury Liability limits, or rejects
     •    coverage entirely.

District of Columbia Commercial Auto, Coverages/Limits Section ACORD 137 DC (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state.

Personal Injury Protection coverages reflect Delaware's unique coverages and options. Refer to your state manual.
Statement added referencing the offer of Uninsured and Underinsured Motorists coverages, and the applicant's right to
  select coverage limits, and reject Underinsured Motorists coverage.
Statement added allowing the applicant to reject Personal Injury Protection coverages. Applicant must signify rejection by
  initialing the form.
Fraud warning specific to DC.
Florida Commercial Auto, Coverages/Limits Section ACORD 137 FL (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. The following are the specific differences in this state. Personal Injury Protection
coverages reflect Florida's unique coverages and options. Refer to your state manual. Underinsured Motorists /Bodily
Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property
Damage coverages are not available. Statement added to the back of the form referencing the various Uninsured
Motorists coverage options, and the use of the state supplement, ACORD 61 FL, if Uninsured Motorists, or non-stacked
coverage, is rejected.
Georgia Commercial Auto, Coverages/Limits Section ACORD 137 GA (2/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    Personal Injury Protection coverage does not apply; this is not a "not-fault" state.
     •    Uninsured Motorists coverage includes Underinsured Motorists coverage; provision is made for per-accident
          deductibles under Uninsured Motorists coverage.
     •    A required statement has been added to the back of the form referring to the state supplement containing
          explanation and selection options for Uninsured Motorists.

Hawaii Commercial Auto, Coverages/Limits Section ACORD 137 HI (2/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.
     •
     •     Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    Uniques Personal Injury Protection and Additional Personal Injury Protection items are provided.
     •    The applicant can select "stacked" or "non-stacked" Uninsured and
     •    Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available.
     •    A state-specific fraud warning is included on the back of the form.
Idaho Commercial Auto, Coverages/Limits Section ACORD 137 ID (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection coverages are not available; this is not a "no-fault" state.
     •    Uninsured and Underinsured Motorist Property Damage coverages are not available.
     •    Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily
          Injury coverages up to the policy's basic Bodily Injury Liability limits, and the applicant's right to select other
          limits, or to reject coverage entirely.

Illinois Commercial Auto, Coverages/Limits Section ACORD 137 IL (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    Personal Injury Protection coverages are not available; this is not a (no-fault) state.
     •    Uninsured and Underinsured Motorist Bodily injury coverages are combined; Underinsured Motorists Property
          Damage coverage does not apply; Uninsured Motorists Property Damage coverage is shown separately.
     •    Statement added referring to the state supplement, ACORD 61 IL, with respect to the selection of
          Uninsured/Underinsured Motorists Bodily Injury Liability coverage lower than the Bodily Injury Liability coverage
          in the policy, or the selection of Uninsured Motorists Property Damage coverage for vehicles not covered by
          collision insurance.

Indiana Commercial Auto, Coverages/Limits Section ACORD 137 IN (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state.
Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury and
  Property Damage coverages.
The applicant must initial the statement if any coverage is rejected.
Iowa Commercial Auto, Coverages/Limits Section ACORD 137 IA (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/ Motor Carrier Section.

The following are the specific differences in this state.

Personal Injury Protection coverages are not available; this is not a "no-fault" state.

Uninsured Motorists and Underinsured Motorists coverage sections include reference to "stacked" and "non-stacked"
coverages; Uninsured and underinsured Motorists Property Damage coverages are not available.

Statement added to the back of the form, referencing the state supplement, ACORD 61 IA, the offer of various Uninsured
and Underinsured Motorists Bodily Injury coverage options, and the applicant's right to select or to reject coverage
entirely. If the insured decides to select "stacked" UM or UIM, or to reject either UM or UIM coverage, the state
supplement must be signed.

A state-specific privacy notice is added.

Kansas Commercial Auto, Coverages/Limits Section ACORD 137 KS (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state.

Personal Injury Protection coverages have been revised to allow for Kansas options. Refer to your state manual.
Uninsured Motorists coverage includes Underinsured Motorists coverage; however, there is no property damage
  coverage available.
A required statement has been added to the back of the form, advising the applicant that auto liability insurance may be
  available through the Kansas Automobile Insurance Plan.

In addition, a statement has been added to the back of the form requiring the applicant to acknowledge available
Uninsured Motorists coverage options, including the option of rejecting UM limits higher than the mandatory minimum
limits.
Kentucky Commercial Auto, Coverages/Limits Section ACORD 137 KY (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state. Provision is made to report the "Tax Territory", as required by
Kentucky law. Personal Injury Protection coverages are revised to reflect Kentucky's unique coverages and options.
Refer to you state manual. Uninsured and Underinsured Motorists Property Damage coverage are not available. Added
section to the back of the form to allow descriptions of motorcycles, and named individuals to be covered, as required
under PIP options. Provided statement referencing the explanation to the applicant of Uninsured and Underinsured
Motorists coverages and available options; provided space to allow the applicant to reject UM and/or UIM. The fraud
statement on the back of the form is revised to reflect Kentucky law.
Louisiana Commercial Auto, Coverages/Limits Section ACORD 137 LA (6/98)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a
"no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorist coverage. Statement added to the
back of the form, referencing the offer of Uninsured Motorists coverages up to the policy's basic Liability limits, and the
applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option(s) selected.
Maine Commercial Auto, Coverages/Limits Section ACORD 137 ME (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
The following are the specific differences in this state.
Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Uninsured and Underinsured Motorists Bodily Injury coverages are combined.
Uninsured and Underinsured Motorists Property Damage coverages are not available.
Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists Bodily Injury
  coverages up to the policy's basic Bodily Injury Liability limits and the applicant's right to select lower limits, or to reject
  coverage entirely.
A state-specific fraud warning is added to the back of the form.
Maryland Commercial Auto, Coverages/Limits Section ACORD 137 MD (6/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection coverages are revised to reflect Maryland's unique coverages and options. Refer to
          your state manual.
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
     •    Statement added to the back of the form, referencing the state supplement, ACORD 62 MD, which must be
          given to the applicant if Personal Injury Protection coverage is rejected, or if Uninsured Motorists' Bodily Injury
          coverage less than the limits of the policy's Bodily Injury Liability limits is selected.

Michigan Commercial Auto, Coverages/Limits Section ACORD 137 MI (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. The following are the specific differences in this state.

Additional Property Damage Liability coverage in the amount of $400.00 is a basic liability coverage option.
Personal Injury Protection coverages have been revised to allow for unique Michigan coverages and options. Refer to
  your state manual.
No property damage coverage is available under Uninsured or Underinsured Motorists.
Several collision options are shown. Refer to your state manual.
Provision is made to allow individuals covered under the policy who are 60 years of age or older, and who have no
  expectation of actual income loss in the event of an accident, to reject coverage for work loss under Personal Injury
  Protection coverage. Each individual eligible must the application.
A statement is added referencing the Michigan Collision Insurance Options Notice (ACORD 62 MI) which must be given to
  every applicant for auto insurance in Michigan.
A statement is added that provides the address and phone number of the Michigan Insurance Bureau.
Minnesota Commercial Auto, Coverages/Limits Section ACORD 137 MN (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. The following are the specific differences in this state. The Personal Injury Protection
items revised to reflect Minnesota's unique coverages. A statement is added requiring the applicant to acknowledge
receipt of a copy of the Minnesota Guaranty Association Notice ( ACORD 65 MN). A statement is added requiring the
applicant to acknowledge the offering of Uninsured/Underinsured Motorists coverage up to the limits of BI Liability. A
statement is added referencing the company's right to cancel coverage during the forty-nine days following the issuance
of coverage, for any reason not prohibited by law. The fraud statement on the back of the form is revised to reflect a new
Minnesota law.
Mississippi Commercial Auto, Coverages/Limits Section ACORD 137 MS (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault"
state. Uninsured and Underinsured Motorists coverages are combined. Statement added to the back of the form,
referencing the offer of Uninsured/Underinsured Motorists coverages up to the limits of the policy's Liability limits, and the
applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected.
Missouri Commercial Auto, Coverages/Limits Section ACORD 137 MO (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state. Personal Injury Protection coverage does not apply; this is not a "no-fault" state.
Uninsured and Underinsured Motorist Property Damage coverages are not available. A required statement has been
added to the back of the form, indicating that the premium quoted is an estimate only, and that premium charged will be in
accordance with the company's filed rates. A statement has been added to the back of the form, referencing the offer of
Uninsured and Underinsured Motorists coverage.
Montana Commercial Auto, Coverages/Limits Section ACORD 137 MT (8/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.

Personal Injury Protection coverage is not available; this is not a "no-fault" state.

Uninsured Motorist Property Damage and Underinsured Motorists Property Damage coverages are not available.

A statement has been added to the back of the form, referencing the offering of Uninsured Motorists coverage up to the
limits of Bodily Injury liability coverage, and the applicants right to reject coverage.

A state-specific privacy notice is added.

Nebraska Commercial Auto, Coverages/Limits Section ACORD 137 NE (8/97)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state.
Personal Injury Protection coverage is not available; this is not a "no-fault" state.
Uninsured and Underinsured Motorists Property Damage coverages are not available.
The Fraud statement is removed.
Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury
coverages up to the limits of the policy's Bodily injury Liability Limits and the applicant's right to select lower limits or reject
coverage entirely.
Nevada Commercial Auto, Coverages/Limits Section ACORD 137 NV (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.
Provision is made in the "Applicant" box at the top of the front of the form to record the applicant's Federal Employer ID
  Number (FEIN), as required by Nevada statutes and regulations.
Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Uninsured Motorists Bodily Injury coverage is included in Uninsured Motorists Bodily injury coverage.
Uninsured and Underinsured Motorists Property Damage coverages are not available.
Statement added to the back of the form, referencing the state supplement, ACORD 61 NV, which must be given to the
applicant to explain the available
options under Medical Payments and Uninsured Motorists coverage.
New Hampshire Commercial Auto, Coverages/Limits Section ACORD 137 NH (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.
Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Underinsured Motorists coverage is included in Uninsured Motorists coverage.
New Jersey Commercial Auto, Coverages/Limits Section ACORD 137 NJ (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.
Personal Injury Protection coverages have been revised to provide for unique New Jersey coverages. Refer to your state
  Manual.
Uninsured and Underinsured Motorists coverages are combined.
Comprehensive is changed to "other than collision coverage".
The fraud statement on the back of the form is revised to comply with New Jersey law.

A statement has been added referencing the offer of Uninsured/Underinsured Motorists coverage up to the policy's BI
limits.
New Mexico Commercial Auto, Coverages/Limits Section ACORD 137 NM (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state.
Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Underinsured Motorists coverage is included in Uninsured Motorists coverage.
Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage
  coverages up to the limits of the policy's Liability limits and the applicants right to select lower limits, or to reject
  coverage entirely. The applicant must initial the option selected.
New York Commercial Auto, Coverages/Limits Section ACORD 137 NY (4/98)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.
Personal Injury Protection coverages are revised to reflect New York's unique coverages and options. Refer to your state
Manual. Uninsured and Underinsured Motorists coverages are replaced by "Statutory UM" and "Supplemental UM
(SUM)". Refer to your state Manual. Fraud statement is replaced with New York's Fraud Statement language. Statement
added to the back of the form referencing the availability of Statutory Uninsured Motorists and Supplementary Uninsured
Motorists coverages and options.
North Carolina Commercial Auto, Coverages/Limits Section ACORD 137 NC (5/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    A box relating to "facility Code" is added to the front of the form, to provide information relating to the re-
          insurance facility.
     •    Personal injury Protection coverage is not available; this is not a "no-fault" state.
     •    Provision is made for combined Uninsured/Underinsured Motorists Bodily Injury coverage, and separately for
          Uninsured Motorists coverage. Underinsured Motorists Bodily Injury coverage is not available by itself.
     •    An instruction is added requiring the fire district name and code number if fire or comprehensive coverage is
          provided.
     •    Statement added to the back of the form to allow the applicant to select or reject the various Uninsured and
          Underinsured Motorists coverage options. The applicant must initial the selection(s).

North Dakota Commercial Auto, Coverages/Limits Section ACORD 137 ND (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state. Personal Injury Protection coverages revised to reflect North Dakota's unique
coverages and options. Refer to your state Manual. Uninsured and Underinsured Motorists Bodily Injury coverages are
combined; Uninsured/Underinsured Motorists Property Damage coverages are not available. Statement is added to the
back of the form to allow the applicant to reject Additional Personal Injury protection coverage. The applicant must initial
the form.

Ohio Commercial Auto, Coverages/Limits Section ACORD 137 OH (4/98)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection is not available. This is not a "no-fault" state
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage
     •    Provision is made for Uninsured Motorists Property Damage coverage
     •    The Fraud Statement is revised to comply with Ohio law
     •    A statement has been added to the back of the form referring to the Uninsured Motorists coverage state
          supplement.

Oklahoma Commercial Auto, Coverages/Limits Section ACORD 137 OK (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.

Personal Injury Protection coverage is not available; this is not a "no-fault" state.
Underinsured Motorists BI coverage is included in Uninsured Motorists coverage; Property Damage coverage is not
  available.
The fraud statement is revised to comply with Oklahoma law.
Oregon Commercial Auto, Coverages/Limits Section ACORD 137 OR (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.

Personal Injury Protection coverages are revised to reflect Oregon's unique coverages and options. Refer to your state
  Manual.
Underinsured Motorists coverage is included in Uninsured Motorists coverage.
Statement added to the back of the form, referring to the state supplement, ACORD 61 OR, which must be given to the
  applicant to explain Uninsured Motorists coverage, and the options available.
Pennsylvania Commercial Auto, Coverages/Limits Section ACORD 137 PA (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.

Personal Injury Protection coverage sections have been revised in accordance with unique Pennsylvania coverages and
  options. Refer to your State Manual.
Provided for the selection of "stacked" or "non-stacked" coverage under Uninsured and Underinsured Motorists BI
  coverages. Property Damage coverage is not available.
The Fraud Statement is revised to comply with Pennsylvania law.
Rhode Island Commercial Auto, Coverages/Limits Section ACORD 137 RI (3/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.
     •     The following are the specific differences in this state:
     •     Personal Injury Protection coverages are not available; this is not a "no-fault" state. Uninsured and
           Underinsured Motorist coverages are combined.
     •     Statements are added to the back of the form that:
                1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected;
                2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if
                Uninsured/Underinsured Motorists Bodily Injury coverage is rejected;
                3. Allow the applicant to acknowledge the offer of Uninsured/Underinsured Motorists Property Damage
                coverage, and the options selected.
     •     The applicant must initial the options selected.

South Carolina Commercial Auto, Coverages/Limits Section ACORD 137 SC (4/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    A box relating to "Facility Code" is added to the front of the form, to provide information relating to the re-
          insurance facility.
     •    Medical Payments coverage is deleted; Medical expenses are included under Personal Injury Protection
          coverage.

South Dakota Commercial Auto, Coverages/Limits Section ACORD 137 SD (2/97)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this State. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state.

Personal Injury Protection coverages are revised to reflect South Dakota's unique coverages and options.
Refer to your State Manual.
Uninsured and Underinsured Motorists Property Damage coverages are not available.
Statement added to the back of the form to allow the applicant to select or reject supplemental auto coverage. The
  applicant must initial the form.
Tennessee Commercial Auto, Coverages/Limits Section ACORD 137 TN (11/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state.
     •    Personal Injury Protection coverages are not available; this is not a "no-fault" state.
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
     •    Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property
          Damage coverages up to the limits of the policy's Liability limits and the applicant's right to select lower limits, or
          to reject coverage entirely. The applicant must initial the option(s) selected.

Texas Commercial Auto, Coverages/Limits Section ACORD 137 TX (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state.

Personal Injury Protection coverages are revised to provide for various Texas coverages and options. Refer to your State
  Manual.
Uninsured and Underinsured Motorists coverages are combined. The Property Damage deductible is $250.00.
Statements are added to the back of the form requiring the applicant to acknowledge the explanation of
  Uninsured/Underinsured Motorists coverage and Personal Injury Protection, and to acknowledge selection/rejection
  decisions by initialing the statements.
Utah Commercial Auto, Coverages/Limits Section ACORD 137 UT (1/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection coverages reflect the unique coverages available in this state.
     •    Underinsured Motorists Property Damage coverage is not available.
     •    A statement is added to the back of the form explaining arbitration as an alternative to court action. This
          statement is required by Utah law.

Vermont Commercial Auto, Coverages/Limits Section ACORD 137 VT (1/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection coverage is not available; this is not a "no-fault" state.
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
     •    The Fair Credit Reporting Act Statement is replaced with Vermont's Fair Credit law requirements.
     •    A statement is added to the back of the form, referencing the explanation of Uninsured Motorists coverage to
          the applicant, and the applicant's selection of coverage.
     •    The fraud warning complies with VT law.

Virginia Commercial Auto, Coverages/Limits Section ACORD 137 VA (8/2001)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state.

Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section.

The following are the specific differences in this state:
     •    Personal Injury Protection coverage is revised to reflect the coverages and options available in Virginia. Refer to
          your state Manual.
     •    Underinsured Motorists coverage is included in Uninsured Motorists coverage.
     •    A required statement is added referring to the Company's right to cancel the policy for any reason within the first
          60 days it is in effect, and thereafter for reason stated in the policy.
     •    A statement is added referencing the offering of Uninsured Motorists coverage.
     •    Dual lines are provided for the initials of more than one named insured at the end of the statement on the back
          of the form relating to Uninsured Motorists coverage selection. A recent court decision determined that each
          named insured must acknowledge the offer of UM coverage.
     •    A state-specific fraud warning and privacy notice are added.

Washington Commercial Auto, Coverages/Limits Section ACORD 137 WA (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state. Personal Injury Protection coverage is revised to
reflect Washington's unique coverages and options. Refer to your state Manual. Added "Auto Loan" coverage in the
Coverages/Premium section. Statement added to the back of the form referring to the options available under
Underinsured Motorists and Personal Injury Protection coverages and the applicant's right to reject these coverages.
West Virginia Commercial Auto, Coverages/Limits Section ACORD 137 WV (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor
Carrier Section. The following are the specific differences in this state.

Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Statement added to the back of the form, referencing the state supplements, ACORD 60 WV, 61 WV, and 62 WV, with
  respect to the offering and selection of Uninsured and Underinsured Motorists coverages.
Wisconsin Commercial Auto, Coverages/Limits Section ACORD 137 WI (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state. Personal Injury Protection coverages are not available; this is not a "no-fault"
state. Uninsured and Underinsured Motorists Property Damage coverages are not available. Statements added to the
back of the form:

1. Acknowledging the offer of Medical Payments coverage, and allowing the applicant to reject this coverage; the
   applicant must initial the form of coverage that is rejected.
2. Acknowledging the offer of Uninsured and Underinsured Motorists Bodily Injury coverage, and the options available.
Wyoming Commercial Auto, Coverages/Limits Section ACORD 137 WY (1/96)
Use this form to collect the coverage, limits and premium information necessary to write Business Auto, Truckers or Motor
Carrier insurance in this state. Required disclosure and coverage acceptance or rejection information is also included.
Use this form with ACORD 127, Business Auto Section, or ACORD 132, Truckers/Motor Carrier Section. The following
are the specific differences in this state.

Personal Injury Protection coverages are not available; this is not a "no-fault" state.
Uninsured and Underinsured Motorists Property Damage coverage is not available.
A statement is added to the back of the form referencing the offering of Uninsured and Underinsured Motorists coverage.
A statement is added advising the applicant that, if a loss occurs to an insured vehicle and the insured is paid for that loss
  but doesn't actually repair the vehicle, any subsequent losses will be paid with the cost of the damage associated with
  prior losses being deducted.




Commercial General Liability Section 126-S (4/2000)

Commercial General Liability is a form of insurance designed to protect owners and operators of businesses from a wide
variety of liability exposures. These exposures include liability for accidents resulting from the insured's operations or
premises, products sold or operations completed by the insured, and contractual liability.

The Coverage and Limits Section of the ACORD 126-S was designed to follow the ISO Policy Simplification Program first
initiated in 1986. To request General Liability coverage from companies not following this format please refer to the
ACORD 126-N.

The ACORD 126-S was designed to be used in conjunction with the Commercial Insurance Application - Applicant
Information Section (ACORD 125). Please refer to the chapter on the ACORD 125 for information on that form.
IDENTIFICATION SECTION
Much of the information for the Identification Section should match that found within the Applicant Information Section of
ACORD 125. Even so, it is still important to complete this section. Many companies separate the applications by line of
business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full
account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name and address.
Phone (A/C, No, Ext)
Producer's telephone number.
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.
Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Effective Date
Month/day/year on which the terms and conditions of the policy will commence.
Expiration Date
Month/day/year on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.
Payment Plan
Plan 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, 40-30-30.)
Audit
The term for policies that are subject to periodic audit. If the audit period is known, enter the code:
A = annual
S = semi-annual
Q = quarterly
M = monthly
O = other

COVERAGES
Commercial General Liability
Indicate if commercial general liability coverage is required.
Claims Made
Check to request that the Commercial General Liability policy be issued on a claims made basis. For Claims Made
policies, be sure to complete the Claims Made section of the application.
Occurrence
Check to request the Commercial General Liability policy be issued on an occurrence basis.
Owner's & Contractors Protective
Check only when separate Owner's & Contractors Protective Liability coverage is being requested.
* Use the blank area to request other coverage forms such as Railroad Protective Liability, Liquor Liability, Pollution
Liability, or a separate Products/Completed Operations Liability Only policy.
Deductibles
If a deductible is requested, indicate the amount and type of deductible, and whether it is to apply per claim or per
occurrence. Use the blank line to indicate options other than Property Damage or Bodily Injury Deductible.
Per Claim
A per claim deductible applies to individual claims even if the claims are all related to the same occurrence or event.
Per Occurrence
A per occurrence deductible applies once to each occurrence no matter how many individual claims result from the
occurrence or event.
Other Coverages, Restrictions, and/or Endorsements
Use this area to request any other coverages, endorsements, or special conditions. Examples:
Include the Vendors Endorsement
Exclude Fire Damage coverage
Exclude Medical Expense coverage
Exclude Personal and Advertising Injury coverage
LIMITS
Enter the policy limits as they are to appear on the policy declarations page. Available limits following the ISO Policy
Simplification Program are: (All limits are in whole dollars.)
General Aggregate
Each Occurrence
Products & Completed Operations Aggregate
Fire Damage (Any One Fire)
Personal & Advertising Injury
Medical Expense (Any One Person)
Employee Benefits
Premiums
Not all companies require that the producer rate the policy prior to submission of the application. If you have done so,
enter the coverage premiums here.
SCHEDULE OF HAZARDS
Location #
For each classification, enter the location number of the risk's location as it appears on the Applicant Information Section
of ACORD 125. All classifications should be grouped by location number.
Classification
Classify the applicant's liability exposures by location, using the ISO Classification Table or other industry organization
rules. Enter the appropriate class description from the table in this field.
Class Code
Provide the general liability class code that corresponds to the class description shown in the previous field.
Premium Basis
Enter the premium basis code followed by the estimated premium basis (exposure) for each class code. This amount
should be listed as a whole number (actual basis) and not as the fraction that will be used in rating. (E.g., "S456,500"
means that the premium basis is gross sales, the estimated amount of gross sales for the coming policy period is
$456,500.) When rated, the rate will be multiplied by 456.5 because gross sales are rated per thousands of estimated
sales.
Terr.
For each discribed exposure, enter the rating territory code based on location from the appropriate state exception page.
Rate - Prem/Ops & Products
If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products
manual rates applicable to each classification.
Premium - Prem/Ops & Products
If the policy has been rated prior to submitting the application, enter the separate Premises Operations and Products
premiums applicable to each classification.

CLAIMS MADE (Explain All "Yes" Responses)
If a Claims Made coverage is requested, this section needs to be completed. Use this section to explain the status of
previous Claims Made coverage. Because a Claims Made policy uses a different coverage "triggering" mechanism, this
additional information is needed to properly process the application.

* It is very important that the information in this section be accurate to ensure uninterrupted general liability coverage for
the applicant. Use the Comments area to provide additional information.
1. Proposed Retroactive Date
The Retroactive Date you are requesting for the policy being applied for. This is the proposed earliest date for which an
occurrence could "trigger" coverage under a Claims Made policy.
2. Entry date into uninterrupted claims made coverage
The retroactive date shown on the applicant's first Claims Made policy. If this is the first such policy, the date will be the
same as the proposed retroactive date shown on the preceding field. If this is a renewal, it is the effective date of the first
policy issued in the sequence of uninterrepted Claims Made policies.
3. Has any product, work, accident or location been excluded, uninsured or self-insured from any previous
coverage?
For yes responses, describe the situations of the above occurrences in the Comment section.
4. Was tail coverage purchased under any previous policy?
For yes responses, describe terms and limits of tail coverage purchased under any previous policy. Tail coverage extends
the reporting period on a Claims Made policy to cover claims arising from occurrences that were not known by the date
the policy was cancelled, non-renewed or replaced.
EMPLOYEE BENEFITS LIABILITY
Use this section when Employee Benefits Liability is to be provided, to collect information about deductibles, number of
employees, number of employees covered by Employee Benefits plans, and retroactive date, if applicable.
CONTRACTORS
The information requested is for any past or present operations. This is important because the contractor applicant
continues to be held responsible for injury or damage that results from completed work done by the contractor, or for it by
subcontractors. Use the Remarks area to provide additional information.
1. Does applicant draw plans, designs, or specifications for others?
If the applicant draws plans, designs or specifications, explain. Indicate whether qualified professionals are employed by
the applicant for preparation.
2. Do any operations include blasting or utilize or store explosive material?
Describe any operation that includes any of these activities.
3. Do any operations include evacuation, tunneling, underground work or earth moving?
Describe any operation that requires any of these activities and the safety measures taken.
4. Do your subcontractors carry coverages or limits less than yours?
State the limits of coverages carried by subcontractors if less than the applicant's. Identify the subcontractors and the
amount of coverage.
5. Are subcontractors allowed to work without providing you with Certificates of Insurance?
Explain why certificates are not requested from subcontractors.
6. Does applicant lease equipment to others with or without operators?
If applicant leases equipment describe the type of equipment, number of operators, frequency, and lease arrangement.

Remarks/Describe the type of work & percentage subcontracted
Describe in detail the type of work the applicant subcontracts. Also include leased equipment activities. (E.g., An
excavation contractor may subcontract the blasting required. This may account for 10% of the contracts it undertakes.)
List any other remarks that may be pertinent to the contractors work.
$ Paid to Subcontractors
Show the total annual dollars paid.
% of Work Subcontracted
List the total percentage of work that the contractor subcontracts.
# Full Time Staff
Indicate the total number of full time staff.
# Part Time Staff
Indicate the total number of part time staff.
PRODUCTS/COMPLETED OPERATIONS
This section should be completed whenever Products/Completed Operations coverage is being requested by the
applicant. While it may seem to be designed with manufacturers in mind, it is also intended to be completed for retail
stores, distributors, and contractors.
Products
Use this field to describe the products for which product liability coverage is being requested. The description should be
detailed enough so that the underwriter can fully understand the nature of each product. If there are too many products to
describe individually, those which share certain characteristics should be grouped under a single generic description and
the characteristics of each group should be described. Attach any literature or brochures available. (E.g., All of the
furniture manufacturer's office desks can be described as "office desks", because each one is very similar to the other,
even though there are several sizes and shapes and they are designed for home or office use. On the other hand, dining
tables and medical office patient examination tables should not be grouped as "tables" because they are dissimilar in
design and function.)

Annual Gross Sales
Estimated dollar amount the applicant expects to sell in the coming year for each product or product group described.
Remember the application is for the next policy year, not the current or past policy year.
An amount should be shown for each product or product group described. This breakdown of sales is primarily needed to
figure the premium, especially when there are two or more products and each one is subject to a different rating
classification.
# of Units
Number of units the applicant expects to sell and/or manufacture in the coming year. An amount should be shown for
each product or product group described. The breakdown of units is primarily needed to estimate the product's claims
frequency potential.
Time in Market
Number of years or months that each described product or product group has been sold by the applicant.

Expected Life
Average length of time, (days, weeks, months, or years) that the applicant expects each described product or group of
products to last until it is worn out, used up, or consumed. This may be the shelf life for products consumed or useful life
for other products.
Intended Use
Describe the use or uses of each product or product group contemplated by the applicant. The following information
should be provided:
What the product is designed to be or do
How the product is designed to work or function
How, when and where the product is designed to be used or consumed
Example: If the product is food, its use is apparent. If it is a chemical or a machine part, there may be a variety of uses. In
these instances, the specific use becomes an important consideration for both coverage and pricing.
This information is necessary for the underwriter to identify and evaluate the hazards associated with the use or potential
misuse of a product.
Principal Components
Major components of the product. If additional space is needed to complete the information required for a particular
product, attach a separate sheet.

Use the Remarks section or a separate sheet of paper to explain any "Yes" responses to the following questions, for any
past or present operation or product.
1. Does applicant install, service or demonstrate products?
The explanation of a "Yes" response to this question should include:
What, how and where it is done
Who does it, employees or independent contractors
Whether a maintenance or repair service is sold
When the work is done by independent contractors, the explanation should also include information on the cost of the
work done for the applicant by the independent contractors.
2. Foreign products sold, distributed, or used as components?
Each foreign-made product or product group bought, sold or distributed by the applicant should be described. In addition,
the following information should be provided on each described product or group of products:
Intended use
Expected use life
Time in the market
Principal components
Estimated annual gross sales
Major source, such as U.S.-based importer or foreign-based exporter or manufacturer
Relationship with manufacturer or exporter
The explanation should also indicate, for each major source, whether or not that source has U.S. products liability
insurance, the limits of that insurance, and the name of the domestic insurer. Indicate whether the applicant markets
products abroad.
3. Research and development conducted or new products planned?
Describe the nature and extent of R&D work. Example: Indicate if it is solely directed at the development of new products
or if some effort is directed to improving or changing existing products.
Describe any new products to be marketed within the next 12 months and the potential market. Provide an estimate of
anticipated sales.
4. Guarantees, warranties, hold harmless agreements?
A guarantee is a promise made by the seller that the product can be returned for repair, replacement or a refund if the
buyer is unsatisfied with it for some reason. A warranty is a positive statement that the product is as represented or will be
as promised by the seller. If the applicant issues written guarantees or warranties with its products, copies should be
attached. Indicate whether they have been reviewed by an attorney.
The presence of a Hold Harmless agreement means that the applicant has assumed certain obligations or liabilities of
another person or firm. Remember, the contractual liability coverage contained in the Commercial General Liability
coverage form applies only to covered bodily injury and property damage for which the indemnitee (the person or firm
being held harmless) is liable in tort. Coverage does not apply to any other obligation or liability that the applicant may
have assumed in the Hold Harmless agreement. Attach copies of any Hold Harmless agreements the applicant may have
signed.
5. Products related to aircraft/space industry?
Describe any aircraft or space industry products sold or installed by the applicant and explain how and by whom they are
used. Many insurers have underwriting restrictions on aerospace related products. (E.g., electronic equipment, aircraft
frames, guided missile systems.)
6. Products recalled, discontinued, changed?
The applicant's current products liability exposure includes products that are still in use but may not have been found and
fixed by a recall, products no longer made, and products made prior to a product change. These exposures must be
separately underwritten when such products are known to exist.

A product recall usually indicates that the products subject to the recall were considered to be unreasonably dangerous.
Consequently, any product recall should be fully explained. The explanation provided for recalled products should include
the following:
A description of the products including their intended use and expected life
The reason for the recall, including a description of the product defects, if any, which made the recall necessary
Who initiated the recall, the applicant or a government agency
The purpose of the recall, modification, repair or replacement of the defective products, and the effectiveness of the recall
A description of the recall method
The total number of the defective products subject to the recall
The result of the recall, including the percentage of recalled products found
The explanation provided for discontinued products should indicate when and why manufacturing ended and how many
  items are estimated to be in current use.
A changed product may forecast a start of or increase in claims or suits from the products made before the change. The
  explanation should indicate when the change was made and the reason for the change.
7. Products of others sold or repackaged under applicant's label?
When the applicant sells products under its name or label that are made by someone else, the applicant should be
considered as the manufacturer of those products. Indicate whether products are repackaged, modified, or further
processed by applicant. The explanation should include information on who supplies the products and the contractual
relationship between the applicant and the actual manufacturer.
8. Products under label of others?
When the applicant makes products that are sold with someone else's name or label on them, the explanation should
provide the following information:
Who has contracted for the products and who is selling them?
Are the products processed further by others before reaching the ultimate consumer?

9. Vendor's coverage required?
The explanation should identify the vendor, explain why the vendor wants to be included as an additional insured, and
indicate the extent of coverage required by the vendor. Provide the gross sales to each vendor.
10. Does any named insured sell to any other named insured?
Provide the product(s) name. All sales of products between multiple named insureds must be included when determining
the total gross sales used for premium computations.

Please attach literature, brochures, labels, warnings, etc.
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS
Use this section for information on any additional interests, employees who should be listed as additional insureds, and
others who require Certificates of Insurance on the general liability portion of this policy. For additional names attach an
ACORD 45, and check the box in the title line of this section.
Interest
Indicate all appropriate options for the individual named.

Rank
Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee.
Name and Address
List the additional interests name and address.
Reference #
Indicate the additional interests reference number for this applicant such as the loan or mortgage number.
Certificate Required
If a Certificate of Insurance is required check this box.
Interest in Item Number
List the item number corresponding with the application for the item of interest for this additional insured.
Item Description
If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a
scheduled item list the description, such as 3 carat diamond in six point setting.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The
overview below lists the expected information that should be added to the Remarks section for "Yes" responses.
1. Any medical facilities provided or medical professionals employed or contracted?
Describe the medical or first aid facilities provided on the premises. Indicate if any physicians or other health care
personnel are employed or contracted.
2. Any exposure to radioactive/nuclear materials?
Indicate if the applicant's operating/manufacturing process involves the use of or deals with these materials. Is a Nuclear
Regulatory (Atomic Energy) Commission license required?
3. Do operations involve storing, treating, discharging, applying, disposing or transporting hazardous material?
Indicate whether the applicant's operations involve any discharge of fumes, acids, caustics, or wastes. List any harmful
by-products generated and how they are controlled, stored or disposed of. Indicate whether the applicant owns or
operates any landfills or fuel tanks.
4. Any listed operations sold, acquired, or discontinued in the last five years?
Explain and describe all such operations.

5. Is any machinery or equipment loaned or rented to others?
Describe the types of equipment the applicant loans, rents, or leases to others.
6. Any watercraft, docks, floats owned, hired, or leased?
Describe any watercraft or waterfront exposures. Indicate if the facilities are for private use or available to the public.
7. Any parking facilities owned/ rented?
Describe if the facilities are for the use of employees, customers, visitors, etc. Give the area in square feet.
8. Is a fee charged for parking?
If a fee is charged for parking, indicate whether the parking is available to the public or used primarily by employees. List
the number of locations involved, and how many parking facilities are at each location.
9. Are any recreational facilities provided?
Describe any recreational facilities provided for both employees or non-employees. This should include gymnasiums,
grandstands, bleachers, parks, playgrounds, exercise rooms, or swimming pools owned or maintained by the applicant.
10. Is there a swimming pool on the premises?
State size, maximum depth, and whether or not the pool is equipped with a diving board or water slide. Also note if a
lifeguard is on duty when the pool is open.
11. Any sporting or social events sponsored?
Describe the nature of such events and include the location and number of spectators and participants. If the applicant
sponsors athletic teams, indicate whether the teams are composed of employees or others, such as Little League.
12. Any structural alterations contemplated?
List any anticipated new construction for any locations included in the insurance being requested. Explain who will do the
work: employees or subcontractors. Provide the payroll of employees or the cost of the work if subcontracted.
13. Any demolition exposure contemplated?
Describe any demolition work contemplated by the applicant. Identify the structure and who will be performing the work.
14. Has applicant been active in or is currently active in joint ventures?
List venture's name and address along with the role of the applicant.
15. Do you lease employees to or from others?
List the companies involved, whether you are the lessor or lessee and attach a copy of the lease agreement.

16. Is there a labor interchange with any other business or subsidiaries?
List the companies involved and outline the agreement.
17. Are daycare facilities operated or controlled?
Indicate if facilities are for employees children only or open to the public. List number of children watched on a daily basis.
If off premises give location of operation.
18. Have any crimes occurred or been attempted on your premises within the last three years?
Describe any crimes or attempted crimes (e.g., burglaries, robberies, etc.).
19. Is there a formal, written safety and security policy in effect?
If yes, provide a copy of the written safety or security policy in cases where your company requires this information.
Indicate if these policies are practiced on a regular basis. Describe activities and precautions that are taken with respect
to safety and security, including use of outside security firms.
20. Does the businesses' promotional literature make any representations about the safety or security of the
premises?
If yes, provide copes of such literature.
REMARKS
Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments
such as Hold Harmless agreements, literature, brochures, labels, warnings or product surveys are being sent.




Commercial Insurance Application/Applicant Info 125 (4/2001)

The underwriting process for any commercial account begins with the
submission of a completed application. This guide will provide assistance
in completing the ACORD Commercial Insurance Applicant
Information Section.

The Applicant Information Section is the foundation on which the
ACORD commercial application program is built. This form contains
information that is not duplicated on other ACORD commercial
application forms. The Applicant Information Section is a required part
of every commercial submission except Workers Compensation, and no
commercial application is complete without it.
IDENTIFICATION SECTION

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

Phone (A/C, No, Ext), Fax No.
Producer's telephone and fax numbers.

Producer
Producer's name, address and telephone number. In Florida and Nebraska, also include the producers state license
number, and in Nebraska, add the agency state license number.

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

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

Agency Customer ID
Customer's identification number assigned by the agency.

Carrier
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
Individual company code assigned by the NAIC.

Underwriter/Und. Off
Use these fields to direct the application to a specific company underwriter and company office.

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.

Policy Number
Use this field to provide the policy number if a policy has already been issued.

Sections Attached
A checklist indicating the other ACORD application sections that are attached to complete the submission. If there are any
other additional forms attached enter the form name on the blank line. The form numbers associated with the listed
section names are:
     •    Property - ACORD 140
     •    Glass & Sign - ACORD 144
     •    Accounts Receivable/Valuable Papers - ACORD 145
     •    Crime - ACORD 141
     •    Miscellaneous Crime - ACORD 151
     •    Transportation/Motor truck Cargo - ACORD 143
     •    Equipment Floater - ACORD 146
     •    Installation/Builders Risk - ACORD 147
     •    Electronic Data Processing - ACORD 148
     •    Commercial General Liability - ACORD 126-S or ACORD 126-N
     •    Business Auto - ACORD 127, and ACORD 137 for the state where the
     •    insurance will be written
     •    Truckers/Motor Carriers - ACORD 132, and ACORD 137 for the state where
     •    the insurance will be written
     •    Garage - ACORD 128
     •    Vehicle Schedule - ACORD 129
     •    Boiler & Machinery - ACORD 155
     •    Workers Compensation - ACORD 130
     •    Umbrella - ACORD 131-S or ACORD 131-N

Additional ACORD forms, such as state-specific forms, may also be filled in.

STATUS OF TRANSACTION
Indicate which company 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 option applies, check multiple boxes.

PACKAGE POLICY INFORMATION
Use this section to indicate common effective and expiration dates or common billing and payment plans for package
policies.

Proposed Eff. Date
Month/day/year on which the terms and conditions of the policy will commence.

Proposed Exp. Date
Month/day/year on which the terms and conditions of the policy will terminate unless renewed.

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

Payment Plan
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, 40-30-30.)

Audit
The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code:
A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other
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. Show the federal employment identification number (FEIN) or social
security number, if the first named insured is an individual. Also include the phone number and internet address (if
applicable.)

Mailing Address (of First Named Insured)
The address at which the first named Insured is to receive all correspondence regarding the insurance.
Form of Business Organization
Identify the applicant as an Individual, Partnership, Corporation,Joint Venture, Subchapter "S" Corporation, Limited
Liability Corporation or Other. If other, provide a description such as Professional Association or Limited Liability
Company.
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.)
Not For Profit Organization
Check this box if the company is registered as a "Not for Profit Organization". This status affects some rating
classifications.

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.

Inspection Contact-Phone
Name and telephone number 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.

Accounting Records Contact-Phone
Name and telephone number of the person to contact to arrange for review of the accounting records. This should be an
individual under the insured's employment or their accountant, not the insurance agent's name and number.

PREMISES INFORMATION

Loc #
Location number for this premesis.

Bld #
Building number for this location. Used when more than one building exists at an individual location.

Street, City, County, State, Zip Code
For each location number, enter the complete physical address (not P.O. Box) including both county and ZIP Code for
each location. If there are more than three locations, attach a separate list.

Address should include:

Street number, if any
     •    Pre-direction, if any (e.g., 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 mortgage holders.

City Limits
For rating purposes indicate if this location is situated within the city limits.

Interest
Indicate the applicant's interest in each location.

Yr Built
Year the building at each location was originally constructed. Specify in the Remarks section any significant additions or
renovations and the year they were completed.

Part Occupied
Identify the portion of the premises or building occupied by the applicant, such as "entire", "first floor" or "800 sq. ft. on the
10th floor."

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

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."

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)
GENERAL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The
overview below lists the expected information that should be added to the Remarks section for "Yes" responses.

1a. Is the applicant a subsidiary of another entity?
If the applicant is a subsidiary of another organization, identify the parent company and describe the relationship including
the percentage owned by the parent.

1b. Does the applicant have any subsidiaries?
If the applicant has any subsidiaries, provide a list and describe each relationship and the percentage owned by the
applicant.

2. Is a formal safety program in operation?
Some larger applicants may have formal safety programs. If this applicant does, be sure to provide an explanation of the
program activities. This could have a positive impact on the underwriter's acceptance and pricing decisions.

3. Any exposure to flammables, explosives, chemicals?
Provide a description of the exposure, identify the substances involved, explain any hazardous processes, and describe
any precautions taken to reduce or control the hazard. If hazardous waste is generated, describe it and explain how it is
disposed of.

4. Any catastrophe exposure?
Describe any known exposures of this nature such as: "located on an earthquake fault," "located in a flood plain," or "next
to a rocket fuel factory."

5. Any other insurance with this company or being submitted?
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 along with any policy numbers available.

6. Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Provide an explanation of how this situation occurred.

7.Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent
hiring?
Provide an explanation if any of the above exposures occurred.

8.During the last five years (ten in RI,) has any applicant been convicted of any degree of the crime of arson? (In
Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a
sentence of up to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.

9.Any uncorrected Fire Code Violations?
Describe any violations of applicable building codes that have not been corrected.

10. Any bankruptcies, tax or credit liens against the applicant in the past five years?
If yes, Describe in detail.

REMARKS/PROCESSING INSTRUCTIONS

Use this space to provide detailed answers to the General Information underwriting questions outlined above. This space
should also be used to provide additional information as required from other sections of the application. If additional space
is needed attach a separate list.

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.

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.

PRIOR CARRIER INFORMATION

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 completeness and accuracy of this information can affect the
underwriter's pricing decisions.

COMMON TO ALL LINES

Carrier
Name of the insurance company that wrote the policy.

Policy Number
Reference identification assigned by the insurance company to identify the policy.
Eff.- Exp. Date
Show the effective and expiration date of the policy.

Modification Factor
The reciprocal of the percentage by which the premium shown differs from the manual. Example: if the General Liability
insurance manual premium is $1,000, but the actual premium charged was reduced to $680 because of a combination of
package, experience and schedule credits, the Modification Factor is .68.

This factor is used by the insurance company to convert premium charged back to manual premium for application of
experience rating plans.

Total Premium
The annual modified premium charged (not including taxes or service charges) for the specified line of business.

COMMERCIAL GENERAL LIABILITY

Policy Type
Indicate whether the policy was issued on a Claims Made or Occurrence basis.

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".

Limits
List the limits as they appeared on the policy declarations page. Limits can be listed following either the ISO simplified
Policy Format or the non-simplified policy format.

AUTOMOBILE LIABILITY

Policy Type
List the policy type that the previous policy was issued on. (e.g., Business Automobile, Truckers policy.)

Limits
List the limits as they appear on the policy declarations page.

PROPERTY

Policy Type
The coverage form that the previous policy was issued on. (e.g., Special excluding Theft.)

Bldg./Pers Prop Amount
Indicate if the amount listed is the Building Limit or the Personal Property Limit.

OTHER

Complete this section for policy history on other lines of business.

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.

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.

See Attached Loss Summary
Check this box if a loss summary report is being sent with the application.

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

Line
Line of business involved in the loss (e.g., Automobile Liability, Property, General Liability).

Type/Description of Occurrence or Claim
A brief description of the loss.
Date of Claim
The date on which the loss or occurrence occurred.

Amount Paid
If the previous carrier has made any payments on this claim, enter the total amount paid to date.

Amount Reserved
If the claim is still open, list the reserve amount the previous carrier is holding open for this claim.

Claim Status
Indicate if this claim is open or closed.

REMARKS

Use this section to list any additional, pertinent information that the underwriter should know about the overall exposures
of this risk.




Commercial Policy Change Request 175 (8/2001)

This chapter provides basic instructions needed to complete the Commercial Policy Change Request (ACORD 175).

Information in this chapter will refer the user to the application section chapter where the full policy sections are
discussed. Additional information will be explained as necessary.

IDENTIFICATION SECTION

Complete this section for all change requests.

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

Producer
Producer's name, address, telephone and fax number.

Code
Identification code assigned to your agency or brokerage firm by the insurer receiving this form.

Subcode
If your agency uses sub-code identification system with the insurer, enter the appropriate code.

Agency Customer ID
Customer's identification number assigned by the agency.

Insured's Name
First named insured as listed on the current declarations page. If this name is to be changed, list the new name in the
Remarks section.

Insured's Mailing Address If Changed
Mailing address only if it has changed.

Policy Type
Policy types or lines of business within a package policy that are being changed on this request. Only one policy, as
controlled by a policy number, should be entered per change request.

Company
Name of the applicable insurance company, and the NAIC code number of the company that issued the policy being
changed. Use the "Attention" space to identify a particular underwriter, if necessary.

Policy Number
Policy number created by the company exactly as it appears on the policy declarations page.

Effective Date of Change
Date that the requested change is to commence. Only one effective date of change should be made per change request.
Policy Inception Date
Effective date of the policy as listed on the policy declarations page.

Policy Expiration Date
Expiration date of the policy as listed on the policy declarations page.

For each section below you may Add, Change or Delete data. Only one form of adjustment should be made per section.
(If you check both Add and Delete, the company will not know which data is being added and which should be deleted.)
Most sections have at least two iterations to handle the addition and deletion of an item such as a vehicle.

PREMISES INFORMATION SECTION

Refer to the chapter on the ACORD 125 for unique data element descriptions.

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

Refer to the chapter on the ACORD 125 for unique data element descriptions.

AUTO-VEHICLE DESCRIPTION/LIMITS

If an addition or change is being made to the policy level limits, check the "Policy Limit(s) Changed" box. Also check the
appropriate box for Add, Change or Delete. Limits should be adjusted in the last line of the section. To delete a limit, write
"delete" in the appropriate limit box.

To delete a vehicle, check the delete box and only enter the data for the Vehicle Year, Make, Model, Body Type and
Vin/Serial Number.

Refer to the applicable state manual for no fault/personal injury protection coverages. Each state where these coverages
are available has unique mandatory coverage and unique coverage options. Use the Remarks section to describe
coverage to be provided.

Refer to the guidelines for ACORD 129 for other unique data element descriptions.

DRIVER INFORMATION

Refer to the chapter on the ACORD 127 for unique data element descriptions.

WORKERS' COMPENSATION RATING INFORMATION

For each classification, indicate if it is an Add (new class), Change (new premium basis) or Delete (class is to be
removed). All data elements should be completed for each type of change. Refer to the chapter on ACORD 130 for
unique data element descriptions.

PROPERTY/INLAND MARINE - PREMISES INFORMATION

Refer to the chapter on the ACORD 140 for unique data element descriptions.

INLAND MARINE- SCHEDULED EQUIPMENT

Refer to the chapter on the ACORD 146 for unique data element descriptions.

GENERAL LIABILITY - LIMITS

Use section to indicate general liability limits changes. New limits cannot be added or deleted on this form, only changed.

GENERAL LIABILITY - SCHEDULE OF HAZARDS

For each classification, indicate if it is an Add (new class), Change (new premium basis) or Delete (class is to be
removed). All data elements should be completed for each type of change. Refer to the chapter on ACORD 126-S for
unique data element descriptions.

UMBRELLA CHANGES

Use this section to describe changes in limits, retained limit, or other changes such as an increase or decrease in
coverage provided. Describe these changes in the space provided, or use the Remarks section.

ADDITIONAL INTEREST

This section should be used to collect information on any additional interest or receiver of Certificates of Insurance.
Interest
Check all appropriate boxes that apply to the additional interest. If 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.

Interest in Item
Use section to designate exactly what the additional interest has an interest in. If the additional interest has an interest in
multiple items, such as a lienholder on multiple vehicles, list all numbers associated with the additional interest. Examples:
     •     Location 2, Building 3, Item 7 (As per schedule)
     •     Vehicle # 2 & 3

Certificate Required
If a Certificate of Insurance is required, check this box.

Reference Number
List any reference number such as a loan number that may help tie the additional interest to item.

ADDITIONAL CHANGES/REMARKS

List any additional change information required to correctly underwrite and rate the request.

PRODUCER'S SIGNATURE / INSURED'S SIGNATURE

Space is provided for signatures of the producer and/or the insured.

Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are
made that are considered significant to the company.

Refer to your company rules.

Many companies, or state laws, require the insured's signature when auto, liability, no fault, or uninsured motorists
coverage is changed or deleted. Refer to your company or state rules.




Crime Section 141 (10/98)

This chapter provides instructions for completing the ACORD Crime Section (ACORD 141). The form addresses the basic
underwriting and rating needs for Plan 1 forms A through H and Q as defined in the ISO Manual or the Surety Manual.
Specific information on this plan and its sections can be found in these manuals. Additional information on Plan 1 forms I
and J can be found in the Miscellaneous Crime Section, ACORD 151. Use this form in conjunction with the Commercial
Insurance Application - Applicant Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for
information on that form.
IDENTIFICATION SECTION
Much of the information for this section should match the data found within the Applicant Information Section of ACORD
125, however, it is still important to complete this section. Since many companies separate applications by line of
business for rating purposes, not completing this part of the application makes it difficult to keep track of the full account.
Date
Month/day/year on which the form is completed.
Phone (A/C, No, Ext)
Producer's telephone number.
Producer
Producer's name, address and telephone number.
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.
Applicant (First Named Insured)
First Named Insured as it appears on ACORD 125.
Effective Date
Effective date on which the terms and conditions of the policy will commence.
Expiration Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.
Payment Plan
Indicate the plan that will 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, 40-30-30).
Audit
Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code:
A         annual
S         semi-annual
Q         quarterly
M         monthly
O         other

PLAN 1
This section is used to collect the coverage limits for Plan 1, forms A through H and Q.
A- Employee Dishonesty
If the risk is on a blanket or scheduled basis, enter the form limit and deductible.
Blanket
Form covers money, securities and property other than money and securities at all premises of the insured against the
cause of loss in the title above. If Blanket coverage applies, complete the Employee Classification section.

Schedule
Form covers money, securities and property other than money and securities for the employees or employee positions
shown in the schedule of this form against the cause of loss in the title above. If Schedule coverage applies, complete the
reverse side of the Miscellaneous Crime Section application (ACORD 151).
ERISA
If ERISA Employee Dishonesty applies, check the box and show the total asset value.
B- Forgery or Alteration
Form covers instruments such as checks, drafts and promissory notes that are made or drawn by the insured or an agent
of the insured against the causes of loss in the above title. Enter the form limit and deductible.
C -Theft, Disappearance and Destruction
Form covers money and securities against the causes of loss in the title. Each of its two sections has a separate limit of
insurance. The limit under Section 1 applies to all premises of the insured. The limit under Section 2 applies to all
messengers of the insured outside the premises. Regardless whether Blanket or Schedule coverage is selected, the
money and securities exposure information should be completed for all the insured's locations on the reverse side of the
application. The Safe and Vault, Messenger/Protection, and Premises/Safe Protection entries should also be completed.
Complete a separate ACORD 141 for each additional covered location. For Schedule coverage, use the reverse side of
ACORD 151.
D -Robbery and Safe Burglary
Form covers property other than money and securities against the causes of loss of robbery and safe burglary. The three
limits on the application should be used as follows:
Limit 1 - Inside premises - robbery of custodians
Limit 2 - Inside premises - safe burglary
Limit 3 - Outside premises - robbery of messengers

Whether Blanket or Schedule Coverage is selected, the Property, Safe/Vault, Messenger/Protection, and Premises/Safe
Protection entries must be completed for each location. If the money and securities endorsements for Coverage Form D is
requested, complete information must be given.

Do not request the money and securities endorsement if the applicant requests Coverage Form C. Robbery and safe
burglary of money and securities is part of the theft coverage provided under Coverage Form C.
E -Premises Burglary
Form covers property other than money and securities against burglary, and applies to all premises of the insured.
Whether blanket or schedule, the Property, General Information and Premises/Safe Protection entries must be completed
for each location. If the Special Covered Causes of Loss Coverage Form has been requested for personal property, do
not request Coverage Form E.
F -Computer Fraud
Form covers money, securities and property other than money and securities against computer fraud. It is designed to
insure against property loss caused by a non-employee using the applicant's computer system. Since the coverage is
similar to a loss caused by an employee using the computer system, limits should be the same as Coverage Form A.

G -Extortion
Form covers money, securities and property other than money and securities against extortion. It applies to one or more
premises of the insured with a single limit of insurance for all premises.
H- Premises Theft and Robbery Outside
Form covers property other than money and securities against theft whether blanket or schedule. Each of its two sections
has a separate limit of insurance. Section 1 limit (Theft) applies to all premises of the insured; Section 2 limit (Robbery
Outside) applies to all messengers of the insured.
Q Robbery and Safe Burglary – Money and Sescurities
This coverage form covers money and securities against the causes of loss in the title. It has two sections. Separate limits
apply to Robbery of a Custodian and Safe Burglary under section 1 and this section applies to all premises of the insured.
The section 2 limit applies to all messengers of the insured.
Additional Options
An additional option box is provided to insert additional Plan 1 Forms. Information on Forms I and J are found on ACORD
151.
COVERAGE AMENDMENTS (Endorsements)
There are many endorsements available for the various crime coverage forms. Refer to the Commercial Lines Manual or
Surety Manual for the pertinent rating and underwriting information needed for each endorsement.
ERISA EMPLOYEE DISHONESTY- ADDITIONAL INFORMATION (Coverage Forms A & B)
Show the name of each plan, principal address, number of trustees or employees handling the plan assets, and the
number of plan participants. If more than on eplan, provide the necessary information for each plan separately.
CLASSIFICATION OF EMPLOYEES/LOCATIONS
(Coverage Forms A & B)
Complete when requesting Plan 1 Coverage forms A or B.
Employee Classification
Number of employees by classification who handle or have custody of money or securities.
Number of Officers
Number of officers other than agents or partners.
Total Number of Other Employees
Number of all other employees not included in the employee classification count. Manufacturers, Processors,
Wholesalers or Distributors: Number of Retail Locations Number of retail locations for the listed classifications.
All Other Classes: Number of Locations Other Than Home or Head Offices
Number of locations other than the home or head office for all other types of classifications.
CONTROLS (Coverage Form A)
Fundamental information to underwrite Coverage Forms A and B. Do not submit requests for these coverages without
complete information in this section. Explain any Yes responses to questions 5 - 8 in the Remarks section (e.g., if the
duties described in questions 5, 6 and 7 are performed by the owner or other excluded people (partners or directors), an
explanation of this will avoid future correspondence. Conversely; if the individual performing these duties is to be a
covered employee, attach a narrative explaining the applicant's accounting and internal control procedures to minimize an
employee dishonesty loss). Questions 5, 6 and 7 address the most common areas where employee dishonesty losses
have occurred.
1. Is there an audit by?
Method by which the company accounts are formally audited.
2. Audit frequency?
Timing of the formal audits.
3. Does audit include inventory?
Indicate if formal audits go beyond looking into the company books, and include a review of all inventory.
4. Audit report is rendered to
Indicate who receives and reviews the final copy of the audit.
5. Are bank accounts reconciled by someone not authorized to deposit or withdraw?
Indicate who reconciles the accounts and how are they reconciled.
6. Is countersignature of checks required? If not, who signs?
Indicate who has check-signing authority.
7. Will securities be subject to joint control of two or more responsible employees?
Indicate who has control of the company securities.
8. Are all officers and employees required to take annual vacations of at least five consecutive business days?
Indicate the procedures taken when book-keepers and executives take vacation, and who takes over.
MONEY - SECURITIES (Coverage Form C or Q- Blanket Coverage, by Locations)
Complete this section for Coverage Form C, or Coverage Form Q if you request the Money and Securities endorsement.

For each category (Inside, Messenger #1, Messenger #2) carefully separate the exposure limits. Each type of exposure is
rated differently. They are:
Money
Checks for deposit
Checks for accounts payable
Payroll Checks
Money Overnight
Securities (in bank/safe deposit)
Securities, including charge account receipts from national charge accounts, will carry a rate 30 percent less than the
  money rate.

If the applicant makes nightly deposits which reduce the overnight exposure, a reduced limit for Coverage Form C while
the premises is/are closed may be requested. There is a premium credit for that reduction. If securities are in a safe
deposit box, consider offering Coverage Form I (Lessees of Safe Deposit Boxes) to insure that exposure.
PROPERTY (Coverage Forms D, E and H)
Specify the property to be insured. Along with the property description, list the maximum value of the property. There are
sublimits in these coverage forms for significantly valuable items, like jewelry made of precious metals. In such cases, the
applicant is a candidate for the appropriate form of Inland Marine insurance designed for those exposures.
GENERAL INFORMATION (All Coverage Forms Except A & B)
This section provides basic underwriting information for Coverage Forms C, D, E, F, G and H. The gross sales information
is necessary for rating Coverage Forms F and G.

Business Hours
Hours and days per week that the business is open for normal operations (e.g., 9:00 AM to 5:00 PM, Monday through
Saturday).
Avg. No. Employees on Duty
Average number of employees on duty during business hours.
Checks Stamped for Deposit Only
Yes or No.
Frequency of Deposits
Frequency that deposits are made to the bank (e.g., daily, twice a week).
Night Depository Used
Yes or No.
Annual Gross Sales or Receipts
Indicate dollar amount for the last fiscal year.
Double Cylinder Door Locks
Indicate if the premises is protected by this type of lock.
Other Information
Supplemental information such as police patrol, central shopping center guard information, proprietary closed circuit
television, etc.
SAFE/VAULT (Coverage Forms C, D & Q)
This section provides underwriting and rating information for Coverage Forms C, D and Q. If you cannot classify the type
of safe, enter the exact information on the label of the safe in the Remarks area.
Manufacturer
Manufacturer's name of the safe or vault.
Label
Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe
Manufacturers National Association (SMNA).
Class
Construction classification representing the extent of burglary protection for this safe or vault. Use the classification from
the Burglary label and not the Fire label located on the safe or vault. For industry definitions of the classifications, refer to
the Commercial Lines Manual.
Door Type
Indicate if the door is round or square.
Combination Locks
Identify the presence of combination locks as well as their placement on the safe/vault. Place an "X" in all boxes that
apply.
Door Thickness
Measurement in inches.
Wall Thickness
Measurement in inches.
MESSENGER PROTECTION (Coverage Forms C,D & Q)
This section is required for Coverage Forms C, D, and Q.
Mess'gr #
Messenger number to which this information applies.
# of Guards Per Messenger
Number of guards assigned to work with each messenger.
Private Conveyance Used?
Indicate if the messenger uses a car or truck provided for his/her exclusive use during the entire trip.
Safety Satchel Used?
Indicate if the insured's property is carried in an Underwriters Laboratories-approved safety satchel (e.g., a key-locked
bank depository bag or case with handcuffs).
PREMISES/SAFE PROTECTION (Coverage Forms C, D, E and H)
Complete this section to describe the location's security systems.

Alarm Type
Style of alarm(s) protecting this premises and any safe or vault. Available options are:
Hold-Up - A manual or semiautomatic control which can transmit an alarm in the event of a hold-up

Premises - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry. The
Premises Extent must be completed for Premises Alarms
Safe/Vault - System that protects the safe or vault and is connected to an outside central station, gong or siren. The
Extent of Protection for Safe/Vault must be completed for all safes/vaults
Alarm Description
Any applicable features of the alarm.
Local Gong - A bell located outside the premises

Central Station - A private security service which monitors the alarm system and may dispatch security officers in
response to an alarm
Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to police headquarters rather than to a private
control station
With Keys - Indicate if security service or police have keys to respond to alarms

Grade
Grade or class A, B, C, etc. This indicates the time required to respond to a signal from the alarm system. Please refer to
manual.
Extent of Protection for Safe/Vault
Extent of the alarm protection for the safe or vault.
Partial - Alarm covers around door only
Complete - Alarm covers sides, top walls, floor and ceiling
Extent of Protection for Premises
Extent of the premises alarm as defined in the ISO Classification and Rating Manual.
Alarm Installed & Serviced By
Name of the company installing and servicing the alarm system. Alarm companies often install, maintain and service the
system, as well as to provide central station facilities.
# Guards
Number of guards within the premises or at its door during regular business hours.
# Watchpersons
Number of watchpersons on the premises during non-office hours.
Watchpersons
Type of watchperson reporting.
Rpt/Cent. St - Report to a central station on an hourly basis

Clock Hrly - Register hourly with an approved watchperson's clock (Detex Time Clock, etc.)
Don't Signal - Do not do any type of reporting or registering
Certificate Number
Alarms which are approved by the Underwriters Laboratories (UL) are identified by a certificate. Record the certificate
number. (Note: UL certification can apply to the entire system or to individual parts.)
Expiration Date
UL certificate expiration date.

Accessible Openings & Protection
Provide information regarding access to the premises. Indicate number of doors and if they are protected. Indicate what
type of locks are used, and if there is a gate or bars.
Other Protection
Other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm). Indicate if the
building has skylights and if windows are visible from the street.
AUDIT PROCEDURES- SAA COMMERCIAL CRIME POLICY
Complete when requesting commercial crime coverage following SAA procedures.
INTERNAL CONTROLS OTHER THAN AUDIT PROCEDURES
Also complete this section when requesting commercial crime coverage following SAA procedures.
REMARKS
Provide any additional information required for underwriting or rating.
Show what corrective measures have been taken by the applicant to prevent future losses, or to provide additional safe
information.




Dwelling Fire Application 84 (4/2001)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide
will provide assistance in completing the ACORD Dwelling Fire Application.

The generic section of personal lines form are explained in the Personal Lines Generic Section at the beginning of the
Personal Lines Section of the Forms Instruction Guide. On the ACORD website (www.acord.org), this information appears
under the title PERSONAL LINES GENERIC SECTIONS.

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/YY). (e.g., March 7, 1944 should be 03/07/44.)

Social Security #
Social security number for each named applicant.

Questions Relating to Knowledge of Applicant and Date Property Was Inspected
Indicate how long the applicant is known to the agent, and when the property was last inspected by the agent.

COVERAGES/LIMITS OF LIABILITY/ ENDORSEMENTS

Enter the anticipated dollar limit amounts for each applicable coverage. List any optional endorsement(s), corresponding
limit(s) and any endorsement information that is to be included in this policy.

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

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.)

Premium
Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit.

Payment Plan
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 to be used for payment.

RATING/UNDERWRITING

Construction Type
Check the primary type of building material used to construct the dwelling

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

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

Sq Foot
Dwelling's total square feet of living area.

# 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 four family building
APART . . . . . . . . . . . . . . . . . . . . . . Apartment
CONDO . . . . . . . . . . . . . . . . . . . . . Condominium
CO-OP . . . . . . . . . . . . . . . . . . . . . . Cooperative

Usage Type
Applicant's use for the dwelling. COC represents "course of construction."

# Families
Number of separate family units in the dwelling.

# 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.

# Units in Fire Div
Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of fire divisions in the
structure and 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 fire walls.

Terr Code
Location of the dwelling based on individual state bureau or company manual pages.

Fire Prem Group
The applicable premium group based upon the dwelling's location, construction and fire protection code. Some companies
require this data; others generate it.

Protect Class
Dwelling's four character fire protection class found in individual state manuals.

Distance to Hydrant
Distance (in ft.) from the nearest hydrant that supports the protection class used.

Distance to Fire Station
Distance in miles from the nearest fire station that supports the protection class used.

Fire/EC Rate
Complete if residence is specifically rated. Refer to company rate manual.

Fire District/Code Number
Dwelling's fire district name and corresponding five character code number which can be found in the individual state
manual pages.

Protection Device Type
For alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application.

Heat Type
Indicate the primary and secondary types of heating devices for the residence. If no heat, check the box.

If fuel storage tanks are located on the premises, describe the type and indicate the location. Use the Remarks section, if
necessary. Possible types include:

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

Oil Storage Tank Location
If the fuel type is oil, provide the location of the fuel oil storage tank. Examples:
      •     Indoors completely above ground on a masonry floor
      •     Indoors completely above ground not on a masonry floor
      •     Outdoors and completely above ground
      •     All other (including underground)

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

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.

Dwelling Location
Location of the dwelling within the guidelines listed.

Occupied By
Check the appropriate box.

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

Smoke Detector
If the dwelling is equipped with smoke detector(s), 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.

Housekeeping Condition
Enter an evaluation of the interior upkeep of the dwelling.

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

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

Storm Shutters
Check the applicable box.

Hurr Res Glass
Check the applicable box to indicate if hurricane resistant glass is installed in the structure.

Bldg Code Grade
Enter the ISO Building Code Grade, if applicable.

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

Class Rated
Rate the risks of similar hazard, i.e., dwellings. When using this rating method, signify by checking this box.

Specific Rated
Rate applying to an individual piece of property. When not using the class rating method, check this box and provide the
Fire/EC Rate in the Remarks section when applicable.

Occupied Daily?
Check the appropriate box.
# Weeks Rented
Number of weeks the dwelling is rented by the insured to others.If any apartment is rented on less than an annual basis,
describe the terms.

Wind Class
Check the applicable wind class.

Roof Type
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


Foundation
Indicate which type of foundation is applicable.

If Replacement Cost applies, check the appropriate box to indicate if any ACORD replacement cost worksheets apply (i.
e., ACORD 40, 41, or 42.) Also provide the square footage for any basement, garage and breezeway.

Rating Credits
Check the appropriate boxes if any rating credit (s) apply.

EC PREM GROUP/PERS LIAB TERR CODE
Use these fields if the company uses Extended Coverage premium groups or personal liability territory codes.

Fireplaces
Check the appropriate box(es) to describe the fireplace(s).



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.

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 or bankruptcy during the past five years?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or
bankruptcy filing during the specified time period.
9. Are there any animals or exotice 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 ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode
Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up
to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.

15-17. Renters and Condos Only
Indicate if:

15. There is a manager on the premises.

16. A security attendant.

17. The building entrance is locked.

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.


LOSS HISTORY

This section shows the losses this applicant has had in the past. List losses for the last three years unless the company
requires a different period of time.

OTHER STRUCTURES

Describe the other structure(s) and its coverage limit to be included under Coverage B - Other Structures.

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.

Risk New to Agency
Indicate whether this is the first time this agency has written this line of business for this applicant.

ADDITIONAL INTEREST

Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or
rank (1st, 2nd), whether the additional interest is the mortgage holder (i.e., bank in which the mortgage is held), or other
interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan
number.




Electric Data Processing 148 (2/2000)

This chapter provides basic instructions for completing the ACORD Electronic Data Processing Section (ACORD 148).
The form has been designed to handle the basic underwriting and rating needs for issuing an EDP policy. Applicant
Information Section (ACORD 125). Refer to the chapter on the ACORD 125 for information on that form.
IDENTIFICATION SECTION
Most information for the Identification Section should match the data found within the Applicant Information Section of
ACORD 125. however, it is still important to complete the section. Many companies, for rating purposes, separate the
applications by line of business. Not completing this portion of the application makes it difficult to keep track of the full
account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Effective Date
Effective date on which the terms and conditions of the policy will commence.
Expiration Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
PREMISES INFORMATION
Use this section to collect the coverage information applicable to the entire policy or to an individual location. If coverages
differ by location, multiple applications must be completed.
Location Number
Premises location number as found in the premises information section on the ACORD 125. If the coverage limits are
blanketed, leave this section blank.
Building Number
If multiple buildings exist for the above location number, enter the number assigned to this building.
For each subject of insurance, use the following fields:
Limit of Insurance
Insurance amount that this subject of insurance is to be written at. If a coinsurance percentage applies to this coverage,
this is the coinsurance limit (e.g., $1 million of coverage written at 80 percent coinsurance is listed as $80,000).
Valuation Type
Indicate which type of value was used in determining the limit of insurance.
ACV = Actual Cash Value
RC = Replacement Cost
Other = List type in the Remarks section.

Coin %
Coinsurance percentage used at time of loss.

Deductible
Requested deductible amount for this subject of insurance.
Forms and Conditions to Apply
All form numbers and special conditions applicable to this subject of insurance.
Subjects of Insurance
Indicate the limits, valuation types, coinsurance percentage and deductibles by the desired subjects of insurance.
Equipment (Hardware) Owned
If covering owned equipment (not leased), list the insurance limit, valuation type, coinsurance percentage and forms and
conditions. This is a separate limit from the leased equipment.
Equipment (Hardware) Leased
List the Leased equipment limit separately from the Owned equipment limit. Attach a copy of the lessors contract for all
leased equipment and also complete the Additional Insured section for the lessors.
Equipment (Hardware) in Transit
For coverage while equipment is in transit, complete this line.
Media/Data (Software)
Limit in terms of the reproduction cost of the software programs, the insured's data and the disks and tapes on which the
data is stored.
Media/Data (Software) in Transit
For coverage while the media/data is in transit, complete this line.
Extra Expense
For the Restoration Period, enter the total number of days expected to be fully operational after a total loss.
Business Interruption
Insurance Limit, the limit per day and number of days for coverage. For deductibles, enter the dollar amount for the
deductible and the number of hours to be applied before the deductible goes into effect (waiting period hours).
Mechanical Breakdown
Check the appropriate box to indicate whether this coverage is applicable.
Protection and Control System
List coverage information if separate limits apply to the security systems for the EDP equipment.
Other
Complete for any additional EDP coverage.
Flood Coverage
If flood applies, check "Yes" and fill in the flood zone. Check the box that pertains to floor level where the better
percentage of the EDP equipment is located. If flood coverage does not apply, check "No."
Earthquake Coverage
If earthquake coverage applies, check "Yes" and fill in the earthquake zone. If earthquake coverage does not apply, check
"No."
RATING INFORMATION
Complete the following information as it applies to the building where the EDP equipment is located.
Building Construction Type
Construction for the building. Common construction classifications are:
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Prot Class
Fire rating protection class for this location.
# of stories
for this building, not including any basement.
Year Built
Year in which the building was first constructed.
SCHEDULE OF EQUIPMENT
Individually schedule hardware.

Loc. #
Location number (as found on the ACORD 125-S) for this piece of equipment.
Bldg #
Corresponding building number for where this piece of equipment is located.
Item #
A unique number assigned to this piece of hardware by the insured. Numbers are usually sequential, starting with one (1).
Manufacturer
Manufacturer's name.
Model
Model name or number.
Serial #
Serial Number assigned to this piece of equipment by the manufacturer.

Leased or Owned
Ownership status of this piece of equipment as "Leased" or "Owned."
Current Full 100% Value
The amount it would currently cost to replace this piece of equipment with the exact same model. Due to the nature of
computer equipment, this value may be substantially less than the applicant's original purchase price.
Amount of Insur. (Coinsurance %)
Amount the piece of equipment is to be insured for at its coinsurance level and requested valuation type.

Totals
Total of the current full value column and the amount of insurance column.
REMARKS
Provide any additional information required for underwriting or rating.
GENERAL INFORMATION
Provide additional information for any questions answered "Yes". The following overview lists information that should be
added to the remarks section for "Yes" responses.
1. If a major or total loss occurs, could you return to operation within one week?
Outline steps you have taken to prepare to return to work within one week.
2. Do you have an arrangement for the use of other equipment?
Outline with whom and from where you have arranged to obtain equipment. Indicate whether or not any emergency
arrangement has been successfully tested.
3. Is your equipment manufacturer in a position to replace your equipment promptly?
Outline any arrangements you have made with the manufacturer to replace equipment in case of a loss.
4. Is your equipment under manufacturer's warranty?
List expiration dates of the manufacturer's warranty.
5. Do you have a service or maintenance contract with a manufacturer or other service contractor?
List the establishment with which you have the contract, contract numbers and expiration dates.
6. Is the equipment shipped by common carrier?
List the common carrier's name that is contracted to handle your shipping needs.
7. Is the equipment shipped by company vehicle?
List the shipping vehicle.
8. Is the media/data shipped by common carrier?
List the common carrier's name.
9. Is the media/data shipped by company vehicle?
List the shipping vehicle.
10. Does the premises have a burglar alarm?
Describe the alarm system.
11. Does the applicant have any of the following devices to protect the hardware from power line problems?
Check each type of device used.
COMPUTER ROOM INFORMATION
1. Is the data processing equipment located in a specifically designated room?
Briefly describe the computer room, security controls and environment controls.
2. Is access to the room restricted?
Describe security controls that restrict non-authorized personnel.
3. Is the equipment controlled by a master shutdown switch?
Describe where the switch is located.
4. Is there a separate air-conditioning system designed to specifically protect the EDP equipment?
List the make and model of the air-conditioner and if it operates on an uninterruptible power supply.
5. Computer room protection systems
Indicate all fire protection systems used in the computer room.
6. Floor construction type
If the computer room has a raised pedestal floor, check the appropriate boxes for both the floor construction type and the
type of fire protection for the space below the floor.
7. Alarm Type
Indicate any applicable alarm types for each of the listed alarm systems: Temperature, Humidity, Smoke, Fire.
Local - rings only on the premises
Central - monitored by the police or a security service

MEDIA AND DATA (SOFTWARE) INFORMATION
1. Are anti-viral safeguards in effect?
Indicate what type of anti-viral safeguards are used, such as closed system or use of virus checker programs.
2. Are duplicates of software maintained?
Software is the operating program(s) and program codes. If backups are kept, complete the software duplicates and Data
Backup Storage section.
3. How often is data backed up?
Indicate how often data is backed up by checking the appropriate box. Data is the variable information entered into the
software program.
SOFTWARE DUPLICATES & DATA BACKUP STORAGE
Duplicate Software
Indicate the location where duplicates of all software are kept. If off premises, list name and address of site below.
Data Backups
Indicate the location where backups of all data are kept. If off premises, list the name and address of the site below.
On Premises Location Information
Indicate the location where the duplicate software and data backups are stored on site.
ADDITIONAL INTEREST
Collect information on any additional interest and/or receiver of Certificates of Insurance.
Interest
Check all boxes that apply to the additional interest. If 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.
Interest in Item
Designate what the additional interest has an interest in (e.g., Location 2, Building 3, Item 7 [as per schedule]).

If the additional interest has an interest in multiple items, such as a lienholder on multiple pieces of computer hardware,
list all of the numbers associated with the additional interest.
Certificate Required
If a Certificate of Insurance is required, check this box.

Reference #
List any reference number, such as a loan number, that may successfully tie the additional interest to item.
REMARKS
Provide any additional information required for underwriting or rating.
Equipment Floater Section 146 (5/2000)

This chapter provides basic instructions for completing the ACORD Equipment Floater Section (ACORD 146). Although
the main function of this form is to collect underwriting and rating information for contractors' equipment schedules, it may
also be used for any other applicable Inland Marine coverage and schedule including those for cameras, musical
instruments and physician and surgeon equipment. Applicant Information Section (ACORD 125). Refer to the chapter on
the ACORD 125 for information on that form.
IDENTIFICATION SECTION
Most information for the Identification Section should match the data found within the Applicant Information Section
(ACORD 125). however, it is still important to complete the section. Many companies, for rating purposes, separate the
applications by line of business. Not completing this part of the application makes it difficult to keep track of the full
account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Proposed Eff. Date
Effective date on which the terms and conditions of the policy will commence.
Proposed Exp. Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
Audit
Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code:
A = annual
S = semi-annual
Q = quarterly
M = monthly
O = other.
TERRITORY OF OPERATION
Specify exactly where the equipment or schedule of items is normally located. For a specific location, give the address, or
information such as the construction site name and address, city, county or state.
TYPE OF OPERATION
Describe the type of work performed by the applicant and nature of this business. This information may also appear on
the Application Information Section (ACORD 125). If so, enter "see ACORD 125".
COVERAGE/DEDUCTIBLE
List the form of coverage desired and all appropriate deductibles in the space provided. Indicate if the Floater is to be
written on a Scheduled or Blanket basis. If scheduled, list all items. Specify if All Risk or Named Perils. Enter any other
options chosen such as Replacement Cost or Actual Cash Value and the desired deductible. Deductibles may be written
on a "dollar amount" or "percentage" basis. Specify how the deductible is to be applied if not familiar with each company's
policy (e.g., Contractors' Equipment, Commercial Articles Floater or Musical Instrument Dealers).

EQUIPMENT STORAGE
Collect limit information applicable to contractor's equipment. If other limits for such coverages as Commercial Article
Floaters fit, enter them here. Limits that don't fit within these section headings should be listed within the Coverage and
Deductible section.
Months in Storage
Number of months equipment is kept in storage. (If less than one month, enter one. All partial months should be rounded
up).
Maximum Value in Building
Indicate the maximum value of the scheduled items stored inside a building.
Maximum Value Outside
Indicate the maximum value of all scheduled items stored outside.
Type of Security
Briefly describe the kind of security employed by the applicant at each location. Specify guards, alarms, fences, dogs, etc.

UNSCHEDULED EQUIPMENT
It may be unnecessary to individually schedule all items owned by an applicant. This section should be used to group
similar items together for unscheduled coverage.
Description
Describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lenses).
Maximum Item
Maximum value of any single item within this grouping.
Amount of Insurance
The total value of all of the unscheduled items. Values can be either on a Replacement Cost or Actual Cash Value basis.
Coinsurance Percent
Coinsurance percentage contemplated by the amount of insurance required. Most insurers require 100 percent
coinsurance.
ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS
Collect information on any additional interest or receiver of Certificates of Insurance.
Name and Address
List the additional Interest's name and mailing address.
Interest
List the scheduled item's item number and the interest in the item. Examples:
Item 15, Loss Payee
Item 2, Additional Insured
Item 1, Additional Insured/Lessor
Certificate Required
If a Certificate of Insurance is required, check this box.
GENERAL INFORMATION
The underwriting questions have been designed for applicants dealing in contractors' equipment. The Remarks section
provides additional information for any questions answered "Yes" and for applicants not associated with contractors'
equipment.

The following overview lists information that should be added to the Remarks section for "Yes" responses.
1. Equipment rented, loaned to or from others with or without operators?
If the applicant is involved in any sort of rental or loan agreement, explain the circumstances and the nature of the
agreement, including who is carrying the insurance for the equipment.
2. Is applicant operating equipment not listed here?
Indicate if applicant owns, leases, or hires equipment not to be insured by this policy. Identify equipment and nature of
operations.
3. Property used underground?
Indicate if any work is done underground and if equipment is left underground. Explain all circumstances of underground
operations.
4. Any Work Done Afloat?
Indicate if any work is done on bodies of water and if equipment is left afloat unattended for extended periods. Explain
circumstances and indicate which bodies of water are involved.
REMARKS
Provide any additional information required for underwriting or rating.
SCHEDULED EQUIPMENT
Individually schedule items.
% Coinsurance
Indicate the percentage of coinsurance used to compute the insurance amounts provided on the equipment schedule.
Most insurers require 100 percent coinsurance.
#
Assign an individual item number to each item scheduled.
Model Year
Model year of each item scheduled, or the specific year in which the equipment was manufactured, if applicable.
Description
Describe the item to be insured. For each item listed, include the manufacturer, model number, make and any other
important information to identify the equipment.
ID#/Serial No.
Item's identification or serial number or any other identifying symbol.
Date Purchased
Date when each piece of equipment was purchased by the applicant.
New/Used
Indicate if the item scheduled was purchased new or used by the applicant.
Amount of Insurance
Amount of insurance representing the liability limit for this particular described equipment. The limit should reflect the
required coinsurance percentage and the requested basis of valuation (ACV or Replacement Cost).




Evidence of Property Insurance 27 (3/93)

The Evidence of Property Insurance (ACORD 27) provides a coverage statement for mortgagees, additional insureds and
loss payees. Often, the form replaces the need to send a complete policy to banks, savings and loans and other lenders,
as well as other additional insureds.
The purpose of the ACORD Evidence of Property Insurance (EPI) is significantly different from the Certificate of Property
Insurance (ACORD 24). Like the Certificate of Insurance, the EPI summarizes property insurance coverages currently in
force on a policy. However, it differs by conveying to the holder of the form all rights that go with the policy, including
notice of cancellation. These "rights" apply only to individuals identified on the policy. In creating this form, ACORD
received input from the American Bankers Association, the Mortgage Bankers Association of America, the Federal Home
Loan Bank Board and the Federal National Mortgage Association.
Research reveals that information included on the form satisfies requirements of mortgagees and other additional
insureds in most situations. Discussions with various lenders indicate that inclusion of items such as coinsurance are not
important. The primary concern is that the amount of insurance is sufficient to cover the amount of the loan. Sufficient
space is provided in the Coverage and Remarks sections of the form to include any additional information that may be
required.
Although many lenders pay the premium for certain types of policies such as Homeowners, inclusion of the premium
amount is inappropriate on the EPI. This information will be communicated to the payor via an invoice. Furthermore, in the
case of continuing coverage, the premium amount would be invalid after the first year.
IDENTIFICATION SECTION
Producer
Producer's name, address and telephone number.
Phone (A/C, No, Ext)
Producer's telephone number.
Code
Identification code assigned to the agency or brokerage firm by the insurance company providing the policy coverages.
Subcode
If the agency use code identification system with the company, enter the appropriate code.
Agency Customer ID
Customer's identification number assigned by the agency.
Company
Name and address of the applicable insurance company. Use the actual name of the company within the group to which
the policy has been issued. Do not use group names.
Insured
Insured's name and address as they appear on the policy declarations page. The line within this field is a margin setting
for window envelopes.
Loan Number
Insured's loan or account number for this additional interest.
Policy Number
Number exactly as it appears on the policy, including prefix and suffix symbols.
Effective Date
Date on which the terms and conditions of the policy commence.
Expiration Date
Date on which the terms and conditions of the policy expires.
Continued Until Terminated if Checked
If the policy is issued on a Continuous basis, check the available box.
This Replaces Prior Evidence Dated
If a prior Evidence of Property Insurance was issued to this additional interest and this form replaces the old one, enter
the date the old form was issued; otherwise, leave this field blank.
PROPERTY INFORMATION
Location/Description
For buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave,
Endicott - Grocery Store with Apartments, or Route 66, five miles south of intersection with I99 - Tobacco Barn).

For other property items, such as a vehicle (for physical damage coverages) or inland marine equipment (for lessor
information), describe the item along with any available vehicle identification number or serial number (e.g., 88 Ford
Fairmont VIN FM123467A88 or 82 Case Backhoe Model H-15, Ser # G5963a57).
COVERAGE INFORMATION
Coverage/Perils/Forms
Narrative description of the coverages provided, causes of loss (perils), and the forms attached (e.g., Homeowner - HO3
0792, or Contractors Equipment CM 00 22 10 90).
Amount of Insurance
Amount of insurance for the associated coverage.
Deductible
Deductible for the associated coverage.
REMARKS
Remarks
Space for any additional comments or to list any special conditions that may exist upon the policy.
CANCELLATION
Unlike the Certificate of Insurance, the Evidence of Property Insurance gives the additional interest certain rights in
accordance with the policy provisions. This includes the right to receive a written notice in case of policy termination.
Number of Days
Number of days before cancellation that the additional interest will be notified prior to termination of the policy (e.g., 10
days).
ADDITIONAL INTEREST
Name and Address
Name and address of the additional interest. The line within this section is a margin setting for window envelopes.
Nature of Interest
Indicate the type of interest by checking the appropriate box. Available options are: Mortgagee, Additional Insured, Loss
Payee. Use the optional space to enter any other type of interest.
Loan #
List any loan number, account number or other controlling number that the additional interest may have assigned the
insureds.

Authorized Representative
This form should be signed by an authorized representative of the issuing company.




FL Workers Compensation Application 130-FL (8/2000)

The generic Workers Compensation Application, ACORD 130, cannot be used in Florida. The ACORD Florida Workers
Compensation Application is a Commercial Lines application that is self-contained, that is, it does not require the
completion of the Applicant Information Section (ACORD 125). As a result, the entire Identification section should be
completed. The Florida Workers Compensation Application provides for Workers Compensation, Employer's Liability, and
Voluntary Compensation coverages. The Policy Information and Rating Information sections follow the Workers
Compensation rules as published by the National Council on Compensation Insurance (NCCI). Other plans may be used
with this form as well. Please refer to the NCCI manual for coverage definitions. ACORD and NCCI cooperated in the
development and promulgation of the Florida Workers Compensation Forms. These forms are a result of the passing of
Section 3 of CS/HB 3809 (Ch. 90-201) Laws of Florida which was signed into effect July 1, 1990. The application
requirement applies to new and renewal policies. Unless the insurance company has been changed, it is unnecessary to
file an application on renewals after filing them the first year. This includes policies written by out-of- state agents that
have covered Florida exposure.
IDENTIFICATION
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Code
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
Subcode
If your agency uses a sub-code identification system with the company, enter the appropriate code.
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.
Underwriter
This field is used to direct the application to a specific company underwriter by name.
Applicant Name
Enter the 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 are not legal entities.
Mailing Address
Address at which the First Named Insured is to receive all mail.
Years in Business
Number of years the applicant has been in business. This is important. It helps the underwriter determine the expertise
and business success of the applicant.
SIC
Enter the appropriate Standard Industry Class code assigned to the type of business engaged in (if known).
Form of Business Organization
Place an "X" in the box to identify the applicant as an Individual, Partnership, Corporation, Subchapter "S" Corporation or
Other. If Other, provide a description. Example: Professional Association. If there is more than one Named Insured, 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."). If the list is too
long for the space provided, attach a separate list.
Federal Employer ID Number
The FEIN is a number assigned by the IRS that specifically identifies the applicant. This number is required in most states
before a policy can be issued. A separate FEIN may apply to each entity named as an insured. For individuals, use Social
Security number.
NCCI I.D. Number
A nine-digit number assigned to the applicant by the National Council on Compensation Insurance (NCCI). The NCCI is a
rating bureau that operates in most states and also provides interstate experience rating for risks that operate in more
than one state. This identification number is required in most states before a policy can be issued. It will also help insure
timely and accurate calculation of experience modifications.
Other Rating Bureau I.D. Number
If the applicant is subject to experience rating in an independent bureau state, that state's rating bureau may assign a
separate identification number. If so, enter that number here.
STATUS OF SUBMISSION
Use the Quote/Issue Policy/Bound boxes to indicate whether the response to this application from the company is
expected to be a quote or an issued policy. If the risk is bound, so indicate, include the date coverage began and attach a
copy of the binder. This application is not a substitute for a binder.
You may "X" more than one box. Example: if the underwriter indicated by telephone that the risk is acceptable and
coverage can be bound, you should "X" both Bound and Issue.
BILLING/AUDIT INFORMATION
Billing Plan
Indicate whether the agency or the company (direct) will bill the insured or other payer for the policy.
Payment Plan
Indicate the plan to be used to pay the company for the policy. For the Other option, use the company's specific
designation for the plan being used. Example: Bi-monthly or 40-30-30.
% Down
For bound policies, list the percentage of the total estimated annual premium that has been (or will be) received as a
down payment.
Audit Record
Use the boxes provided to indicate the frequency with which audits should be undertaken for this policy.
LOCATIONS
List all usual work places of the applicant. Provide the physical address, not post office boxes. Place an "X" beside Yes or
No to show if the applicant is a long term employee leasing company. Example: Staff Leasing. If yes, then the name of the
client and the address where the employees will be located must be included, in addition to the address of the applicant.
POLICY INFORMATION
Proposed Eff. Date
The Effective Date is the date on which the terms and conditions of the policy will commence.

Proposed Exp. Date
The Expiration Date is the date on which the terms and conditions of the policy will expire.
The normal policy period (effective date to expiration date) is one year. However, a policy may be issued for any length of
time up to a maximum of three years. Certain rules and endorsements must be used if the policy is written for more than
one year. It may be necessary to use Effective and Expiration Dates that do not indicate a one year term to gain
concurrence with other policies.
Normal Anniversary Rating Date
Normally, the rates used are those in effect on the effective date of the policy. NCCI Manual rules require the rates to
apply for a period of one year. If a policy is canceled or short-termed, the rating bureau requires the original effective date
to be considered the Normal Anniversary Rating Date for both rates and experience modifications. This is a temporary
situation that will last until the next renewal, whereupon the new policy effective date will again determine the rates. The
purpose of this rule is to prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule
changes. For canceled or short-termed polices, enter the original effective date.
Participating/Non-Participating
A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the
insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available
through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating
basis. Check with your company on the availability of plans.
Retro Plan
Retrospective rating plans permit the adjustment of the final premium based on the actual premiums and losses of the
applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check
with your company on the availability of plans.
Part 1 (States)
Indicate the states in which Part 1 will apply. Part 1 refers to the Workers Compensation Law and/or Occupational
Disease Law in states where the applicant has operations.
Part 2 - Employers Liability
Enter the requested limits for Part 2 of the policy (Employers Liability Insurance). The standard limits of liability under Part
2 are: Bodily Injury By Accident: $100,000-each accident/Bodily Injury by Disease: $500,000-policy limit/Bodily Injury by
Disease: $100,000-each employee. Be sure to express limits with full dollar amount (all zeros shown) on the application.
Other Coverages
Use this space to request optional United States Longshoremen's & Harbor Worker's (U.S.L. & H.) Coverage and
Voluntary Compensation Coverages. Exposures for these optional coverages as well as additional coverages should be
described in the Specify Additional Coverages/Endorsements section.
Dividend Plan or Safety Group
Identify the specific plan or the safety group of which the applicant is a member. This field is related to the participating
plan. Check with your company on the availability of plans.
Additional Company and State Information
If Part 3 - Other States Insurance - is to be written, states falling under Part 3 need to be listed in this section. State
abbreviations should be listed preceeded by the words Part 3 - Other States Insurance - Included. Any additional
company or state specific information should also be listed in this section.
Deductible
Made available at the written request of the employer, in the amount of $500, $1,000, $1,500, $2,000 and $2,500 per
claim. See the Florida Benefits Deductible And Coinsurance Programs for more details.
Coinsurance Limit
Made available at the written request of the employer. The carrier will pay 80 percent and the employer will pay 20
percent per claim of the benefits due to an employee for an injury compensable under Florida Benefits Deductible And
Coinsurance Programs.
RATING INFORMATION
Location Number
The location number for each entry which corresponds to the locations listed in the Locations section above.
Class Code
The Classification Code which best describes the business of the applicant. It is important to remember that it is the
business of the employer, not the individual employees, that is being classified. Consult the proper rating manual to
determine the code. Rating bureaus may exercise control over classification assignment.
Company Use
Leave this space blank. The insurer may use this space for special computer codes, to identify the applicable class
description wording.
Categories, Duties, Classifications
A single class code may include several related descriptions of activities/operations. Therefore, it is extremely important to
enter the specific classification description or, at the very least, a brief statement regarding the duties of the employees.
Enter as much information as necessary to avoid misclassifying the operations.
No. of Employees
Indicate the Number of Employees to whom the classification applies. The average number is sufficient when the total
number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate.
Actual Remuneration Past 12 Months
Indicate the remuneration (payroll) for the previous 12 months for the appropriate class. Remember, payroll means money
or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help to avoid
additional premium at the time of audit.
Estimated Remuneration for Next Policy Period
The total estimated payroll for the period between the proposed effective date and proposed expiration date.
Rate
Enter the manual Rate for the classification from the appropriate state manual.
Estimated Annual Premium
The rate is applied (multiplied) to every $100 of remuneration (payroll) and the result is the Estimated Annual Premium for
this classification.
Total
Add the amounts for each class to obtain the Total estimated pre-modified premium.
Experience Modification
Enter the Experience Modification factor in this space if the applicant is subject to experience rating. Generally, the
business has to have been operating for at least two years under present ownership and the premium must meet or
exceed a level which is established by the state to qualify for experience rating. If more than one modification factor
applies to the applicant, explain the details in the Remarks section. Attach the most recent experience rating data sheet if
you have a copy.
Modified Premium
Enter the amount resulting from multiplying the Total estimated pre-modified premium by the Experience Modification
factor.
Premium Discount
If a Premium Discount is applicable, enter the total dollar amount to be deducted from the modified premium. This
generally applies only if the policy premium exceeds $5,000. Refer to the state manual.
Expense Constant
Enter the applicable charge for the state Expense Constant. This charge is no longer limited only to small accounts where
it was intended to recover issuing and servicing costs.
Total Estimated Annual Premium
Enter the Total Estimated Annual Premium resulting from applying all modifications, discounts, and other rating criteria to
the Total estimated pre-modified premium.
Minimum Premium
The Minimum Premiums are found on state rate sheets opposite the class code; they apply by policy. If two or more
classifications with different Minimum Premiums are included on one policy, the highest usually applies. Please check the
appropriate rate manual.
Deposit Premium
Enter the dollar amount due the insurer at inception.
Specify Additional Coverages/Endorsements
Use this area to explain the applicant's exposures and payroll for any other coverage requested, including U.S.L. & H. and
Voluntary Compensation.
INDIVIDUALS INCLUDED/EXCLUDED
Sole proprietors and a maximum of three partners or corporate officers may elect to be exempted from coverage if they
are actively engaged in the construction industry. For any clarification of this subject you should contact the Bureau of
Compliance, at (904) 488-2713. Those persons with exemptions and inclusions signed and approved prior to enactment
of the law signed on January 25, 1991, should review their status and take appropriate actions to reject or continue
coverage.
Certain other positions within an organization, such as sole proprietors and partners, may not be covered by the
applicable Workers Compensation Law, but they may be permitted to elect to be brought under it. Conversely, executive
officers of corporations are generally considered employees, but may have the option to elect to be excluded from
coverage. Refer to the NCCI or applicable state Workers Compensation manual for the details. Since the inclusion or
exclusion affects coverage and premium, this section must be fully completed.
Name
Enter the name of the partner, executive officer or relative for purposes of indicating whether or not the individual is to be
covered by the policy.
Date of Birth
This individual's birth date.
Title/Relationship
Provide either the individual's title within the organization or relationship to the organization's owners.

Ownership %
Indicate the percentage of ownership the individual has in the organization, if applicable.
Duties
Briefly identify the duties of the individual. This will help to ascertain the proper classification.
Inc/Exc
Indicate if the individual is to be Included or Excluded under the policies coverages.
Class Code
Enter the Class Code for individuals to be included based on the duties described above.
Remuneration
Provide the estimated annual Remuneration for individuals to be included. Minimum or maximum remunerations may be
applicable based on the state law. (Be sure to enter the class code and remuneration in the Rating Information section of
the application for all included individuals).
PRIOR CARRIER INFORMATION/LOSS HISTORY
Either this section should be completed or a loss history report should be attached covering the last five years. If a loss
history report is attached, enter "See Attached Report" in the first Carrier & Policy Number section.

Year
Enter the Year or policy period. The most recent policy period should be listed first.
Carrier & Policy Number
Provide the carrier's name and policy number for the corresponding policy.
Annual Premium
The Annual Premium for the corresponding policy. Use the final audited premium when that is available.
Mod.
If the risk was subject to experience rating, enter the Experience Modification in this column for the corresponding policy.
# Claims
Enter the total number of Claims for the corresponding policy term.
Amount Paid
This is the total dollar amount actually paid for all open or closed claims.
Reserve
Enter the amount in Reserve for any open claims, along with the valuation date of the reserves. Estimates are acceptable;
enter zero if none.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
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.
Example: location #1 may be the general offices while location #2 may be 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 phraseology 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."
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 and indicate if of 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
Applicant's clients (for example: general public, dentists, banks)
EMPLOYEES
List all the names of the employees on the payroll. If the company has more than four employees, an "X" must be placed
in the box labeled "Check if a list of additional employee names is attached".
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes" response.

1. Does applicant own, operate or lease aircraft/watercraft?
Describe any Aircraft exposure with the exception of commercially scheduled flights. Name any employee who is a
licensed pilot and explain his or her duties and the type of license held. Describe any Watercraft which is owned, leased,
or operated, and explain its use.
2. Do operations involve storing, treating discharging, applying, disposing, or transporting of hazardous
material? (e.g. landfill, asbestos, wastes, fuel tanks, etc.)
Explain the exposure and the precautionary measures implemented to handle hazardous materials. The exposures would
include: flammable, explosives, radioactivity, caustics, or fumes and their storing, disposing, or transporting, or any other
material with a known occupational disease exposure.
3. Any work performed underground or above 15 feet?
Provide the frequency and explain the nature of such work, and the number of people involved.
4. Any work performed on barges, vessels, docks, bridge over water?
Describe any work on Barges, Vessels or Docks and indicate the location, frequency, and number of people involved.
5. Is applicant engaged in any other type of business?
List all other businesses and identify the carrier for that business's workers compensation coverage.
6. Are sub-contractors used?
Explain the nature and frequency of any subcontracted work. Are Certificates of Insurance required?
7. Any work sublet without certificates of ins.?
Describe the nature and frequency of the work subcontracted and indicate if the classifications and remuneration for such
work have been included in the Rating Information section.
8. Is a formal safety program in operation?
Describe the safety program. Does it involve meetings, classes, incentives?
9. Any group transportation provided?
Is a van pool program in effect? Does the employer shuttle employees to job sites? What type of conveyance is used?
How many employees are transported? How often? Over what distance? Provide details.

10. Any employees under 16 or over 50 years of age?
If Yes, specify the number of employees in each category and the duties they perform.
11. Any part time or seasonal employees?
How many employees? How many hours do they work? At what time of the year are they employed? What are their
duties?
12. Is there any volunteer or donated labor?
Explain the circumstances under which volunteer labor is used and the nature of the work.
13. Any employees with physical handicaps?
Describe the nature of the work and explain the circumstances under which physically handicapped workers are
employed. Indicate the number of employees and the type of handicaps. Is the applicant involved in a special community
program for handicapped people? If eligible, has the employee been registered in a second injury fund?
14. Do employees travel out of state?
Describe the nature of the travel and indicate the number of employees, frequency and mode of transportation.
15. Are athletic teams sponsored?
Describe the nature of the athletic activities and indicate the number of employees involved (if any). Indicate whether the
applicant provides an accident and health policy to cover athletic activities. This may include company, school, or
community teams or leagues. Example: Little League.
16. Are physicals required after offers of employment are made?
Are all employees required to undergo a physical examination after they have been made an offer for employment?
Describe the extent of the physical examination and indicate which applicants are required to take them.
17. Any other insurance with this insurer?
If other insurance policies of any kind are in force with this insurer, identify the coverages, policy numbers, and terms. It
may also be desirable to note other submissions for this account that are under consideration.
18. Any prior coverage declined/canceled/non-renewed (last 3 yrs.)?
The mere fact that such action occurred is not as important as the reason for the action. Provide all the details.
19. Are employee health plans provided?
Indicate the carrier name and policy number for the health plan.
20. Is there a labor interchange with any other business/subsidiary?
Indicate who the interchange is being done with and their relationship to the insured.
21. Do you lease employees to or from other employers?
For leasing employees indicate who you are leasing them to. For leased employees indicate who you are leasing them
from and if you have a certificate of insurance from the lessor.

22. Do any employees predominantly work at home?
Indicate who works at home and what their hours of operation are.
23. What are your estimated annual revenues?
This requires a dollar amount, not a yes/no response. Enter the estimated revenues (income) for the next year.
Inspection
Enter the name and full telephone number of the individual who should be contacted in order for the insurer to conduct a
physical inspection survey.
Accounting Records
The insurer may need to contact the applicant for audit purposes. Please provide the name and full telephone number of
the individual responsible for such records.
Claims Information (Phone and Name)
Provide the telephone number and name of the person the insurer is to contact regarding any potential claims inquiries.
Remarks
Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.
I understand that as the employer, . . .
This section spells out the conditions required of the employer in securing Florida Workers Compensation Coverage.

Applicant's Signature
The applicant must sign and date the form in the presence of a Notary Public.
Producer's Signature
The producer's signature and date the form is signed.
Notary Public Signature
A Notarized signature is required for the applicant's signature only (not the producer's signature).
FL Workers Compensation/Monthly Change 175-FL (11/2001)

The ACORD Florida Workers Compensation Monthly Change Sheet is to be used on new and renewal policies. This form
is to be used to request monthly changes to the Florida Workers Compensation application. The form must be used as a
result of the passing of Section 3 of CS/HB 3809 (Ch. 90-201) Laws of Florida which was signed into effect July 1, 1990.

The form is designed to be completed by the applicant. It must be mailed to the company writing the Florida Workers
Compensation coverage on a monthly basis if a change is to be made. If there are no changes, a monthly change sheet is
not mandatory.

This includes policies written by out of state agents that have covered Florida exposure. It is expected that all carriers will
be uniformly using this monthly change sheet at this time.

Copies of the monthly change sheet shall be retained for a minimum of three years.

IDENTIFICATION

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

Producer
Producer's name, address and telephone number.

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.

Underwriter
This field is used to direct the application to a specific company underwriter by name.

Applicant Name
Enter the full name of the applicant as it appears on the original Florida Workers Compensation Application.

Policy Number
Number assigned by the company for the Florida Workers Compensation policy.

Policy Eff. Date
The Effective Date is the date on which the terms and conditions of the policy began.

Pol. Exp. Date
The Expiration Date is the date on which the terms and conditions of the policy will expire.

INSURANCE

The address of the insurance company writing the Florida Workers Compensation policy. The company name, address
and zip are entered into the white space. This form may be folded at the designated line and mailed in a window
envelope.

APPLICANT NAME

Enter the new 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.
Example: 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
are not legal entities.

MAILING ADDRESS

The new address at which the First Named Insured is to receive all mail.

LOCATIONS
   List
   The locations that have changed since the initial application or the last monthly change sheet. Place an "X" beside
   add to enter a new location, or "X" beside delete to delete a location no longer in use. Provide the physical address,
   not post office boxes. Place an "X" beside Yes or No to show if the applicant is a long term employee leasing
   company. Example: Staff Leasing. If yes, then the name of the client and the address where the employees will be
    located must be included.
RATING INFORMATION

Place an "X" for the addition of a new location or class code at the location, "X" for the deletion of an unused location or
class code, or "X" if change in class code, categories, duties, classifications, number of employees or estimated
remuneration for present policy period.
     Street, City, State
     The information on this change sheet must match the information provided on the original application or location
     information on this form.

     Location Number
     Enter the location number for each entry which corresponds to the locations listed in the Locations section above.

     Class Code
     Enter the Classification Code which best describes the business of the applicant. It is important to remember that it is
     the business of the employer, not the individual employees, that is being classified. Consult the proper rating manual
     to determine the code. Rating bureaus may exercise control over classification assignment.

     Company Use
     Leave this space blank. The insurer may use this space for special computer codes, to identify the applicable class
     description wording.

     Categories, Duties, Classifications
     A single class code may include several related descriptions of activities/operations. Therefore, it is extremely
     important to enter the specific classification description or, at the very least, a brief statement regarding the duties of
     the employees. Enter as much information as necessary to avoid misclassifying the operations.

     No. of Employees
     Indicate the Number of Employees to whom the classification applies. The average number is sufficient when the
     total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear
     adequate.

    Estimated Remuneration for Present Policy Period
    Total estimated payroll expected as a result of this change for the period between the effective date and expiration
    date.
INDIVIDUALS INCLUDED/EXCLUDED

Add if a new partner, officer, relative; delete if partner, officer, relatives employment is terminated, or change if the partner,
officer, relatives title/relationship, ownership %, duties, inc/exc, class code or remuneration has changed since the original
application or previous monthly change sheet.
      Name
      Enter the name of the partner, executive officer or relative for purposes of indicating whether or not the individual is
      to be covered by the policy.

     Date of Birth
     This individual's birth date.

     Title/Relationship
     Provide either the individual's title within the organization or relationship to the organization's owners.

     Ownership %
     Indicate the percentage of ownership the individual has in the organization, if applicable.

     Duties
     Briefly identify the duties of the individual. This will help to ascertain the proper classification.

     Inc/Exc
     Indicate if the individual is to be Included or Excluded under the polices coverages.

     Class Code
     Enter the Class Code for individuals to be included based on the duties described above.

     Remuneration
     Provide the estimated annual Remuneration for individuals to be included. Minimum or Maximum remunerations may
     be applicable based on the state law.

   (Be sure to enter the class code and remuneration in the Rating Information section of the application for all included
   individuals).
EMPLOYEES
Add new employee, delete employee if employment has been terminated, or change due to the name provided on the
original application or previous submission of the change sheet is being changed; example due to marital status. If your
company has more than six changes in employee names, an "X" must be placed in the box labeled "Check if a list of
additional employee names is attached".

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS

Used to describe a revision in the operations and should include an explanation for the revision.

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.
Example: location #1 may be the general offices while location #2 may be 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 phraseology from the Commercial Lines Manual or Workers Compensation Manual; it does 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."

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 and indicate if of 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
      •    Applicant's clients (for example, general public, dentists, banks)
Remarks
Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.

I understand that as the employer, . . .

This section spells out the conditions required of the employer in securing Florida Workers Compensation Coverage.

Applicant's Signature
The applicant's signature and date the form is completed.

Producer's Signature
The producer's signature and date the form is completed.




Garage and Dealers 138

Alabama Garage and Dealers, Coverages/Limits Section ACORD 138 AL (2/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 AL.
Alaska Garage and Dealers, Coverages/Limits Section ACORD 138 AK (4/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 AK.
Arizona Garage and Dealers, Coverages/Limits Section ACORD 138 AZ (3/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 AZ.
Arkansas Garage and Dealers, Coverages/Limits Section ACORD 138 AR (10/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 AR.

California Garage and Dealers, Coverages/Limits Section ACORD 138 CA (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 CA.
Colorado Garage and Dealers, Coverages/Limits Section ACORD 138 CO (1/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 CO.
Connecticut Garage and Dealers, Coverages/Limits Section ACORD 138 CT (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 CT.
Delaware Garage and Dealers, Coverages/Limits Section ACORD 138 DE (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 DE.
District of Columbia Garage and Dealers, Coverages/Limits Section ACORD 138 DC (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 DC.
Florida Garage and Dealers, Coverages/Limits Section ACORD 138 FL (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 FL.
Georgia Garage and Dealers, Coverages/Limits Section ACORD 138 GA (2/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 GA.

Hawaii Garage and Dealers, Coverages/Limits Section ACORD 138 HI (2/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 HI.

Idaho Garage and Dealers, Coverages/Limits Section ACORD 138 ID (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 ID.
Illinois Garage and Dealers, Coverages/Limits Section ACORD 138 IL (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 IL.

Indiana Garage and Dealers, Coverages/Limits Section ACORD 138 IN (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 IN.
Iowa Garage and Dealers, Coverages/Limits Section ACORD 138 IA (8/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 IA.

Kansas Garage and Dealers, Coverages/Limits Section ACORD 138 KS (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 KS.
Kentucky Garage and Dealers, Coverages/Limits Section ACORD 138 KY (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 KY.
Louisiana Garage and Dealers, Coverages/Limits Section ACORD 138 LA (6/98)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 LA.
Maine Garage and Dealers, Coverages/Limits Section ACORD 138 ME (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 ME.
Maryland Garage and Dealers, Coverages/Limits Section ACORD 138 MD (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 MD.

Massachusetts Garage and Dealers, Coverages/Limits Section ACORD 138 MA (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 MA.
Michigan Garage and Dealers, Coverages/Limits Section ACORD 138 MI (4/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 MI.
Minnesota Garage and Dealers, Coverages/Limits Section ACORD 138 MN (1/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 MN.
Mississippi Garage and Dealers, Coverages/Limits Section ACORD 138 MS (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 MS.
Missouri Garage and Dealers, Coverages/Limits Section ACORD 138 MO (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 MO.
Montana Garage and Dealers, Coverages/Limits Section ACORD 138 MT (8/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 MT.
Nebraska Garage and Dealers, Coverages/Limits Section ACORD 138 NE (8/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 NE.
Nevada Garage and Dealers, Coverages/Limits Section ACORD 138 NV (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 NE.

New Hampshire Garage and Dealers, Coverages/Limits Section ACORD 138 NH (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 NH.
New Jersey Garage and Dealers, Coverages/Limits Section ACORD 138 NJ (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 NJ.
New Mexico Garage and Dealers, Coverages/Limits Section ACORD 138 NM (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 NM.
New York Garage and Dealers, Coverages/Limits Section ACORD 138 NY (4/98)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 NY.
North Carolina Garage and Dealers, Coverages/Limits Section ACORD 138 NC (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 NC.

North Dakota Garage and Dealers, Coverages/Limits Section ACORD 138 ND (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 ND.
Ohio Garage and Dealers, Coverages/Limits Section ACORD 138 OH (3/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 OH.

Oklahoma Garage and Dealers, Coverages/Limits Section ACORD 138 OK (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 OK.
Oregon Garage and Dealers, Coverages/Limits Section ACORD 138 OR (7/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 OR.
Pennsylvania Garage and Dealers, Coverages/Limits Section ACORD 138 PA (9/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 PA.
Rhode Island Garage and Dealers, Coverages/Limits Section ACORD 138 RI (3/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.
The specific differences in this state are the same as shown above for ACORD 137 RI.

South Carolina Garage and Dealers, Coverages/Limits Section ACORD 138 SC (4/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 SC.

South Dakota Garage and Dealers, Coverages/Limits Section ACORD 138 SD (2/97)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section.
The specific differences in this state are the same as shown above for ACORD 137 SD.
Tennessee Garage and Dealers, Coverages/Limits Section ACORD 138 TN (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 TN.
Texas Garage and Dealers, Coverages/Limits Section ACORD 138 TX (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 TX.

Utah Garage and Dealers, Coverages/Limits Section ACORD 138 UT (1/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 UT.

Vermont Garage and Dealers, Coverages/Limits Section ACORD 138 VT (1/2001)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included.

Use this form with ACORD 128, Garage and Dealers Section.

The specific differences in this state are the same as shown above for ACORD 137 VT.

Virginia Garage and Dealers, Coverages/Limits Section ACORD 138 VA (10/98)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 VA.
Washington Garage and Dealers, Coverages/Limits Section ACORD 138 WA (8/2000)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 WA.
West Virginia Garage and Dealers, Coverages/Limits Section ACORD 138 WV (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Use this form with ACORD 128, Garage and Dealers Section. The specific differences in this state are the
same as shown above for ACORD 137 WV.
Wisconsin Garage and Dealers, Coverages/Limits Section ACORD 138 WI (4/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 WI.
Wyoming Garage and Dealers, Coverages/Limits Section ACORD 138 WY (3/96)
Use this form to collect the coverage, limits and premium information necessary to write Garage and Dealers insurance in
this state. Required disclosure and coverage acceptance or rejection information is also included. Use this form with
ACORD 128, Garage and Dealers Section. The specific differences in this state are the same as shown above for
ACORD 137 WY.
Garage and Dealers Section 128 (3/2001)

This guide provides the user with basic instructions for completing the
ACORD Garage & Dealers Section. This form has been designed to
handle the basic underwriting needs for automobile service operations
and automobile dealers.

Space is provided to enter driver information for up to eight drivers. For
additional drivers, ACORD 163, Driver Information Schedule, can be
attached.

Insurance coverage, "no fault" and uninsured/underinsured motorists
coverages in particular, varies widely from state to state. In addition,
there are numerous state-specific requirements that apply to Garage and
Dealers applications. ACORD 128 cannot address these various unique
specifications. Therefore, state specific forms, ACORD 138, have been
developed to respond to these requirements. Use the ACORD 138 for
your state to provide coverages/limits information, as well as the
required disclosure and other data unique to the state. See the State
Forms section of this Guide for more information.

This form was alsodesigned to be used in conjunction with the
Commercial Insurance Application - Applicant Information Section
(ACORD 125) and the Vehicle Schedule (ACORD 129). Please turn to
the chapters on these forms for specific information on completing
them.

Many states require supplements to all auto applications, to provide
specific coverage explanations or to allow applicants to accept or reject
certain coverages. In some cases, the applicant must be allowed to select
among various options. In others, laws or regulations require disclosure
of information pertinent to auto insurance.

ACORD has provided the necessary supplements in most states. Refer
to the State Forms section of this Guide.

IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the
Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it.
Many companies separate the applications by line of business for rating purposes. Not completing
this portion of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address and telephone number.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

Proposed Eff. Date
Enter the Effective date on which the terms and conditions of the policy will commence.

Proposed Exp. Date
Enter the Expiration date on which the terms and conditions of the policy will terminate
unless renewed.

Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
40-30-30).

Audit
Use this field to indicate the audit term for policies that are subject to periodic audit. If the
audit period is known, enter the code:
A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other

BUSINESS/VEHICLE STORAGE INFORMATION
This section is used to identify the type of insurance necessary for the applicant.

Auto Service Operations or Trailer Sales
Place an "X" in all applicable boxes to identify the type of operations in which the applicant
is involved.

Auto Dealers
Indicate if the dealership is franchised, deals in one or more specific lines of cars such as
Ford or GM, or if it is a non-franchised dealer. Indicate the percentage of vehicle style in
relation to total inventory.

Vehicle Storage
Indicate where the applicant's vehicles are stored.

Location Number
Enter the location number as it relates to the numbers found on the ACORD 25. For each
location, identify where the vehicles are stored.

Building
Vehicles are stored within a building.

Standard Open Lot
The lot is enclosed by walls or fences at least six feet in height, with openings securely
locked when unattended.

Non-Standard Open Lot
The lot is either an open lot or an unroofed space and the building is not securely enclosed
or locked when unattended.

COVERAGES/LIMITS

Covered Auto Symbols
Garage or Dealers policies use numeric symbols on the policy declarations to indicate the
type(s) of vehicles for which coverage is in effect. Be sure to place an X in the appropriate
box for each type of coverage. Only those symbols specified for a coverage may be used.
Symbols 21 through 26 provide fleet automatic coverage. Symbol 21 includes Hired and
Non-Owned auto coverage. If symbol 21 is not used and Hired Auto (symbol 28) or Non-Owned
Auto (symbol 29) coverage is desired, those symbols must be checked.
The symbols indicate the automobiles to which each coverage applies. The symbol
"triggers" the coverage. For exact policy definitions of the symbols, please refer to the
company's policy declarations page.

Symbol 21 - Any Auto
Can only be used for Liability insurance and/or Medical Payments insurance. Its use
provides coverage for any auto the insured will have contact with, including owned & non-owned
& hired vehicles. It includes coverage for non-owned autos, no-fault, uninsured
motorists or physical damage insurance. Damage to customers' autos is provided by using
Symbol 30, Garage Keepers Insurance.

Symbol 22 - All Owned Autos
Provides coverage for owned autos only and includes automatic coverage for autos you
newly acquire. This symbol cannot be used to provide liability coverage for dealers, but can
be used to provide liability for non-dealers. It can also be used for dealers and non-dealers to
provide any of the physical damage coverages or uninsured motorist's insurance.

Symbol 23 - Owned Private Passenger Autos Only
Provides coverage for owned private passenger autos only and includes automatic coverage
for private passenger autos you newly acquire. It can be used for dealers and non-dealers to
provide uninsured motorist's insurance and physical damage coverages. It may also be used
to provide medical payments insurance for non-dealers.

Symbol 24 - Owned Autos Other Than Private Passenger
Provides coverage for owned autos other than private passenger autos and includes
automatic coverage for autos you newly acquire, other than private passenger autos. It is not
limited to trucks or truck tractors, but also includes taxis, motorcycles, emergency vehicles,
trailers and buses. Any vehicle which is not a private passenger auto fits within this symbol.

Symbol 25 - Owned Autos Subject to No-Fault Laws
Applies to owned autos where no-fault is required by law including automatic coverage for
autos you newly acquire.

Symbol 26 - Owned Autos Subject to Uninsured Motorist Laws
Applies to owned autos where there is a compulsory uninsured motorist's law including
automatic coverage for autos you newly acquire where rejection of UM is not permitted by
law.

Symbol 27 - Specifically Described Autos
Provides coverage for scheduled autos only with no automatic coverage for autos you newly
acquire. Use Vehicle Schedule, ACORD 129, to provide information on individual
vehicles.

Symbol 28 - Hired Autos Only
Provides coverage only for autos leased, hired, rented or borrowed by the named insured.
This does not include autos owned by employees or members of their families.

Symbol 29 - Non-Owned Autos Used in Garage Business
Provides liability coverage for autos not owned by the named insured but used in
connection with the garage business. This includes autos owned by employees.

Symbol 30 - Autos Left for Service/Repairs/Storage
Provides coverage for customer's autos which are in the care, custody, and control of the
named insured. It provides garage keepers insurance for dealers and non-dealers when autos
are left for service, repair or storage.

Symbol 31 - Autos On Consignment and Dealer Autos
Provides physical damage coverages for autos consigned to dealer or held for sale in
possession of non-dealer.

Symbol 32 - Company Use
This is a company specific code. It can be used to provide coverage when no other symbol
applies (e.g., to provide coverage for Long Term Leased Vehicles). It will be necessary to
write in this symbol if used.

Coverages & Limits - Use ACORD 138

AUTO DEALERS OPERATORS

The Insurance Services Office developed the Dealers Class Plan to rate liability and collision
coverages. The basis for rating involves assigning rating factors and rating units for employees and
non-employees.

Record by location the number of persons within each category. If rating the policy, refer to the
Commercial Lines Manual for additional information.

DEALERS PHYSICAL DAMAGE

Indicate if the autos to be covered are New or Used for each coverage and check the interest to be
insured.

NON-DEALERS PREMISES & OPERATIONS

Payroll is the basis for rating this coverage. Enter the location number as it appears on the ACORD
125, the estimated annual remuneration and number of employees at each location. See the
appropriate manual for the payroll limitations that apply.

DRIVER INFORMATION
This section is used to collect information on all the drivers that will be covered under this
account. The driver list should include any family member who will be driving company vehicles
and employees who regularly drive their own vehicles for company business.

Name
Enter the driver's full name. If the company requires the address, enter it as well.

Sex
Enter F for female, M for male.

Marital Stat
Enter the marital status for each driver. Examples:

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

Date of Birth
Enter the driver's birth date.

Yrs Exp
Enter the number of years of driving experience for each driver.

Year Licensed
Enter the year in which the driver was first licensed.

Driver's License Number/Soc. Sec. #
Enter the complete driver's license number. If a license number is unavailable, enter the
driver's social security number.

State Lic.
Enter the state in which the license was issued.
Date Hire
Enter the date of hire for each driver.

Use Vehicle and %
Enter the vehicle number that this driver primarily uses and the percentage of driving done
by this driver in this vehicle.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "Yes"
response. The overview below lists the expected information that should be added to the remarks
section for "Yes" responses.

1. Does applicant rent, lease or loan vehicles to others?
List the frequency, who receives the vehicles and if this is part of the normal business
operations. Indicate if insurance is provided.
2. Does applicant pick-up or deliver customer's cars?
Indicate how many cars per day, and how the employee commutes to the location.

3. Does pick-up or delivery exceed 50 miles?
Indicate the radius of this operation if it exceeds 50 miles, and how often.

4. Is tire recapping or retreading performed?
List the percentage of gross sales this operation represents. Indicate if the applicant sends
out for retreads, or if the applicant performs the operation.

5. Does applicant own or sponsor a car for racing?
Provide a description of the car. Indicate how frequently the car is raced, who drives the car
and how the car is transported.

6. Does applicant handle butane, propane or other gases?
State what type of storage facilities are used, what gases are involved and if they are for sale
to the general public.

7. Are any vehicles furnished for groups or organizations?
Identify the group (school, hospital, church, or civic organization) to which the vehicle is
loaned. Indicate if there is a charge.

8. Does applicant perform spray painting or welding?
Indicate how frequently this type of operation is performed, and if the applicant has
approved booths or ventilated spray areas. Describe the type of welding or painting job
handled and where in the building each job is located.

9. Does applicant drive away or haul away vehicles from factory distributing
point or other dealers?
Describe circumstances causing drive-aways. Indicate if this is a regular operation, how
many cars are involved, and give the radius of operation.

10. Does applicant dismantle autos or have salvage operation?
Describe this type of operation completely. If there is a salvage operation on premises, so
indicate.

11. Does applicant use tow trucks?
Indicate how many trucks are owned or used by the applicant and describe towing
operations. These trucks may be listed on ACORD 129 Vehicle Schedule and attached to
the Garage Section.

12. Do employees regularly use their own autos on company business?
List who, what vehicle and for what operations.

13. Does applicant park customers' vehicles on public streets or off
premises?
Describe any type of off-premises parking of vehicles.

14. Is a charge made for parking?
Indicate how much is charged, how many attendants are on duty, and the hours of
operation. Indicate if employees drive vehicles or if customers self-park.

15. Any private protection systems?
Describe all such systems in detail.

16. Is applicant involved in any "non-garage" operations?
If a retail operation, mini-mart, liquor store, or other operation is run on the premises, list
the operation and annual gross sales from this portion of the business. Indicate if there is
any insurance for this operation.

17. Does applicant perform any road emergency services?
Indicate if the applicant is on call for any highway or other emergencies, and if towing
operations are available around the clock.

18. Any drivers with moving traffic violations?
Give driver name and number, date, type and place for each conviction. Enter the number
of years reviewed, in accordance with the company's and state's requirements.

ADDITIONAL INTEREST

Use this section to collect information on any additional interest or receiver of Certificates of
Insurance.

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.

Interest in Item
Use this section to indicate what the additional interest has an interest in. Examples:
     •     For a Mortgagee, list the location and building number.
     •     For an automobile lienholder, list the vehicle number.

If the additional interest has an interest in multiple items, such as a lienholder on multiple
vehicles, list all of the numbers associated with the additional interest.

Certificate Holder
If a Certificate of Insurance is required, check this box.

Reference Number
List any reference number, such as a loan number, that may be beneficial in tying the
additional interest to item.

REMARKS
Use this section to provide any additional information required for underwriting or rating.




General Liability Notice of Occurrence/Claim 3 (1/2002)

Use ACORD 3 to report both commercial and personal liability losses.

IDENTIFICATION SECTION

Date
Month/day/year on which this form is completed.

Producer
Producer's name and address.

Phone (A/C, No, Ext)
Producer's telephone number.

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

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

Agency Customer ID
Customer's identification number assigned by the agency.

Notice of Occurrence / Notice of Claim
Mark the appropriate block. Notice of Occurrence applies to both occurrence policies and to the report of incidents for
Claims Made policies. The Notice of Claim applies only to Claims Made policies and is used for the reporting of suits or
actual claims filed against the insured.

Date of Occurrence and Time
For Occurrence policies, enter the date and time of the incident. For Claims Made policies, enter the date and time that
the insured discovered the event, incident, or accident which might later result in a claim being made. This date is
important for establishing the applicable policy in extended reporting period/movement of retro date situations.

* After a Claims Made policy has been terminated, any claim may be valid if the incident occurred during the life of the
policy and was reported within 60 days of its termination.

Date of Claim
This applies only to Claims Made policies. It is the date on which the actual suit was brought or claim filed against the
insured. In many cases, this will be the same date that the insured first becomes aware of the incident, so both dates can
be the same.

Previously Reported
Indicate if this is the first report on the loss that has been given to the company, whether written or by telephone. If it is not
the first, list in the remarks section when other report(s) have been made.

Effective Date
Date on which the terms and conditions of the policy commenced.

Expiration Date
Date on which the terms and conditions of the policy will or have expire(d).

Policy Type
Indicate whether the policy is written on an Occurrence or Claims Made basis.

Retroactive Date
This applies to Claims Made policies only. Enter the retroactive date indicated on the policy.

Company
Name of the applicable insurance company and its' NAIC number. Do not use group names, use the actual name of the
company within the group to which you are sending the loss notice.

Miscellaneous Info
Miscellaneous Information. Use this field to list site and location codes for large accounts or to enter the claim number on
a phone-in report.

Policy Number
Number assigned by the insurance company for the policy.

Reference Number
Insured's claim number or other reference number to identify this notice.

INSURED

Name & Address
Enter the name, mailing address and social security number (or Federal Employer Identification Number (FEIN) if
applicable,) of the insured as found on the declarations page of the policy.

Residence Phone
For an individual, the home telephone number, including area code, of the insured.

Business Phone
The business telephone number, including area code and extension of the insured.

CONTACT

Contact Insured
If the individual to contact is the same as the insured, check this box and leave blank the areas for contact name, address
and phone number.

Person to Contact
Name and address of the individual who is to be contacted as a representative of the insured on all subsequent business
relating to this incident. No entry is needed if the "Contact Insured" option is checked.

Enter the home telephone number, including area code, of the contact named above. If it is the insured, leave this blank.

Business Phone
Enter the business telephone number, including area code and extension, of the contact. If it is the insured, leave this field
blank.

Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).

When
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).

OCCURRENCE

Location of Occurrence
Give the physical location of the occurrence. If the insured has multiple locations on the policy, include the policy location
number and building number (e.g., insured's home or Loc 3, BLd 2; 151 Main St).

Authority Contacted
Enter the name of the municipal or county police or fire department to which the loss was reported. Include the precinct or
station number if available.

Description of Occurrence
Describe the incident resulting in a potential loss to the insured.

POLICY INFORMATION

Use this section to list the policy limits and deductibles as printed on the declarations page for the insured.

Coverage Part or Forms
Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, include a brief
description of the endorsement.
Limits
Enter the limits for each applicable category. If coverage is not provided, enter N/A. Abbreviations are:

PROD./COMP-OP AGG.. . . . . . . Products/Completed Operations
Aggregate
PERS. & ADV. INJ . . . . . . . . . . . Personal and Advertising Injury

Deductible
Enter the dollar amount of the deductible and indicate whether it applies on a Per Claim or Per Occurrence basis.

Deductible Type
If the deductible applies to Property Damage (PD) or Bodily Injury (BI) check the appropriate box. For Combined Bodily
Injury and Property Damage deductible, check PD & BI.

Umbrella/Excess
Indicate if such a policy is in force by checking the appropriate box.

Carrier
The name of the Umbrella/Excess policy/carrier.

Enter the umbrella or excess policy limits. Indicate if limits apply on a "per claim" or "per occurrence" basis. Also show the
applicable self insured retention or deductible.

TYPE OF LIABILITY

This section is used to collect information about the type of exposure which has resulted in the damage or injury reported
in this notice.

Premises: Insured is
Indicate the relationship of the insured to the premises by placing an "X" in the appropriate box. List the type when "Other"
is checked.

Type of Premises
Give a brief description of the premises (e.g., mercantile with apartments).

Owner's Name & Address
If other than the insured, provide the owner's name and address. If this is the insured, enter "insured."

Owner's Phone
If other than the insured, provide the owner's telephone number, including area code and extension.

Products: Insured Is
For products coverage, indicate the business the insured is in by placing an "X" in the appropriate box. List the type when
"Other" is checked.

Type of Product
Give a brief description of the insured's product (e.g., automobile parts, sales, appliances repair).

Manufacturer's Name & Address
If other than the insured, enter the manufacturer's name and address. If this is the insured, enter "insured."

Manufact Phone
If other than the insured, list the manufacturer's telephone number, including area code and extension.

Where Can Product Be Seen?
Indicate where the product can be inspected by the adjuster. If other than the insured's address, include the address.

Other Liability Including Completed Operations
Provide any additional pertinent information on the liability exposure. Also list any additional liability insurance carried by
the insured. Include carriers, policy numbers, and limits.

INJURED/PROPERTY DAMAGED

Use this section to collect information on any injured party or any property damage.

Name & Address
Enter the name and address of any injured party, or owner of damaged property.

Phone
Enter the telephone number, including area code, of any injured party or owner of damaged properties.

Age
Give the age of any injured person.

Sex
Indicate by "F"-Female or "M"-Male.

Occupation
Enter a brief description of the injured person's occupation.

Employer's Name & Address
Enter the name and address of any injured person's employer.

Phone
Enter the employer's telephone number, including area code and extension.

Describe Injury
Give a brief description of the injury. If fatal, check the available box.

Where Taken
Indicate where the injured was taken (e.g. St. Luke's Hospital, home).

What Was Injured Doing?
Briefly describe the activities of the injured person when the accident took place.

Describe Property
Give a brief description of any damaged property (e.g. printer # 31).

Estimate Amount
If known, give an estimate for the cost of repair to the damaged property.

Where Can Property Be Seen?
Indicate where the damaged property is located so the adjuster can inspect it.

When Can Property Be Seen?
Indicate the best time of day to inspect the damaged property (e.g., evenings, days, noon to 3:00 P.M.).

WITNESSES

Use this section to identify any witnesses to the incident.

Name & Address
Enter the name and address of any witness.

Business Phone
Enter the witness's business telephone number, including area code and extension.

Residence Phone
Enter the witness's residence phone number, including area code.

Remarks
List any other additional information that will assist in properly reporting and settling this claim.

Reported By
Indicate the name of the individual who reported the loss.

Reported To
Indicate the name of the individual within the agency or company to whom this loss was reported.

Signatures of Producer and Insured
This form should be signed by the producer and the insured.

* Important state information is on the second side of this form.




General Liability Section 126-N (3/93)
This edition of the General Liability Section has, in most cases, been superseded by the ACORD 126-S. The ACORD
126-N is still used for risks containing commercial liability coverages not using the ISO policy simplification format. All
other risks should use the ACORD 126-S. The instructions within this chapter contain only information on completing data
(within the Coverage/Limits section and the Schedule of Hazards section) that differs from the data on the ACORD 126-S.
For instructions on the additional sections of this form and general information on using the General Liability Section,
please refer to the chapter on the
COVERAGES/LIMITS
Coverages
Indicate all desired coverages.
Comprehensive General Liability
Indicate if Comprehensive General Liability coverage is being requested.
Owners, Landlords & Tenants
Indicate if this coverage was requested.
Manufacturers & Contractors
Indicate if the coverage is being requested.
Storekeepers Liability
This coverage is written on a combined single limit basis and requires a separate limit for Premises Medical.
Owners & Contractors Protective
Indicate if this coverage is being requested.
Contractual
Indicate whether coverage is to be provided on a Blanket basis or for Designated contracts. Describe all agreements in
the Contractual section on the reverse side.
Products/Completed Operations
Indicate this coverage if written on either a stand-alone basis or as part of the Comprehensive General Liability coverage.
Options
Indicate all desired coverage options. Available options are:
Broad Form Property Damage - Also, indicate if this coverage will include or exclude Completed Operations.
Broad Form C G L Endorsement - This endorsement differs throughout the industry in terminology and content. Please
  check the company policy.
Include X/C/U - X = Explosion, C = Collapse, U = Underground work.
Fire Legal Liability
Specify the locations to be covered and the limits applicable to each location.
Elevator Collision
Enter the number of elevators if required by the company.
Non-Owned Auto
Indicate the territory and the number of employees in the Other Coverages section. (Coverage is intended only for risks
having incidental auto exposures. It will usually be more appropriate to arrange this coverage under an Auto Policy.)
Property Damage Deductible
Enter the Deductible amount, if any, and indicate whether it will apply Per Claim or Per Occurrence. Bodily injury
deductibles are not used with any frequency, however if one applies, enter the information at the bottom of the Options
section.
Limits
The limits as they are to appear on the policy declarations page.
Bodily Injury
The bodily injury limit for each occurrence and the aggregate limit for all losses occurring during an annual policy period.
The aggregate limit applies only to Products, Completed Operations and Professional Liability.
Property Damage
The property damage limit for each occurrence and, if applicable, the aggregate limit for all losses applying to each project
and occurring during an annual policy period.
Combined Single Limit
The combined single limit of liability, if applicable.
Premises Medical
The limit for each person and the limit for each accident.
Personal Injury
The aggregate limit of liability for all losses occurring during an annual policy period. Check the applicable coverage.
A = False Arrest, Detention or Imprisonment or Malicious Prosecution
B = Libel, Slander, Defamation or Violation of Right of Private Occupancy
C = Wrongful Entry, Eviction or other Invasion of Right of Private Occupancy
Indicate the Insured's participation and if exclusion C is to be deleted.
Other Coverages and/or Endorsements
Enter any additional coverages or endorsements that are desired.
SCHEDULE OF HAZARDS
Complete the Schedule of Hazards in the same manner as documented for the ACORD 126-S. Scheduled classes
should be separated into the following categories:
Premises & Operations
Escalators
The premium basis is per landing.
Independent Contractors
The premium basis is by total estimated annual cost for the work performed by others.
Contractual
The premium basis tracks the number of contracts and the total estimated cost of the contracts.
Products/Completed Operations
The premium basis is based on receipts.




Glass and Sign Supplement 144 (11/94)

This chapter provides basic instructions for completing the ACORD Glass and Sign Supplement which addresses basic
underwriting and rating needs for glass and sign coverages written under an Inland Marine or Property policy.

The applicant should describe the "glass" or "sign" in detail, including lettering, ornamentation, class, mechanical
operation and other important information which aids in the total evaluation of the risk. Applicant Information Section
(ACORD 125). Refer to the chapter on the ACORD 125 for information on that form.
INFORMATION SECTION
Applicant (first Named Insured)
Applicant's name as found on the ACORD 125.
Glass Deductible
For glass coverage, enter the deductible amount desired.
Glass Retention
Amount of liability retained by the insured. If applicable, enter the retention percentage.
Sign
If sign insurance is requested, check the appropriate box to indicate whether full coverage or coverage with a deductible is
desired.
GLASS SCHEDULE
Complete this section and the General Information section for glass coverage.
Premises Number
Premises number where the glass is located. This may also appear on the Application Information Section (ACORD 125).
Building Number
Specific number for the building if more than one building exists at the premises location.
Item Number
List each piece of glass to be scheduled by assigning it an item number. Plates with the same dimensions and description
can be batched under the same number.
Number of Plates
Number of plates of glass to be insured with the same dimensions and description.
Plate Size
Length (horizontal) and width (vertical) of each of plates to be insured. These should be measured in feet and inches. For
odd-sized plates, you may need to compute the area (e.g., the size needed to replace a round piece of glass is a
rectangle large enough to allow the circle to be cut from it).
Description
Detailed description of the glass to be insured. Identify stained glass items and specify lettering, ornamentation, or class.
Describe the type of frame holding each piece of glass and whether or not it is safety glass.
Use and Position
Use and position of glass at each location (e.g., ground floor show windows, ground floor door). This is especially
important for freezer cases and display windows. Indicate what floor the glass is on and whether it is interior or exterior
glass.
Limit of Insurance
Replacement cost of the pane, plus lettering, tape and any other item that increases the value.
SIGN SCHEDULE
Complete this section and the General Information Section for sign coverage.
Premises Number
Premises number where the glass is located. This may also appear on the Application Information Section (ACORD 125).

Building Number
Specific number for the building if more than one building exists at the premises location.
Item Number
Assign an item number to each sign to be scheduled.
Inside/Outside
Indicate whether each sign listed is located inside or outside a building. Different rates may apply for each.
Description
Detail the kind and size of the sign to be insured. Specify any lettering or ornamentation including whether the sign has
mechanical parts or lighting. Specify neon light, electrical, fluorescent bulbs, etc.
Limit of Insurance
Replacement cost for the sign.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered "Yes." The following overview lists
information that should be added to the remarks section for "Yes" responses.
Questions 1 - 9 apply to Glass only, Questions 10 -13 apply to Glass and Sign, and Question 14 to Sign only.
1. Are there any partial or complete painted plates?
Indicate if plate glass to be insured has any design or lettering painted on it. Specify what percentage of the plate has
been painted. Include the type of decoration and if hand-painted.
2. Any plates fixed, glued or in angle settings?
Indicate which, if any, plates are fixed, glued, or in special angle settings.
3. Any obstruction or unusual settings?
Indicate if glass has any obstructions or has other unusual features that make replacement difficult, or if the frames are
unusual. Both situations can make it difficult or costly to repair/replace.
4. Does applicant wish to insure tape on glass?
If so, specify type of tape and value.
5. Does applicant wish to insure lettering on glass?
Indicate if applicant has special lettering to be insured. Specify type of lettering and give approximate value.
6. Is glass protected by wire mesh or U.L.-approved burglary resistant glazing material?
Indicate the security measures taken to protect the glass.

7. Is all exterior glass above second floor?
Indicate which panes are located above the second floor.
8. Is all exterior glass insured?
Indicate what panes are not being insured and their floor location.
9. Is any glass structural?
Indicate which panes are part of the building structure.
10. Is the building or area under construction?
Indicate whether there is construction or renovation taking place at any location.
11. Does glass or signs have scratches, cracks or defects?
Describe any defects in the glass or sign at the time of this application. Indicate whether any corrective measures are
underway. Provide diagram, if required, and specify location of glass.
12. Did agent inspect signs or glass?
Indicate the inspection date and location. If a photograph is available, please attach.
13. Are any locations with glass or signs vacant?
Indicate which locations are vacant and when occupancy is expected, and if any security precautions have been taken to
protect the premises.
14. Any signs off premises or not attached to building?
Specify location and type of protection provided for the sign. Indicate if any signs to be covered are not attached to
building locations described in the Applicant Information Section (ACORD 125). Give location of signs.
REMARKS
Use this section to provide any additional information required for underwriting or rating.Use this space for your notes.




Good Student/Driver Training 91 (3/93a)

Auto Supplemental Forms
The Good Student/Driver Training (ACORD 91), Medical Statement (ACORD 92) and the Young Driver Questionnaire
(ACORD 93) are to be used when required as supplements to the auto application. The identification section of each form
must be fully completed so that it can be matched to the auto application and file.
This form can be used for two purposes: to qualify for a credit/discount for achieving a good student status in school, or
for completing driver training instruction. An operator can qualify for both credits. Please check with the company on
whether one or both credits are available. This form is generally used for operators age 21 or younger.




Homeowner Application 80 (4/2001)

The underwriting process for any personal lines policy begins with submitting a completed application. This guide assists
in completing the ACORD Homeowner Application. The ACORD Personal Inland Marine Application (ACORD 81) should
be used for scheduling personal property which is being submitted as part of the Homeowner Application.

The Generic sections of each personal lines form are explained in the
Personal Lines Generic Section at the beginning of the Personal Lines
Section of the Forms Instruction Guide.On the ACORD website (www.acord.org), , this information appears under the title
PERSONAL LINES GENERIC SECTIONS.

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 Different From Above
Enter the physical address of the property to be insured only if it is different from the mailing 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 the 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 the 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/YY). (E.g., March 7, 1944 should be 03/07/44.)

Social Security #
Social security number for each named applicant.

Questions Relating to Knowledge of Applicant and Inspection of Property
Indicate how long the applicant is known to the agent, and the date of the last property inspection.

COVERAGES/LIMITS OF LIABILITY/ENDORSEMENTS/PAYMENT PLAN

Enter the anticipated dollar limit and premium charge for each applicable coverage. List any optional endorsement(s),
corresponding limit(s) and any endorsement information that is to be included in this policy.

HO Form
Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are:

1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic
2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad
3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special
4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents
4A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Tenants
5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive
6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Condominium
6A . . . . . . . . . . . . . . . . . . . . . . . . . . . All Risk Condominium.

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.)

Premium
Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit.

Payment Plan
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 to be used for payment.

RATING/UNDERWRITING

Provide the information below for each dwelling.

Construction Type
Check the primary type of building material used to construct the dwelling.

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

Sq Ft
Dwelling's total square feet 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 . . . . . . . . . . . . . . . . . . . Intended to be a free standing, up to 4. . family building.
APART . . . . . . . . . . . . . . . . . . . . . . . Apartment.
CONDO . . . . . . . . . . . . . . . . . . . . . . Condominium.
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.

# Units in Fire Div
Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of fire divisions in the
structure, and 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 fire walls.

Terr Code
Location of the dwelling based on individual state bureau or company Homeowner's Manual pages.

Prem Group
Premium Group is a combination of Protection Class, Territory Code and Construction Type Code and determines the
applicable rate based on the dwelling's location, construction and fire protection code. The codes are found in individual
state homeowner's manuals. Some companies require this data; others generate it.

Protect Class
Dwelling's four-character fire protection class found in individual state homeowner's manuals.

Distance to Hydrant
Distance (in ft.) from the nearest hydrant that supports the protection class used.

Distance to Fire Station
Distance in miles from the nearest fire station that supports the protection class used.

Fire/EC Rate
Complete if residence is specifically rated. Refer to company rate manual.

Fire District/Code Number
Dwelling's fire district name and corresponding five-character code number which can be found in individual state
homeowner's manual pages.

Protection Device Type
For temperature, smoke or 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 no heat in the residence, check the box.

If more than one type exists, indicate the primary and secondary types. Use the Remarks section if necessary. If fuel
storage tanks are located on the premises, describe the type and indicate the location. Possible types include:
     •    Electric - Permanent/Portable
     •    Natural Gas
     •    Liquid Propane - Permanent/Portable
     •    Oil - Permanent/Portable
     •    Kerosene - Permanent/Portable
     •     Solar
     •     Coal - Professionally/Non-Professionally Installed
     •     Wood
     •     Other - Explain the heating system in Remarks section
     •     Central Heating


Oil Storage Tank Location
If the fuel type is oil, provide the location of the fuel oil storage tank. Examples:
      •     Indoors completely above ground on a masonry floor
      •     Indoors completely above ground not on a masonry floor
      •     Outdoors and completely above ground
      •     All other (including underground)

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

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.

Dwelling Location
Location of the dwelling within the guidelines listed.

Occupied By
Check the applicable box to indicate occupancy by owner or tenant.

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

Smoke Detector
If the dwelling is equipped with smoke detector(s), 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.

Housekeeping Condition
Enter an evaluation of the interior upkeep of the dwelling.

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.

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 or approved fence.

Storm Shutters
Check the applicable box.

Hurr Res Glass
Check the applicable box with respect to hurricane resistant glass.

Bldg Code Grade
Enter the ISO Building Code Grade, if applicable.

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

Rating
Check the appropriate box to indicate if class rating or specific rates apply.

Occupied Daily
Check the appropriate boxes.
# Weeks Rented
Number of weeks the dwelling is rented by the insured to others. If any apartment is rented on less than an annual basis,
describe the terms..

Wind Class
Check the applicable box.

Roof Type
Enter the material used to construct the roof. Examples:
     •    Composition (fiberglass, asphalt, etc.)
     •    Metal
     •    Poured
     •    Slate
     •    Tile
     •    Wood Shake/Shingle
     •    Other ñ If used, explain in Remarks

Foundation
Check the applicable box.

If Replacement Cost coverage applies, check the appropriate box if an ACORD replacement cost worksheet has been
used (i. e., ACORD 40, 41, or 42.) Also provide the square footage of any basement, garage and breezeway.

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

Fireplaces
Check the applicable box(es) to describe the fireplace(s.)

GENERAL INFORMATION
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 business is conducted on the premises, and if applicable, whether corporal punishment or
day care coverage is to be provided.

2. Any residence employees?
Use the Remarks section to provide information regarding the number of employees, the nature of their employment,
hours worked per week, and whether employed inside (inservants) or outside (outservants).

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 detail the occupancy or use of the other residence. If no liability coverage is requested for this
residence, detail where the coverage is provided if liability coverage is to be included in the policy for any property.

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. If other insurance is
in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal.

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, including the reason for the cancellation. This question cannot be
asked in Missouri.

8. Has applicant had a foreclosure, repossession or bankruptcy?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, or
bankruptcy filing 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. Indicate actual distance.

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 ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode
Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up
to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.

15-17. Renters and Condos Only.
Indicate if:

15. There is a manager on the premises.

16. A security attendant.

17. The building entrance is locked.

18. Any uncorrcted 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 structure originally built & converted for other than private residence?
Indicate what the structure was originally built for.

24. Any lead paint hazard?
Describe the location and the extent of the hazard.

25. If a fuel tank is on premises, has other insurance been obtained for the tank?
Give the First Party and the applicable limit, and the Third Party and the applicable limit.

LOSS HISTORY

This section shows the losses this applicant has had in the past. List losses for the last three years unless the company
requires a different time period.

Provision is made for the applicant to initial this section.

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.

Risk New to Agency
Indicate whether this is the first time this agency has written this line of business for this applicant.
ADDITIONAL INTEREST

Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or
rank (1st, 2nd), whether the additional interest is the mortgage holder (e.g., bank in which the mortgage is held) or other
interest, the name and address of the
interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.




Installation/Builders Risk 147 (2/2001)

This chapter provides basic instructions for completing the ACORD
Installation/Builders Risk Section (ACORD 147). This form was designed to
request Installation or Builders Risk coverage on a specific job basis or on a
blanket annual or open reporting basis. The front of the form is for Open
Reporting, the reverse for Specific Jobs.

This form was designed to be used in conjunction with the Commercial Insurance
Application - Applicant Information Section (ACORD 125). Refer to the
chapter on the ACORD 125 for information on that form.

IDENTIFICATION SECTION

Most information for the Identification Section should match the data found within the Applicant
Information Section of ACORD 125-S. However, it is still important to complete the section.
Many companies, for rating purposes, separate the applications by line of business. Not completing
this portion of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address, telephone and fax numbers.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125-S.

Proposed Eff. Date
Effective date on which the terms and conditions of the policy will commence.

Proposed Exp. Date
Expiration date on which the terms and conditions of the policy will terminate unless
renewed.

Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
40-30-30).

Prem. Adj.
Indicate if the policy is to be written on a premium adjustment basis.

INSTALLATION/BUILDERS RISK
Check the appropriate box to indicate which coverage, Installation or Builders Risk is being applied for.

OPEN REPORTING FORM

Use this section when the applicant is requesting coverage on a reporting basis.

COVERAGE

Limit at Any Single Location
Limit of insurance for any one job site.

Limit per Disaster
Overall disaster limit required.

Limit at Temporary Location
Insurance limit required for property to be installed while held at any temporary location.

The insured's own premises is frequently excluded, so indicate if the premises is owned by
the insured.

Transit Limit
Limit of insurance for materials while they are being shipped in transit.

CAUSES OF LOSS & DEDUCTIBLE

Causes of Loss
Indicate the specific Causes of Loss applicable to this risk.

Sub Limit
If earthquake, flood or an optional cause of loss is selected, list the limit applicable to the
cause of loss.

Deductible
All applicable deductibles.

TERRITORY

Specify where the applicant's job sites are located, including job site name, city, county and state.

RECEIPTS

List the applicant's gross installation receipts for the past 12 months and the projected receipts for
the next 12 months.

JOBS/VALUES

This section classifies the applicant's jobs. For each classification, indicate the requested values
based on residential jobs and commercial jobs.

Annual Number
Number of jobs the applicant performed in the last 12 months.

Duration
Indicate the average length of time (in months) of any one job from first entry to
acceptance and transfer of risk of loss to others. This underwriting information indicates if
coverage extended during hurricane/storm season.

# Jobs in Progress
Give the maximum and average number of jobs the applicant is involved in at any one
time.

Cost or Value of Each Installation
Indicate the maximum value, lowest value and average value at any one job site.

Material Cost
Indicate the percent of the total price that the material costs represents for each type of
installation job.

ADDITIONAL INTEREST/CERTIFICATE RECIPIENTS

Use this section to collect information on any additional interest or receiver of Certificates of
Insurance.

Name and Address
List the Additional Interest's name and mailing address.

Interest
List the subject of interest along with the interest type. Identify the subject of insurance by
description and/or item number, whichever is required (e.g., Job Site # 12, Mortgagee, Lot
10, Mortgagee).

Certification Required
If a Certificate of Insurance is required, check this box.

RIGGING

Describe any hoisting or lowering operations and the equipment used. State the type of material to
be moved and its value. Indicate if individuals other than the applicant are involved in the
operations.

TRANSPORTATION/SECURITY

Indicate the percentage of material usually shipped to job sites at the applicant's risk. Describe the
type of job site security the applicant employs to reduce vandalism, theft or other mishaps,
including items such as fences, watchmen, police and patrol dogs. Note if equipment is left in
trailers and if generators are hoisted by crane at night.

REMARKS

Provide any additional information required for underwriting or rating.

SPECIFIC JOB

This side of the application should be completed when the applicant is requesting coverage
for a specific job.

COVERAGE - CAUSES OF LOSS & DEDUCTIBLE

The Coverage and Causes of Loss and Deductible sections should be completed as stated in the
Open Reporting Form section.

JOB TERM/VALUES

Commencement
Date the job is to begin.

Completion
Date the job is to be completed.

Contract Amount
Total dollar amount of the completed job to be insured. Any requests for soft cost coverage
(e.g., mortgage costs, financing fees, insurance premiums, excavation of land costs) should
be identified separately since they will be covered separately.

Value of Owner Supplied Property
Total dollar amount of property supplied by the owner at the specific job location. If the
value of such property is in addition to the contract amount, identify in the Remarks
section.

SECURITY

Describe the type of job site security the applicant employs to reduce vandalism, theft or other
mishaps, including fences, watchmen, police and patrol dogs. Note if equipment is left in trailers
and if generators are hoisted by crane at night.

JOB DESCRIPTION

Describe the work to be performed, the job location and the building construction. Enter insured's
job number in the space provided.

ADDITIONAL INTEREST

Complete this section as per instructions in the Open Reporting Form section.

TRANSPORTATION

Use this section to collect information on the applicant's transportation exposure.

Amount Shipped
Total amount shipped to the job site at the applicant's risk.

% Applicant's Vehicles
Indicate the percentage of property shipped to the job site using the applicant's own
vehicles.

% by Common/Contract Carrier
Indicate the percentage of property shipped to the job site by common or contract carriers.

Distance
Average distance involved in shipping property to the job site from its point of origin.

RIGGING

Describe any Hoisting or Lowering operations and the equipment used. State the type of material to
be moved and its value. Indicate if individuals other than the applicant are involved in the
operations.

REMARKS

Provide any additional information required for underwriting or rating.




Insurance Binder 75-N (12/93)

This form is still used for risks containing commercial liability coverages not using the ISO policy simplification format. All
other risks should use ACORD 75-S.
The instructions within this section contain only information on completing the four coverage sections. For instructions on
the other sections of this form and general information on using insurance binders, please refer to the chapter on ACORD
75-S.
COVERAGES
PROPERTY
Complete this section when binding property coverages.
Type and Location of Property
Type of property covered (building, personal property) and the location address for the property (e.g., Building - 123
Howard Street, Newburgh, New York).
Coverage/Perils/Forms
Coverages for the property being covered and any appropriate form numbers (e.g., Special Excluding
Theft - CP 10 33).
Amt of Insurance
Amount of insurance for the corresponding property coverage.
Deductible
Any deductible associated with the property coverage.
Coins %
Any applicable coinsurance percentage associated with the property coverage.
LIABILITY
Complete this section when binding liability coverages.
Scheduled Form
If the policy is written on a Scheduled Form basis, check this box and the appropriate boxes below to indicate which
liability forms the policy is being bound. Available scheduled forms are:
Premises/Operations, Products/Completed Operations, and Contractual.
Comprehensive Form
If the policy is written on a Comprehensive Form basis, check this box.
Other
If binding liability forms other than those listed above, such as Professional Liability, indicate by checking the "Other" box
and list the form name either in the available space.
Medical Payments
If binding Medical Payments coverage, check this box and list the Per Person and Per Accident Limits in the available
space.
Personal Injury
If binding Personal Injury coverage, check this box and the appropriate Coverage form box(es), A, B, or C.
Coverage/Forms
When applicable, show the coverage using the form number and/or title of the form (e.g., OL&T 0066).
Form A, B, C
These are Personal Injury coverage form numbers. If Personal Injury coverage is being bound, check the appropriate
box(es).
A = False Arrest, Detention or Imprisonment, or Malicious Prosecution.
B = Libel, Slander, Defamation, or Violation of Right of Private Occupancy.
C = Wrongful Entry or Eviction or other Invasion of Right of Private Occupancy.

Limits of Liability
Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts.




Insurance Binder 75-S (1/2001)

This guide provides basic instructions to complete the ACORD Binder forms. The descriptions explain the information
needed to properly issue a binder.
The ACORD Insurance Binder addresses both Personal Lines and Commercial Lines risks, although most ACORD
Personal Lines applications contain a "built-in" binder. For Commercial Lines, the layout format within the General Liability
Section of the ACORD 75-S is customized to the ISO Policy Simplification program. This allows for binding of both Claims
Made and Occurrence policies. The format of the ACORD 75-N follows the older, non-simplified format.
Before issuing any binder, the following important considerations should be reviewed and considered carefully:
A Binder (Cover Note) is a temporary insurance contract which provides coverage and must be underwritten as an
    insurance policy.
The improper use of binders has become a major cause of producer's Errors and Omissions claims. It is imperative that
    only authorized people prepare them. Preparation must be complete and accurate.
All binders must conform to the state insurance code for the state in which the subject of insurance is located.
The maximum and/or minimum term of a binder may be governed by state statute and/or company underwriting
    instructions.
At the end of the binder's specified term, all coverage expires unless a new binder has been issued or the expired binder
    has been replaced with a policy.
The language in the binder must be precise. Do not use vague or all-encompassing terms which may imply coverages not
    intended, such as "All Risk." If possible, use the same language and terminology that will appear on the policy.
An agent may only issue binders which comply with the company's underwriting instructions (per company manual,
    agency agreement, correspondence and/or company underwriter). If the authority is not in writing, the agent should
    obtain written authority. Most agency agreements contain stated "time frames" within which the company must be
    notified of any risk bound.
Generally, a broker cannot bind insurance. A broker may only exercise the authority extended by the company.
It is recommended that individual binders be issued for each company affording coverage.
Most agency agreements dealing with surplus lines and specialty market contracts do not allow the agent or broker to
    bind coverage. Authorization must be secured prior to binding.
A binder provides coverage for a specified period. In most jurisdictions, a premium must be charged for this period unless
    the binder is replaced by a policy or endorsement. A deposit should be obtained when issuing a binder. A deposit
    premium may be required by some companies.
* Most companies prohibit issuing or extending binders where coverage has been refused or cancelled by any carrier.
Limits
All Limits should be listed as whole dollar amounts. Enter Limits corresponding to those found on the policy declarations
page.

IDENTIFICATION SECTION
Issue Date
Month/day/year on which the form is completed.
Producer
Name and address of the producer or broker issuing this form.
Phone (A/C, No, Ext)
The producer's telephone number.
Code
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
Subcode
If your 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. Use the actual name of the company within the group to which this binder is
being issued. Do not use group names.
Binder No.
Control number assigned to the binder for referencing purposes. If created by the agent, this number should be sequential
and tracked within the Binder Log (ACORD 76). It may also be assigned by the company, in which case it might be the
actual policy number. For control purposes, the number should be tracked within the Binder Log.
Effective Date
Date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of
the policy or of an endorsement to the policy.
Effective Time
Time when the binder commenced. Check the appropriate AM or PM box associated with this time.
Expiration Date
Date on which the terms and conditions of the policy will or have expired. Certain state laws limit the terms of a binder, so
this date may not coincide with the policy expiration date.
Expiration Time
Check the appropriate time of 12:01 AM or Noon when the binder expires.
This Binder is issued to extend coverage in the above named company per expiring policy #
Check the available box and enter the policy number of the expiring policy. Use this option to extend coverage on a policy
where renewal is not yet available.
Insured
Name of the insured and mailing address requested or found on the declarations page of the policy. The line within this
field is a margin setting used for window envelopes.
Description of Operations/Vehicles/Property
Outline the operations of the insured, vehicle information and usage, and, for property exposures, location information.
Examples:
Machine Tool Die Casters
91 Chevy H10 Pick Up Truck - VIN C12345P8991, used for delivery
Location 1 - 123 North Main St, Hartford, Ct

If the location is the same as the mailing address, and this address is properly descriptive, state "same as mailing
address," rather than repeat the address.
COVERAGES
All limits should be listed as dollar amounts.

PROPERTY
Complete this section when binding property coverages.
Causes of Loss
Check the appropriate box to indicate the Cause of Loss for which the property coverage is being bound. For options
outside of Basic, Broad, or Special (Spec.), such as Special Excluding Theft or Homeowners, enter the coverage name in
the available space.
Coverage/Forms
Subjects of insurance that are being covered and any necessary location information (e.g., Loc 1 Building Personal
Property Dwelling).
Coins %
Any applicable Coinsurance percentage associated with the corresponding subject(s) of insurance.
Amount
Corresponding amounts of insurance for the corresponding subject(s) of insurance.
Deductible
Any deductible associated with the corresponding subject(s) of insurance.
GENERAL LIABILITY
Complete this section when binding general liability coverages.
Commercial General Liability
Check this box for Commercial General Liability (CGL) and the corresponding box to designate the type of policy issued -
Claims Made or Occur. (Occurrence).
Owners & Contractor's Prot
Owners & Contractor's Protective (OCP); Check this box if this is an OCP policy.
Other General Liability Coverages
Liability coverages not found on the form may be listed in the last two option boxes. The coverage type should be listed
next to the available box (e.g., when binding Comprehensive Personal Liability, check the first box and insert
"Comprehensive Personal Liability" on the line after the box).
Coverage/Forms
For Commercial Lines policies, enter the classification code(s) and description of the class(es) for which the binder is
being issued. Include any form numbers. For Personal Lines enter the policy form numbers.
Retro Date For Claims Made
If the Claims Made option box is checked, and there is a retroactive date, enter the date. If there is no retroactive date,
enter "none."
Limits
Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts.
Abbreviations
Products Comp/Op Agg = Products Completed Operations Aggregate
Personal & Adv. Injury = Personal and Advertising Injury
Med. Exp = Medical Expense

AUTOMOBILE LIABILITY
Complete this section when binding automobile liability coverages.

Indicate which classes of vehicles are being bound by checking the appropriate boxes. Available options are: Any Auto,
All Owned Autos, Scheduled Autos, Hired Autos and Non-Owned Autos. If coverage is for scheduled autos only, attach a
list of the vehicles with their appropriate coverages. If other automobile coverages are desired, use the optional box and
write the coverage name next to the box.
Coverage/Forms
List any policy form numbers in this section.
Limits
Complete the appropriate limits to match the policy declarations page. All limits should be listed as whole dollar amounts.
Use the optional limit line to list any coverage not specifically listed, such as Additional Personal Injury Protection (APIP).
AUTO PHYSICAL DAMAGE
Complete this section when binding automobile physical damage coverages.

If physical damage coverage is being bound, use the appropriate box to indicate Collision or Other than Collision
coverage. List any deductibles in the available space.
All Vehicles/Scheduled Vehicles
Indicate if collision coverage applies to all or only scheduled vehicles.
Valuation Type
Check the appropriate box to indicate what basis is to be used for determining the vehicle's value. Options are: Actual
Cash Value, Stated Amount and Other. For "Other," list the valuation type in the space provided.
Limit
List the combined sum of the vehicle's physical damage valuation.
GARAGE LIABILITY
Complete this section only if you are binding garage liability. Use the available lines or the "Any Auto" option to indicate
coverage specifics.
Coverage Forms
List any applicable coverage form numbers.
Limits
Complete the limits found on the Garage declarations page.
EXCESS LIABILITY
Complete this section when binding some type of excess liability policy. For Umbrella policies, check the appropriate box.
If the Other Than Umbrella box is checked, an additional reference should be made in the Coverage/Forms section stating
the kind of policy and to which coverages the policy applies (e.g., Excess - Auto section).
Retro Date For Claims Made
If this is a Claims Made policy and there is a retroactive date, enter the date. If there is no retroactive date, enter "none."
Limit
Complete the limits in accordance with the policy declarations page.
Workers Compensation and Employer's Liability
Complete this section when binding workers compensation and/or employer's liability policies. If the policy being bound is
written using Statutory Limits, check the appropriate box. If Employers Liability is included, show the limits for "Each
Accident," "Disease-Policy Limit," and "Disease-Each Employee."
Special Conditions/Other Coverages
Provide any additional information pertinent to the bound policies. Include any special endorsements that are not specified
in other sections of the binder. The area can also be used to add other coverages, refer to other binders, acknowledge
receipt of deposit premium, or show fees, taxes and/or estimated premium.
NAME & ADDRESS
This section tracks any additional interest to the policy.
Name & Address
Complete name and address of an additional interest if any have been indicated. The line within this section is a margin
setting used for window envelopes.
Interest Type
Check the additional interest's type in the appropriate box. Options are:
Mortgagee
Loss Payee
Additional Insured
Other.
Loan #
List any loan number, account number or other controlling number that the additional interest may have assigned the
insured.
AUTHORIZED REPRESENTATIVE
Binders must be signed by authorized representatives of the issuing company.




Automobile Insurance ID Card 50 (1/83)

The ACORD Automobile Insurance Identification Card (ACORD 50) is accepted in the majority of states that require the
insured to carry/produce upon demand proof of insurance.
The ACORD Automobile Insurance Identification Card (ACORD 50) is accepted in the majority of states that require the
insured to carry/produce upon demand proof of insurance.
The states where ACORD 50 is not acceptable are:
Delaware
Michigan
Florida
Oklahoma
Hawaii
Mississippi
Texas
Kentucky
West Virginia
Louisiana
For the states listed above, refer to the State Forms section of this manual. Specific ID cards are provided for each state,
and information about each ID card is provided. Each completed ACORD 50 ID card should include the appropriate state
title on the top line before Insurance Identification Card. The card is available in single sheets and two part sets to
correspond with different states' specifications for the number of copies required to be produced. Some states require
additional wording and/or supplemental information when ACORD 50 is issued. Information on these states follows.
ACORD 50 WM may also be used in all states where ACORD 50 is acceptable. This card contains a watermark (the
word "ACORD") which is invisible when the form is photocopied. This feature helps to prevent fraudulent reproduction.
Special Provisions/State Exceptions to ACORD ID CARD (ACORD 50).
California
Wording: "The policy meets the requirements of Section 16056 of the California Vehicle Code."
Colorado
Must display the coverage required by law; BI, PD, PIP (limits need not be stated).
Connecticut
Add the following wording: "Connecticut Insurance Card issued pursuant to Connecticut Law." This text should appear
under the pre-printed words Insurance Identification Card. Issue in duplicate. Expiration date must be one year from
effective date.
Idaho
Title should be either Certificate of Liability or Liability Insurance Identification Card. Inclusion of "State of Idaho" is
optional.
Illinois
Add the following wording: "Examine policy exclusions carefully. This form does not constitute any part of your nsurance
policy."
Indiana
Financial Responsibility filing only.
Kansas
Cannot be used by those vehicles subject to the State Corporation Commission.
Maine
Title should be "Maine Motor Vehicle Insurance Identification Card." The following should also be added to the card (may
be added to the reverse side): "The policy provides the minimum insurance required by law."
Mississippi
This auto ID card was developed in response to Mississippi law requiring that all vehicles after 1/1/01 must have proof of
insurance in the vehicle.
Minnesota
Plain language summary must accompany the card but does not have to be printed on card. The following language is
advisory and can be modified: "Pursuant to M.S. 65B.67; failure to provide proof of insurance at the request of a law
enforcement official or within 14 days is a misdemeanor punishable by a $700 fine and/or 90 days in jail, and revocation of
driving privileges."
Nebraska
Title: Nebraska Auto Liability.
Nevada
Title: Evidence of Motor Vehicle Liability Insurance. Add the following wording: "This card approved by the Nevada
Insurance Commisioner" (on front side). Suggest issuing in duplicate since one copy is rendered to the Department of
Motor Vehicles when registration is renewed.
New Jersey
If the card is being used for coverage under the New Jersey Automobile Full Insurance Underwriting Association, wording
must appear on the front to that effect. Also: only two sided, preprinted ACORD 50 or ACORD 50WM are acceptable
The following should be added to the back of the card: Insert address for notification of commencement of medical
treatment."
Pennsylvania
Title: Financial Responsibility Identification Card. Expiration Date: Not Valid More Than One Year From Effective Date.
ACORD Card must be accompanied with the instructions set forth in section 67.25 of the insurance department
regulations, 14 Pa.B.2949. (These instructions must also accompany any other identification card issued under the
Financial
Responsibility Law.)
Rhode Island
Add the following wording: "Policy meets Rhode Island limits."
South Carolina
Add the following wording: "Coverage meets SC minimum financial responsibility requirements."
South Dakota
Issue in duplicate. Title: Add the following wording: "Coverage provided by this policy meets the minimum liability limits
prescribed by law."
Vermont
Title: "Vermont Automobile." Add the following wording: "Policy provides the minimum insurance prescribed by law."
Michigan Certificate of No-Fault Insurance 50MI (6/93)
The Michigan Certificate of No-Fault Insurance Card was created to satisfy Michigan statutory and regulatory
requirements with respect to proof of no-fault insurance coverage. The part of ACORD 50 MI which includes the
statement "Secretary of State Copy" should be used by the insured to apply for vehicle registration. The other part must
be kept in the insured's vehicle at all times.
New York State Insurance Identification Card (1/98)
Use ACORD 50 NY to comply with New York State Department of Motor Vehicle regulations. This card is identical to the
New York State Insurance Identification Card FS-20. This card may only be issued by an authorized representative of a
licensed New York state insurer.
ACORD 50 NY is printed on watermarked paper (the word "ACORD" is the watermark). For agents or companies that will
print copies of 50 NY from their software systems, ACORD 360 WM is watermarked paper that can be ordered from
ACORD. This paper can be used to satisfy the watermark requirement.
Delaware
Auto Insurance I.D. Card 50WM (2/95)
This card includes a watermark which is invisible when the form is photocopied. This feature is intended to help prevent
fraudulent reproduction. ACORD Form 50 WM must be used in Delaware. It may also be used in lieu of ACORD Form
50, in any state where ACORD 50 is accepted.
Florida Auto Insurance Identification Card 50FL (3/94)
The Florida Auto Insurance Identification Card was created in response to Florida regulations. The main differences
between the generic ACORD Automobile Insurance Card, ACORD 50, and the Florida card are:
The size of the card is 3 1/2 inches wide, 2 1/4 inches high (wallet size)
Boxes referring to Personal Injury Protection Benefits/Property Damage Liability and Bodily Injury Liability must be
  checked, according to the coverage provided Statements are included on the back of the card, referring to the providing
  of Rental Car Coverage, and the fact that misrepresentation of insurance is a first degree misdemeanor
Oklahoma Security Verification Form 50OK (3/94)
The Oklahoma Automobile Insurance Identification Card was created in response to Oklahoma regulations. The main
differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Oklahoma card are:
The address of the insured cannot be shown on the card
The front of the card includes a series of letters of the alphabet that correspond to pre-printed coverages shown on the
   back of the card. The appropriate letters must be checked or circled to indicate actual coverage in the policy
The front of the OWNERS FORM states that a liability insurance policy has been issued pursuant to the compulsory
   insurance law of Oklahoma and that this form must be kept in the vehicle at all times
The back of the OWNERS FORM contains a statement describing Oklahoma state law with respect to the use of the
   requirement that this form be produced upon request by a peace officer, or representative of the Department of Public
   Safety or, in case of an accident, other persons affected by the accident
The second part of ACORD 50 OK, which includes the statement "submit this part with your application for registration",
   should be used to apply for vehicle registration
Hawaii No-Fault Insurance Identification Card 50HI (1/99)
The Hawaii Automobile Insurance Identification Card was created in response to Hawaii regulations. The main differences
between the generic ACORD Automobile Insurance Card, ACORD 50, and the Hawaii card are:
The size of the card is 3 1/2 inches wide by 2 1/4 inches high (wallet size)
A statement is added to the front of the card referencing an authorized Hawaii insurer who issued an insurance policy
  which complies with Hawaii's motor vehicle insurance law
The order of entries on the front of the card is prescribed by regulation
The card is printed on watermarked paper. The watermark is the word "ACORD."
Commonwealth of Kentucky Proof of Insurance 50KY (3/98)
The Kentucky Automobile Insurance Identification Card was created in response to
Kentucky regulations. The main differences between the generic ACORD Automobile
Insurance Card, ACORD 50, and the Kentucky card are:
The size of the card is 3 1/2 inches wide and 2 1/4 inches high (wallet size)
The order of entries on the front of the card is prescribed by regulation State mandated "Instructions to Policyholder" are
  included on the back of the card
Two copies of this ID card must be given to the insured. One will be used to present to the county clerk when renewing
  motor vehicle registration; the other must be carried in the identified motor vehicle.
Louisiana Automobile Insurance Identification Card 50LA (4/96)
The Louisiana Automobile Insurance Identification Card was created in response to Louisiana regulations. The main
differences between the generic ACORD Automobile Insurance Card, ACORD 50, and the Louisiana card are:
The company NAIC number and name and address must be shown on the front of the card.
The explanation of penalties for failure to comply with statutes and regulations is revised
A statement is added to the front of the card referencing an authorized insurer who has issued a motor vehicle policy with
   coverage that meets the minimum liability limits prescribed by law
The back of the form contains an Important Notice, required by regulation, that explains Louisiana compulsory insurance
   requirements, and the possible penalties for failing to comply
The name, address and telephone number of the insurance agent, and a list of any excluded drivers, must appear on the
back of the form.
Missouri Auto Insurance Identification Card (2/98)
This ID card was created in response to Missouri law. The main differences between the generic ACORD Auto Insurance
Card, ACORD 50, and the Missouri card are:
Space is provided on the front of the card for the name and complete address of the insurance carrier
The text of the "use" statement on the back of the card is revised to comply with Missouri law.
Texas Liability Insurance Card 50TX (2/97)
The Texas Liability Insurance Card was created in response to the Texas State Board of Insurance Order No. 58994
which became effective September 1, 1991. The Texas Liability Insurance Card is similar in data content to the generic
ACORD
Automobile Insurance Card. The main difference between the two cards is that Texas requires:
A Spanish translation of the text
A toll free phone number of the insurer for consumer inquiries
The Motor Vehicle Safety-Responsibility text
West Virginia Certificate of Insurance 50WV (3/94)
The West Virginia Automobile Insurance Card was created in response to West Virginia regulations. The main differences
between the generic ACORD Automobile Insurance Card, ACORD 50, and the West Virginia card are:
The plate number must be shown in the upper right corner of the front of the card.
The front of the card includes a statement referring to an authorized insurer who has issued a policy in accordance with
    West Virginia law.
If the owner and the insured are different, both names must be shown.
The owner must sign the form.




Automobile Insurance ID Card 50WM (2/95)

See ACORD Form 50
* ACORD 50 WM may also be used in all states where ACORD 50 is acceptable.
This card contains a watermark (the word "ACORD") which is invisible when
the form is photocopied. This feature helps to prevent fraudulent reproduction.




Medical Statement 92 (2/95)

This form is submitted if the applicant or another driver on the policy has a medical condition/history requiring that further
information be provided to the company. Some companies require the form be submitted for all drivers over a certain age.
If question #11 on the auto application has been answered "Yes", this form should be completed. The form should be
completed and signed by the individual with the medical condition.




Miscellaneous Crime Coverage 151 (7/2001)

This form can be used to provide information about premises and safe protection, messengers and armored motor
vehicles, additional locations, and scheduled employees where required.

This form is to be used in conjunction with the Commercial Insurance
Application - Applicant Information Section (ACORD 125). Refer to the
chapter on the ACORD 125 for information on that form.

IDENTIFICATION SECTION

Most information for the Identification Section should match the data found within the Applicant Information Section of
ACORD 125. However, it is still important to complete the section. Many companies, for rating purposes, separate the
applications by line of business. Not completing this
part of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address, fax and telephone number.

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.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

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

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

Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).

Audit
Indicate the audit term for policies that are periodically audited. If the audit period is
known, enter the code:
A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . other.


PREMISES/SAFE PROTECTION

Complete one section per location to describe the location's security systems.

Alarm Type
Indicate the style of alarm(s) for the premises safes or vaults on it. Available options are:
     •     Hold-Up - Manual or semiautomatic control which can transmit an alarm in the event of a hold-up.
     •     Premises - Sensing device installed on premises which transmits an alarm in the event of unauthorized entry.
           The Premises Extent must be completed for Premises Alarms.
     •     Safe/Vault - Alarm system that protects the safe or vault and is connected to outside central station, gong or
           siren. The Extent of Protection for Safe/Vault must be completed for all safes/vaults.
Alarm Description
Indicate any applicable features of the alarm.
     •     Local Gong - Bell located outside the premises.
     •     Central Station - Private security service which monitors the alarm system and may dispatch security officers in
           response to an alarm.
     •     Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a
           private control station.
     •     With Keys - Indicate if security service or police have keys to respond to alarms.
Grade
Grade or class A, B, C, etc. which indicates the time required to respond to a signal from
the alarm system. Refer to manual.

Extent of Protection for Safe/Vault
Indicate the extent of the alarm protection for the safe or vault.
     •     Partial - Alarm covers around door only
     •     Complete - Alarm covers sides, top walls, floor and ceiling.

Extent of Protection for Premises
Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual.

Alarm Installed & Serviced By
Name of the company installing and servicing the alarm system. Alarm companies often install, maintain and service the
system in addition to providing Central Station facilities.

# Guards
Number of guards within the premises or at its door while regularly open for business.
# Watchpersons
Number of watchpersons on the premises retained during non-office hours.

Watchpersons
Indicate the type of watchpersons reporting.
     •     Rpt/Cent. St - Report to a central station on an hourly basis
     •     Clock Hrly - Register hourly with an approved watchpersons' clock (Detex Time Clock, etc.)
     •     Don't Signal - Do not do any type of reporting or registering

Certificate Number
Alarms approved by the Underwriters Laboratories (UL) are earmarked by a certificate. Record the certificate number;
(Note: UL certification can apply to the entire system or to individual parts).

Expiration Date
UL certificate expiration date.

Accessible Openings & Protection
Provide information regarding access to the premises. Indicate number of doors and if they are protected in any manner.
Indicate what type of locks are used and if there is a gate or bars.

Other Protection
Describe any other protective measures or devices (e.g., if windows have steel grates and are connected to an alarm).
Indicate if the building has skylights and if windows are visible from the street.

PREMISES, MESSENGER & ARMORED MOTOR VEHICLE SCHEDULE


Loc
Applicant's premises location number as found on ACORD 125, or listed below in the Additional Locations section.

# Mess'gr
Number of messangers to which the limits apply.

# of Arm'd Veh.
Number of armored vehicles to which the limits apply.

Inside/Outside Limits
Any appropriate limit inside or outside the premises.

ADDITIONAL LOCATIONS

Use this section when the applicant is requesting coverage on locations that did not fit onto the ACORD 125 Location
section.

Loc #
Location number to be associated with this address. This number should not be one of the numbers used on the ACORD
125.

Address
Applicant's address associated with this location number.

EMPLOYEE SCHEDULE

Use this section to specifically schedule employees.

Loc #
Location number where the employee works.

Name of Employee
Employee name that coverage is specifically being scheduled for.

Title
Employee's job title.

Limit
Specific limit scheduled to this employee.

Deductible
Specific deductible scheduled to this employee.
REMARKS

Provide any additional information required for underwriting or rating.




Personal Automobile Application 90

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide
provides assistance in completing the ACORD Personal Auto Application. The generic sections of each personal lines
form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms
Instruction Guide.
There are three additional, optional forms in the personal auto series: Good Student/Driver Training (ACORD 91), Medical
Statement (ACORD 92), and Young Driver Questionnaire (ACORD 93).
IMPORTANT - State-specific personal auto applications, together with all necessary required supplements and notices,
have been provided for all states. All comply with current state statutes and regulations, and all will be revised as
necessary to comply with future changes in state requirements. The original ACORD 90, Personal Auto Application, was
withdrawn July 1, 1996, two years after the introduction of all of the state-specific forms. The original ACORD 90 was not
acceptable because of laws or regulations in thirty-three states. However, the state-specific applications developed by
ACORD to replace the original ACORD 90 are acceptable in each respective state.

The unique sections of the state applications are the Coverages/Premium section on the front of the form, and the Fair
Credit, Fraud, coverage acceptance/rejection, and other disclosure requirements on the bottom of the back of the form.
The balance of each state form is identical to all the others. The following pages include a depiction of the common
sections, and instructions relating to the completion of these sections. Refer to the State Forms section of this Guide, and
your company rating manual, for information about the state-unique coverage and requirements.
RESIDENCE
Number of Years at Address Current and Previous
Number of years present at both the applicant's current and previous addresses.

Previous Address
Physical address of the first named insured if the applicant has been at the current address for less than three years.
GARAGE LOCATION
Indicate vehicle number and complete address including ZIP code for any vehicle not kept at the mailing address. Also,
provide this information if the mailing address is a post office box or rural route address, or when a driver is at school with
a vehicle.
VEHICLE DESCRIPTION/USE
Total # Vehicles In Household
All owned, leased, or regularly used vehicles in household, including non-registered and non-insured vehicles.
Year
Model year of the vehicle.
Make, Model and Body Type
Manufacturer's trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4 door sedan).
VIN/Registered State
Vehicle identification number as it appears on the title certificate or registration. Also enter the state where the vehicle is
registered. If the vehicle is registered in a state different from where it is garaged, provide an explanation in the Remarks
section.
HP/CC
Horsepower, or the number of cubic centimeters of displacement.
Date Purch
Year the applicant acquired the vehicle in YYYY format.
New/Used
Enter "N" if the applicant bought the vehicle new, "U" if the vehicle was used.
Cost New
Original cost of the vehicle.
Symbol Age Grp
If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual.
Terr
Rating territory code where the vehicle is principally garaged. Refer to rating manual.
Miles 1 Way Wk/Schl
Number of miles from the garage location to school or work.
# Days Week
Number of days per week the vehicle is used to commute from the garage location to work or school. This includes driving
to and from a commuter lot or transit station.
# Weeks/ Mo.
Number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes
driving to and from a commuter lot or transit station.
Usage
Enter pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation,
profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of
occupation, profession or business is considered pleasure.
Perform
Vehicle's performance level. Indicate High (H), Intermediate (I) or Sport (S).
Multi-Car
Check box only if multi-car credit applies.
Carpool
Indicate if any vehicle is used in a car pool for travel to work or school.
Garaged
Indicate if the vehicle is parked in a garage at night. If the vehicle is left on the street, at school or some other equally
exposed place, provide this information in Remarks. Examples of exposures are:

Off street (driveway)
Off street (school)
On street (at residence)
On street (at school)
Odometer Reading
Current number of miles on the odometer.
Annual Mileage
Total estimated annual mileage for each vehicle.
Govern Driver
Driver to be assigned to each vehicle for rating purposes.
Driver Use %
Percentage that each driver uses each vehicle. Each vehicle should total 100 percent. If any driver has 0 percent use for
all vehicles, indicate why in the Remarks section.
Class
Rate classification for each vehicle. Refer to manual; some companies determine class automatically from information
provided in Vehicle Use and Driver Information sections.
Seat Belt
Check the box if the vehicle is equipped with automatic seat belts.
Air Bag
Indicate D for driver side air bag, B for vehicle equipped with air bag for both front driver and passenger.
Anti-Lock Brakes 2/4
For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel anti-lock braking
system.
Anti-Theft Devices
If vehicle is equipped with an anti-theft device, indicate type.

Credits and Surcharges
Enter any other credits and/or surcharges that are to apply to any or all vehicles.
COVERAGES/PREMIUMS
For information relating to each state's unique coverages, refer to the State Forms section in this guide, and your
company's rating manual.
DRIVER INFORMATION
Name
Name of each licensed operator (resident or not) as it appears on their drivers licenses, and every resident of the
household regardless of age. Enter the surname only if different from the applicant's. Show the applicant as driver #1,
even if not an operator.
Sex
Enter F for female, M for male.

Mar Stat
Enter the marital status of each listed driver. Examples:
S=Single
M=Married
D=Divorced
SP=Separated
W=Widowed

Relation to Applicant
Driver's relationship to the applicant. Examples:
I=Insured
Sp=Spouse
C=Child
Sib=Brother/Sister
P=Parent
E=Employee
Date of Birth
Date of birth of each driver and household resident (MM/DD/YY) (e.g., March 7, 1944 should be 03/07/44).
Occupation
Occupation of each operator.
Date Lic
Date (MM/YY) each driver was permanently licensed.
Stdt >> 100
Indicate if any youthful driver is residing at a school over 100 road miles from the principal place of garaging. Show name
of institution and address in the Remarks section.
Good Stdt
Indicate if any driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a
Good Student Certificate (ACORD 91) for each operator who qualifies.
Drv Train
Indicate if driver training credit applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate for any operator under age 21 who has
successfully completed this training and qualifies for the credit.
Acc Prev Cse
Date on which the driver successfully completed an approved motor vehicle accident prevention course (or a similarly
recognized defensive driving course). Attach a completion certificate for each driver who qualifies.

Drivers License #/ Licensed State
Complete drivers license number and licensed state for each licensed operator. Copy directly from license if possible.
Social Security #
Social security number for each named driver and household resident.
ACCIDENTS/CONVICTIONS
It is important that this section be completed fully and accurately. Many companies verify driving records with state motor
vehicle departments. Discrepancies between the application and the report may result in processing delays and
unnecessary correspondence with the company. If there have not been any accidents, convictions or comprehensive
losses during the indicated time period, enter "None". Be sure to enter the number of years reviewed, in accordance with
the company's and state's requirements, as the experience period.
Drv #
Driver number as found in the driver information section.
Date of Accident/Conviction
Date the accident or conviction occurred.
Description of Accident or Conviction
A complete description of the accident or conviction. This would include the number of vehicles involved and the type of
vehicles (private passenger or commercial). Convictions constitute a judgement of guilty, plea of nolo contendere or
forfeiture of bail. Use the Remarks section or an additional piece of paper if necessary.
Place of Accident/Conviction
City and state of the accident or conviction.
BI or Death
Indicate whether bodily injury or death occurred. Include details in the description of accident.
Amount of Property Damage
Total amount of property damage, both the applicant's and all claimant's combined damages. Refer to company manual.
ADDITIONAL INTEREST
Indicate if additional interest is an additional insured-lessor, certificate holder or a loss payee. Show complete name and
mailing address. Provide the following information for each entity having an interest in the personal automobile(s) to be
insured. The interest number or rank (1st, 2nd), whether additional interest or loss payee, the name and address of the
interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
EMPLOYMENT INFORMATION
Applicant's/Co-Applicant's Employer
Name of the organization that employs the applicant(s) named in the identification section.
Applicant's Employment Location
Applicant's employment location. This may differ from where the main office/plant is situated.
Work Phone Number
Work phone number at which the applicant/co-applicant may be reached.
Yrs Empl
The number of years the applicant(s) have been with the employer indicated above. If less than 2 years, provide the
number of years previous employment. Provide the name of the previous employer and previous occupantion in the
remarks section.
PRIOR COVERAGE
Provide the prior insurance company's name, producer, number of years with the company, policy number and the date
the prior policy expired.
GENERAL INFORMATION
If there are any Yes responses, provide a complete explanation in the Remarks section. Use an additional sheet of paper
if the room in the Remarks section is not adequate.
1. Vehicle not registered to applicant?
Provide the vehicle number and the name of any vehicle not owned by or registered to the applicant.
2. Any car modified/special equipment?
Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any
customized painting such as murals or pin striping, any equipment installed to overcome a physical handicap. Indicate
vehicle number, a description of the modifications and the cost of the special equipment.
3. Any existing damage?
Indicate if any vehicle has been damaged and not repaired as of the date of application. Indicate the vehicle number and
a complete description of the damage.
4. Any other losses incurred?
Any other losses, such as glass damage, vandalism, fire or theft, not shown in the Accident/Conviction section, incurred
within the last three years. Provide description and amount of loss.
5. Any car kept at school?
Identify the household member and the name and location of the school. Provide the distance between the school and the
residence garage location.
6. Any car parked on street?
Determine if any vehicle is parked on the street or kept in other than an enclosed garage when not in use. Indicate vehicle
number from vehicle description area and where the vehicle is parked.
7. Any other automobile insurance?
Provide the insured's name, vehicle description, insurance company, type of coverage and policy number for any other
household resident's automobile insurance.
8. Any other insurance with company?
Indicate the type and policy number of any other insurance the applicant has with the company.
9. Any household member in military service?
Provide details on branch of service, rank, and location of base for any household member in active military service.
Determine if any vehicle is at the military location.
10. Any license suspended/revoked?
Indicate the driver number, the period of suspension, the reason for suspension, and the date the license was reinstated.
11. Any physical/mental impairments?
List any operator with a physical or medical impairment which could hinder the safe operation of a vehicle ( amputation,
epilepsy). If impaired, enter the name of the driver, a description of any special equipment installed, and treatment or
medication being administered. This question cannot be asked in some states. In those states, the question does not
appear on the application.
12. Any financial responsibility filing?
Indicate the driver's name, the reason for the filing, and the date of original filing.
13. Has insurance been transferred within agency?
Indicate if prior carrier and previous policy number information shown on the front of the application represents a policy
being transferred within the agency. If Yes, give reason for transfer.
14. Any insurance declined/cancelled?
Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within
the last three years. List the person's name and why the action was taken. This question cannot be asked in some states.
n those states, the question does not appear on the application.
15. Is this brokered business to the agent?
Indicate if the application came through a broker not part of the agency.
Alabama Personal Auto Application ACORD 90 AL (2/2001)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is not available; this is not a "no-fault" state. Uninsured Motorists Bodily Injury coverage includes Underinsured Motorists
Bodily Injury coverage; Uninsured or Underinsured Motorists Property Damage coverage is not available. Statement
added to the back of the form referencing the explanation and offer of Uninsured Motorists Bodily Injury coverage up to
the policy's Bodily Injury Liability limits, and the right of the applicant to reject this coverage. The statement must be
initialed by the applicant.
Alaska Personal Auto Application ACORD 90 AK (2/2001)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90, the generic Personal Auto Application, on this website.
     • Personal Injury Protection coverage does not apply; this is not a "no-fault"state.
     • A required statement has been added to the back of the form with respect to the offer of Rental Vehicle Damage
        coverage if Comprehensive and/or Collision coverage has been rejected by the applicant.

Arizona Personal Auto Application ACORD 90 AZ (3/97)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are not
available. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.
Statement added to the back of the form, referencing the Arizona Supplement, ACORD 61 AZ, which must be signed by
the applicant.
Arkansas Personal Auto Application ACORD 90 AR (10/2000)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.

Personal Injury Protection coverages are revised to reflect unique Arkansas coverages and options. Refer to your state
  manual.
Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorists Property Damage is not
  available.
Statement added to the back of the form, referencing the Arkansas Supplement, ACORD 61 AR, which must be used if
  the applicant chooses Uninsured or Underinsured Motorists Bodily Injury coverages less than the limits of the policy's
  basic Bodily Injury Liability limits.
California Personal Auto Application ACORD 90 CA (1/2000)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
does not apply. This is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists
coverage. Reference to "Waiver of Collision Deductible" is added. Statement added referring to the offer of Uninsured
Motorists coverage up to the Bodily Injury Liability coverage in the policy, and the applicant's right to select lower limits,
reject coverage for certain drivers, or reject UM coverage entirely. If the applicant chooses any option other than limits
equal to the policy's BI limits, the California Auto Supplement, ACORD 61 CA, must be signed. Statement added referring
to the offering of a Waiver of the Collision deductible. A column titled "Good DRV" is added to the Resident and Driver
Information section, to recognize "Good Drivers" as required by California Law. The column titled "Defensive Driving
Date" is retitled "ACC Prev CSE Date" (Accident Prevention Course Date). A General Information question (No. 15) is
added, relating to brokered business. The Fair Credit Reporting Act on the back of the form is editorially revised. The
generic fraud statement is replaced by a fraud statement now mandated by California law. A statement is added to the
back of the form as required by California law, advising the applicant of his or her rights with respect to "good driver"
policies.
Provision is made in the Applicants section to record the name of the registered owner if different from the applicant. A
field to record date leased, if applicable, is added to the Vehicle Description/Use section. An instruction is added to
General Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver
numbers is added to General Information question 11 (regarding physical/mental impairments). A new General
Information question 17 is added to capture the years licensed to drive motorcycles, when such vehicles are to be
insured. This complies with a new California requirement.

Colorado Personal Auto Application ACORD 90 CO (1/99)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are replaced with Colorado's unique coverages and options. Refer to your state manual. Underinsured Motorists
coverage is included in Uninsured Motorists coverage. Statements added referring to the explanation and offer to the
applicant of Uninsured Motorists coverage, and the right of the applicant to select/reject coverage. If Uninsured Motorists
Bodily Injury coverage is rejected entirely, the applicant must initial the statement.
Connecticut Personal Auto Application ACORD 90 CT (10/96)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Although the Connecticut legislature
revised the state's no-fault law January 1, 1994, so that these coverages are no longer mandatory, coverage can still be
made available. Many companies are continuing to offer Basic Reparations Benefits and/or Added Basic Reparations
Benefits (no-fault coverages). Consequently, these items are included in to the Coverages/Premium section. Uninsured
Motorists and Underinsured Motorists coverages are combined. Uninsured Motorists Conversion coverage is added to
the Coverages/Premiums section. This coverage can be purchased instead of Uninsured/Underinsured Motorists
coverage. Full Glass Optional coverage added to Comprehensive. Reference to the Privacy Act notice is added. This
notice must be given to the applicant in this state.
Delaware Personal Auto Application ACORD 90 DE (8/98)
Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is
added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. Reference to
"Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agents that charge policy
fees. Added instruction in the Resident and Driver Information section to show name as it appears on drivers license. At
the request of the Delaware Department of Insurance, "3 years" is printed in the sentence in the Accidents/Convictions
section relating to information about accidents and traffic violations. A note is added to the Employment Information
section requiring that self-employed applicants state the nature of their business. An instruction is added to General
Information question 2 requiring that the cost of special equipment be provided. An instruction to list driver numbers is
added to General Information question 11 (regarding physical/mental impairments). Reference to "no-fault application" is
removed from the Attachments section. Such forms are no longer necessary. The "Applicants Statement" on the back of
the form is editorially revised. These revisions will be made to all state-specific ACORD 90 forms, but only when other
specific changes must be made in the individual states.
District of Columbia Personal Auto Application ACORD 90 DC (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to reflect D.C.'s unique coverages and options. Refer to your state manual. Statement added referencing the
offer of Uninsured and Underinsured Motorists coverages, and the applicant's right to select coverage limits, and reject
Underinsured Motorists coverage. Statement added allowing the applicant to reject Personal Injury Protection coverages.
Applicant must signify rejection by initialing the form. Question relating to cancellation or declination of coverage is
deleted; this question cannot
be asked in D.C.
Florida Personal Auto Application ACORD 90 FL (7/2000)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to reflect Florida's unique coverages and options. Refer to your state manual. Underinsured Motorists/Bodily
Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property
Damage coverages are not available. References to "stacked" and "non stacked" options are added to Uninsured
Motorists coverage. Statement added to the back of the form referencing the various Uninsured Motorists coverage
options, and the use of the state supplement, ACORD 61 FL, if Uninsured Motorists, or non-stacked coverage, is rejected.
The fraud statement is revised to comply with a new Florida law.
Georgia Personal Auto Application ACORD 90 GA (10/96)
Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
does not apply; this is not a "no-fault" state. Uninsured Motorists coverage includes Underinsured Motorists coverage;
provision is made for per-accident deductibles under Uninsured Motorists coverage. Required statements have been
added to the back of the form:
1. Noting if copies of the Privacy Act and Fair Credit Reporting notices have been given to the applicant
2. Referring to the state supplement containing explanation and selection options for Uninsured Motorists and Medical
   Payments coverages
3. Providing a statement regarding the advance payment of the first sixty days of coverage by the applicant, unless the
   policy is a continuation of another policy, and there has been no lapse in coverage
Hawaii Personal Auto Application ACORD 90 HI (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
and options available. Refer to your state manual. The applicant can select "stacked" or "non-stacked" Uninsured and
Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available.

Idaho Personal Auto Application ACORD 90 ID (11/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are
not available. Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists
Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits, and the applicant's right to select other limits,
or to reject coverage entirely.
Illinois Personal Auto Application ACORD 90 IL (8/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
deleted; this is not a "no-fault" state. Uninsured and Underinsured Motorists Bodily Injury coverages are combined;
Underinsured Motorists Property Damage coverage does not apply; Uninsured Motorists Property Damage coverage is
shown separately. Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.
Statement added referring to the state supplement, ACORD 61 IL, with respect to the selection of
Uninsured/Underinsured Motorists Bodily Injury Liability coverage lower than the Bodily Injury Liability coverage in the
policy, or the selection of Uninsured Motorists Property Damage coverage for vehicles not covered by collision insurance.
Indiana Personal Auto Application ACORD 90 IN (8/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the offer of Uninsured
and Underinsured Motorists Bodily Injury and Property Damage coverages. The applicant must initial the statement if any
coverage is rejected.

Iowa Personal Auto Application ACORD 90 IA (10/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured Motorists and Underinsured Motorists coverage sections include
reference to "stacked" and "non-stacked" coverages; Uninsured and Underinsured Motorists Property Damage coverages
are not available. Statement added to the back of the form, referencing the state supplement, ACORD 61 IA, the offer of
various Uninsured and Underinsured Motorists Bodily Injury coverage options, and the applicant's right to select or to
reject coverage entirely. If the insured decides to select "stacked" UM or UIM, or to reject either UM or UIM coverage, the
state supplement must be signed.
Kansas Personal Auto Application ACORD 90 KS (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
have been revised to allow for Kansas options. Refer to your state manual. Uninsured Motorists coverage includes
Underinsured Motorists coverage; however, there is no Property Damage coverage available. Information relating to
accidents or convictions on the front of the form is limited to the last 3 years, as is information regarding license
suspension/revocation on the back of the form. Reference to the Privacy Act notice is added. This notice must be given to
the applicant in this state. A required statement has been added to the back of the form, advising the applicant that auto
liability insurance may be available through the Kansas Automobile Insurance Plan. In addition, a statement has been
added to the back of the form requiring the applicant to acknowledge available Uninsured Motorists coverage options,
including the option of rejecting UM limits higher than the mandatory minimum limits.
Kentucky Personal Auto Application ACORD 90 KY (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Provision is made to report the "Tax
Territory" as required by Kentucky Law. Personal Injury Protection coverages are revised to reflect Kentucky's unique
coverages and options. Refer to your state manual. Uninsured and Underinsured Motorists Property Damage coverages
are not available. Added section to the back of the form to allow descriptions of motorcycles, and named individuals to be
covered, as required under PIP options. Provided statement referencing the explanation to the applicant of Uninsured
and Underinsured Motorists coverages and available options; provided space to allow the applicant to reject UM and/or
UIM. The fraud statement on the back of the form is revised to reflect a new Kentucky law.
Louisiana Personal Auto Application ACORD 90 LA (6/98)
Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is
added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. Provision is made
to select "Economic & Non Economic" Loss coverage or "Economic Loss only" coverage in the Uninsured Motorists
coverage item. Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those
companies or agent sthat charge policy fees. Added instruction in the Resident and Driver Information section to show
name as it appears on drivers license. A note is added to the Employment Information section requiring that self-
employed applicants state the nature of their business. An instruction is added to General Information question 2
requiring that the cost of special equipment be provided. An instruction to list driver numbers is added to General
Information question 11 (regarding physical/mental impairments). The "Applicants Statement" on the back of the form is
editorially revised. The statement relating to Uninsured Motorists BI and PD coverage selection and rejection is revised to
refer to the new Louisiana Auto Supplement. The new supplement must be used if UMBI or UMPD coverage is rejected,
or if the applicant selects UMBI coverage lower than the policy's liability limits. These revisions will be made to all state-
specific ACORD 90 forms, but only when other specific changes must be made in the individual states.
Maine Personal Auto Application ACORD 90 ME (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Bodily Injury coverages are
combined.
Uninsured and Underinsured Motorists Property Damage coverages are not available. Statement added to the back of
the form, referencing the offer of Uninsured/ Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily
Injury Liability limits and the applicant's right to select lower limits, or to reject coverage entirely.
Maryland Personal Auto Application ACORD 90 MD (1/98)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to reflect Maryland's unique coverages and options. Refer to your state manual. Underinsured Motorists
coverage is included in Uninsured Motorists coverage. A limit of three years is added to the question relating to accidents
and convictions on the front of the form, as required by the Maryland Insurance Department. Statement added to the
back of the form, referencing the state supplement, ACORD 61 MD, which must be given to the applicant if Personal
Injury Protection coverage is rejected, or if Uninsured Motorists' Bodily Injury coverage less than the limits of the policy's
Bodily Injury Liability limits is selected.
Application For Massachusetts Motor Vehicle Insurance ACORD 90 MA (1/2000)
This application is entirely different than applications in other states. Therefore, all the instructions for completing the form
are provided.

The state of Massachusetts requires personal automobile, new business and renewals, to be submitted on forms that are
prescribed by the Massachusetts Commissioner of Insurance. The ACORD 90 MA, Application for Massachusetts Motor
Vehicle Insurance, meets the
prescribed requirements. Questions or comments regarding this form should be directed to the Massachusetts Automobile
Insurance Bureau.

This application is designed for up to two vehicles and six operators. If these limits are insufficient, attach an additional
ACORD 90 MA.

Company/Producer
Name of the insurance company that will receive the application or name of the producer submitting the application. Use
the actual name of the company within the group in which you wish to have the policy issued. Do not use group names.

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

Binder/Policy
Number assigned by the agent, if a binder is used, or the company, if the policy number is known.

Effective Date
Month, day and year on which the terms and conditions of the policy will commence.

Expiration Date
Month, day and year on which the terms and conditions will terminate unless renewed.

Applicant's Name and Residential 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 the additional insured 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 correspondence.

Phone
Telephone number at which the applicant may be reached, including area code and extension, if applicable.
Mail Address (if different)
Address at which the applicant is to receive mail; this may be a P.O. Box.

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.

Deposit Premium
Deposit submitted with the application.

COVERAGES

Space is provided for two vehicles. Coverages 1-4 are compulsory and must be provided for each vehicle. Coverages 5-
12 are optional. The applicant may choose all, none or any number of these optional coverages. Refer to the
Massachusetts Personal Automobile Manual for descriptions of coverages.

Est. Total Premium
Aggregate dollar amount owed to the company for all vehicles on this policy.

VEHICLE INFORMATION

Principal Garaging - City or Town and /Zip
City or town in which vehicle number one is primarily located.

Year
Model year of the vehicle.

Make
Vehicle manufacturer.

Model
Manufacturer's trade name for the vehicle.

Motorcycle CC
Number of cubic centimeters of displacement for motorcycles.

Vehicle Identification Number
Full vehicle identification number appearing on the title certificate or registration.

Registration Plate Number
Number on the license plate for the vehicle.

Date of Purchase
Year the applicant acquired the vehicle.

Cost New
Original cost of the vehicle.

Estimated Annual Mileage
Total estimated annual mileage for each vehicle.

Odometer Reading
Current number of miles on the odometer.

Air Bag/Passive Seat Belt
Answer "Yes" if the vehicle is equipped with an air bag or automatic shoulder harness seat belt.

Anti-Theft Device
Answer "Yes" if the vehicle is equipped with an anti-theft device.

Vehicle Recovery System
Answer "Yes" if the vehicle is equipped with a vehicle recovery system.

Leased Auto
Answer "Yes" if the vehicle is currently provided through a leasing program.

Secured Lender/Lessor
Provide complete name and mailing address of the lending institution holding the loan on the vehicle.

Date of Final Payment
Date on which the vehicle's loan payments will be completed.

DRIVER INFORMATION

Operator Name
Name of each licensed operator (resident or not). Show the applicant as driver #1, even if not an operator.

Date of Birth
Birth date of each driver and household resident (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44).

Driver's License #/Licensed State
The complete driver's license number for each licensed operator. Copy directly from license if possible. List the licensed
state for each operator.

Date First Licensed
Month and year in which each operator became licensed. Enter both dates if applicable.

Approved Driver Training
Answer "Yes" if the operator has completed an approved driver training course.

% of Use
Indicate how much each vehicle is driven by each operator. Usage for each operator should total to 100%.

Driver Information Questions
Answer questions A through F with respect to all listed operators. Explain "Yes" responses in the Description of Incident
section.

Fully describe accidents or convictions, including the number of vehicles involved and the type of vehicles (private
passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail. Use
Remarks section or an additional piece of paper if necessary.

Location
City and state of the accident or conviction.

Date
Date of the incident.

GENERAL INFORMATION

Provide a complete explanation in the Remarks section for any "Yes" responses for questions 1-7. Use additional paper if
space in the Remarks section is inadequate. Respond to questions 8-12 in the spaces provided.


Michigan Personal Auto Application ACORD 90 MI (10/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Additional Property Damage Liability
coverage in the amount of $500.00 is a basic liability coverage. Personal Injury Protection coverages have been revised
to allow for unique Michigan coverages and options. Refer to your state manual. No property damage coverage is
available under Uninsured or Underinsured Motorists. Several collision options are shown. Refer to your state manual.
The "Good Student" box in the Resident and Driver Information section is deleted, as required by the Michigan Insurance
Bureau. Information relating to accidents is limited to the last 5 years, and information relating to coverage cancellation or
declination is limited to the last 3 years. Reference to Young Driver Questionnaire, Good Student Certificate and Medical
Statement are deleted from the Attachments section. The Fair Credit Reporting Account Statement, Fraud Statement and
Applicants Statement on the back of the form have been revised to comply with Michigan law and regulations. The
question "How long have you known the applicant?" is deleted, to comply with regulations. Provision is made to allow
individuals covered under the policy who are 60 years of age or older, and who have no expectation of actual income loss
in the event of an accident, to reject coverage for work loss under Personal Injury Protection coverage. Each individual
eligible must sign the application. A statement is added referencing the Michigan Collision Insurance Options Notice
(ACORD 62 MI) which must be given to every applicant for auto insurance in Michigan. A statement is added that
provides the address and phone number of the Michigan Insurance Bureau.
Minnesota Personal Auto Application ACORD 90 MN (1/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
reflects Minnesota's unique coverages. Uninsured and Underinsured Bodily Injury coverage is combined; there is no
Property Damage coverage. Comprehensive coverage can include "Full Glass" coverage; refer to your rating manual.
Information relating to accidents is limited to the last 5 years, and information relating to suspension or revocation of
drivers licenses is limited to l0 years. Reference to the Privacy Act notice is added. This notice must be given to the
applicant in this state. A statement is added requiring the applicant to acknowledge receipt of a copy of the Minnesota
Guaranty Association Notice (ACORD 65 MN). A statement is added requiring the applicant to acknowledge the offering
of Uninsured/Underinsured Motorists coverage up to the limits of BI Liability. A statement is added referencing the
company's right to cancel coverage during the forty-nine days following the issuance of coverage, for any reason not
prohibited by law. The fraud statement on the back of the form is revised to reflect a new Minnesota law.
Mississippi Personal Auto Application ACORD 90 MS (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists coverage's are combined.
Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists coverage's up to the
limits of the policy's Liability limits, and the applicant's right to select lower limits, or to reject coverage entirely. The
applicant must initial the option selected.
Missouri Personal Auto Application ACORD 90 MO (10/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
does not apply; this is not a "no-fault" state. Uninsured and Underinsured Motorist Property Damage coverage's are not
available. A required statement has been added to the back of the form, indicating that the premium quoted is an
estimate only, and that premium charged will be in accordance with the company's filed rates. A statement has been
added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists coverage.
Montana Personal Auto Application ACORD 90 MT (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is not available; this is not a "no-fault" state. Uninsured Motorists Property Damage and Underinsured Motorists
coverage's are not available. A statement has been added to the back of the form, indicating that a copy of the Privacy
Act notice has been given to the applicant. A statement has been added to the back of the form, referencing the offering
of Uninsured Motorists coverage up to the limits of Bodily Injury liability coverage.
Nebraska Personal Auto Application ACORD 90 NE (8/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Fields are added to the Producer
section, to identify "Producer ID" and "Agency ID," as required by Nebraska regulation. Personal Injury Protection
coverages are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage
coverages are not available. Statement added to the back of the form, referencing the offer of Uninsured and
Underinsured Motorists Bodily Injury coverages up to the limits of the policy's Bodily Injury Liability limits and the
applicant's right to select lower limits. The fraud statement is removed. It does not apply in Nebraska.
Nevada Personal Auto Application ACORD 90 NV (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage's
are not available; this is not a "no-fault" state. Underinsured Motorists Bodily Injury coverage is included in Uninsured
Motorists Bodily Injury coverage. Uninsured and Underinsured Motorists Property Damage coverage's are not available.
Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. Statement added to
the back of the form, referencing the state supplement, ACORD 61 NV, which must be given to the applicant to explain
the available options under Medical Payments and Uninsured Motorists coverage.
New Hampshire Personal Auto Application ACORD 90 NH (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage's
are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists
coverage.
New Jersey Personal Auto Application ACORD 90 NJ (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
have been revised to provide for unique New Jersey coverages. Refer to your State Manual. Uninsured and
Underinsured Motorists coverages are combined. Comprehensive is changed to "other than collision coverage".
Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. The fraud statement
on the back of the form is revised to comply with New Jersey law. A statement has been added referencing the offer of
Uninsured/Underinsured Motorists coverage up to the policy's BI limits. A statement has been added referencing the
Insurance Inspection Report, ACORD 94. The producer will indicate if a vehicle inspection has been requested or waived,
according to individual company procedures.
New Mexico Personal Auto Application ACORD 90 NM (11/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists
coverage. Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and
Property Damage coverages up to the limits of the policy's Liability limits and the applicants right to select lower limits, or
to reject coverage entirely. The applicant must initial the option selected.
New York Personal Auto Application ACORD 90 NY (9/2000)
Reference to "Registered Owner if different from above" in the Applicants section is deleted. This item is covered by
General Information question 1. Reference to "Supplementary Uninsured Motorists Coverage" is revised to
"Supplementary Uninsured/Underinsured Motorists Coverage" in the Coverages/Premium section on the front of the form,
and in the last statement on the bottom of the back of the form. These changes are required by a recent change in NY
law.

North Carolina Personal Auto Application ACORD 90 NC (9/2000)
Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section. A new field is
added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable. A field is added in
the Coverages/Premiums section to record information about a new option, "Alternative Economic Loss Coverage."
Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agent sthat
charge policy fees. Added instruction in the Resident and Driver Information section to show name as it appears on
drivers license. A note is added to the Employment Information section requiring that self-employed applicants state the
nature of their business. An instruction is added to General Information question 2 requiring that the cost of special
equipment be provided. An instruction to list driver numbers is added to General Information question 11 (regarding
physical/mental impairments). These revisions will be made to all state-specific ACORD 90 forms, but only when other
specific changes must be made in the individual states.
North Dakota Personal Auto Application ACORD 90 ND (10/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
revised to reflect North Dakota's unique coverages and options. Refer to your State Manual. Uninsured and Underinsured
Motorists Bodily Injury coverages are combined; Uninsured/Underinsured Motorists Property Damage coverages are not
available. Statement is added to the back of the form to allow the applicant to reject Additional Personal Injury Protection
coverage. The applicant must initial the form.
Ohio Personal Auto Application 90 OH (4/98)
The statement on the back of the form relating to Uninsured Motorists coverage is revised to include reference to UMPD,
in addition to UMBI.
Oklahoma Personal Auto Application ACORD 90 OK (10/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is not available; this is not a "no-fault" state. Underinsured Motorists BI coverage is included in Uninsured Motorists
coverage; Property Damage coverage is not available. The fraud statement is revised to comply with Oklahoma law.
Oregon Personal Auto Application ACORD 90 OR (2/98)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to reflect Oregon's unique coverages and options. Refer to your State Manual. Underinsured Motorists
coverage is included in Uninsured Motorists coverage. Reference to the Privacy Act notice is added. This notice must be
given to the applicant in this state. Statement added to the back of the form, referring to the state supplement, ACORD 61
OR, which must be given to the applicant to explain Uninsured Motorists coverage, and the options available.
Pennsylvania Personal Auto Application ACORD 90 PA (9/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
sections have been revised in accordance with unique Pennsylvania coverages and options. Refer to your state Manual.
Provided for the selection of "stacked" or "non-stacked" coverage under Uninsured and Underinsured Motorists BI
coverages. Property Damage coverage is not available. The Fraud Statement is revised to comply with Pennsylvania law.
Puerto Rico Personal Auto Application ACORD 90 PR (3/97)
Following are the differences from ACORD 90, the generic Personal Auto Application. In the "Vehicle Description/Use"
section, reference to "car pool," "odometer reading," "annual mileage," "governing driver" and "anti-lock brakes" were
deleted. Reference to vehicle registration and plate number were added. The "Coverages/Premiums" section is revised to
reflect only coverages offered in Puerto Rico. In the "Resident and Driver Information" section, reference to driver training
and student discounts were deleted.
Rhode Island Personal Auto Application ACORD 90 RI (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists coverages are combined.
Statements are added to the back of the form that:

1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected;
2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if Uninsured/Underinsured
   Motorists Bodily Injury coverage is rejected;
3. Allow the applicant to acknowledge the offer of Uninsured/Underinsured Motorists Property Damage coverage, and the
   options selected. The applicant must initial the options selected.
South Carolina Personal Auto Application ACORD 90 SC (1/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. A box relating to "Facility Code" is
added to the front of the form, to provide information relating to the re-insurance facility. Provision is made to record the
Fire District (required when Physical Damage coverage is written). Medical Payments coverage is deleted; Medical
expenses are included under Personal Injury Protection coverage. A mandatory $200.00 deductible is shown for both
Uninsured and Underinsured Motorists Property Damage coverages.
South Dakota Personal Auto Application ACORD 90 SD (9/98)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to reflect South Dakota's unique coverages and options. Refer to your state Manual. Uninsured and
Underinsured Motorists Property Damage coverages are not available. Statement added to the back of the form to allow
the applicant to select or reject supplemental auto coverage. The applicant must initial the form.
Tennessee Personal Auto Application ACORD 90 TN (11/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists
coverage. A mandatory $200.00 deductible is shown for Uninsured Motorists Property Damage coverage. Statement
added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage coverages
up to the limits of the policy's Liability limits and the applicant's right to select lower limits, or to reject coverage entirely.
The applicant must initial the option(s) selected.
Texas Personal Auto Application ACORD 90 TX (11/96)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are revised to provide for various Texas coverages and options. Refer to your state Manual. Uninsured and Underinsured
Motorists coverages are combined. The Property Damage deductible is $250.00. Comprehensive coverage is replaced
by "Other than Collision"; refer to your State Manual for options. Statements are added to the back of the form requiring
the applicant to acknowledge the explanation of Uninsured/Underinsured Motorists coverage and Personal Injury
Protection, and to acknowledge selection/rejection decisions by initialing the statements.
Utah Personal Auto Application ACORD 90 UT (1/2001)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
reflect the unique coverages available in this state. Underinsured Motorists Property Damage coverage is not available.
A statement is added to the back of the form explaining arbitration as an alternative to court action. This statement is
required by Utah law. A statement is added requiring the insured to initial the selection/rejection of various Uninsured
and/or Underinsured Motorists coverage options.
ACORD 90 VI (2001/03)
Following are the differences specific to the Virgin Islands.
Checkboxes are provided to record NEW or RENEWAL in the APPLICANTS section.
Personal Injury Protection, Uninsured and Underinsured Motorists coverage fields reflect the territory's unique coverages.
Vermont Personal Auto Application ACORD 90 VT (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is not available; this is not a "no-fault" state. Underinsured Motorists coverage is included in Uninsured Motorists
coverage. The Fair Credit Reporting Act Statement is replaced with Vermont's Fair Credit law requirements. A statement
is added to the back of the form, referencing the explanation of Uninsured Motorists coverage to the applicant, and the
applicants selection of coverage.
Virginia Personal Auto Application ACORD 90 VA (10/98)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is revised to reflect the coverages and options available in Virginia. Refer to your state Manual. Underinsured Motorists
coverage is included in Uninsured Motorists coverage. A required statement is added referring to the Company's right to
cancel the policy for any reason within the first 60 days it is in effect, and thereafter for reasons stated in the policy.
Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state. A statement is
added referencing the offering of Uninsured Motorists coverage. Dual lines are provided for the initials of more than one
named insured at the end of the statement on the back of the form relating to Uninsured Motorists coverage selection. A
recent court decision determined that each named insured must acknowledge the offer of UM coverage.

Washington Personal Auto Application ACORD 90 WA (8/2000)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage
is revised to reflect Washington's unique coverages and options. Refer to your state Manual. Added "Auto Loan"
coverage in the coverages/Premium section. Reference to the Privacy Act notice is added. This notice must be given to
the applicant in this state. Statement added to the back of the form referring to the options available under Underinsured
Motorists and Personal Injury Protection coverages and the applicant's right to reject these coverages.
West Virginia Personal Auto Application ACORD 90 WV (11/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Statement added to the back of the form, referencing the state
supplements, ACORD 60 WV, 61 WV, and 62 WV, with respect to the offering and selection of Uninsured and
Underinsured Motorists coverages.
Wisconsin Personal Auto Application ACORD 90 WI (7/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages
are not available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverages are
not available. Statements added to the back of the form:

1. Acknowledging the offer of Medical Payments coverage, and allowing the applicant to reject this coverage; the
   applicant must initial the form of coverage that is rejected.
2. Acknowledging the offer of Uninsured and Underinsured Motorists Bodily Injury coverages, and the options available.
Wyoming Personal Auto Application ACORD 90 WY (1/97)
Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the
balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection is not
available; this is not a "no-fault" state. Uninsured and Underinsured Motorists Property Damage coverage is not available.
A statement is added to the back of the form referencing the offering of Uninsured and Underinsured Motorists coverage.




Personal Inland Marine Application 81 (4/2001)

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide
provides assistance in completing the ACORD Personal Inland Marine Application.

This form can be used as a stand-alone application. It can also be used as a supplement to the Homeowners Application
(ACORD 80) if scheduled personal property is being submitted as part of a homeowners transaction.

The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of
the Personal Lines Sections of the Forms Instruction Guide. On the ACORD website (www.acord.org), this information
appears under the title PERSONAL LINES GENERIC SECTIONS.

APPLICANT INFORMATION

Age
First named applicant's age at time of application.

Marital Status
Marital status of the first named applicant. Examples:

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

Occupation/Spouse's Occupation
A brief text description of the occupation of the applicant(s) named in the top identification section.

Terr Code
Location of the dwelling based on individual state bureau or company homeowner,s manual pages.

Protect Class
Dwelling,s four-character fire protection grade found in individual state homeowner,s manuals.

Fire District/Code Number
Dwelling's fire district name and corresponding five-character code number found in individual state homeowner,s
manuals,

Location of Property
Indicate the physical address of the property to be insured only if it is different from the mailing address.
Dwelling Type(s)
Indicate each residence type. Possible options are:
     •    Dwelling, up to four family building
     •    Townhouse
     •    Rowhouse
     •    Apartment
     •    Condominium
     •    Co-operative.

Construction Type(s)
Primary type of building material used to construct the dwelling.

# Families
Number of families in each listed location.

Other
List any other information that may be required by or helpful to the company receiving this application.

COVERAGES

Enter the amounts of insurance, the rate (carried to three decimal places), and premium (rounded to the nearest whole
dollar) for each applicable coverage.

If objects are stored at different locations, include information for each additional location.

Jewelry
Total amount for all jewelry.

Furs
Total amount for all furs. If more than one category of furs is to be covered, use the blank space provided (Nos. 10-14).

Fine Arts
Total amount for all fine arts. Include paintings, pictures, etchings, sculptures or other objects of art. Note general
information question 2.

Cameras
Includes photographic equipment and supplies; note general information question 5.

Musical Instruments
Includes musical instruments, instrument cases, sound and amplifying equipment; note general information question 5.

Silverware
Includes flatware and other silverware and goldware.

Stamps and Coins
Stamps and coins may either be scheduled individually or blanket coverage may be provided. Check the box below No. 7
if unattended car coverage is to be included.

Golfer's Equipment
Total amount for golfer's equipment.

Personal Computers
Total amount for personal computers.

Unattended Car Coverage (Stamps and Coins)
Additional rating information may be required for this coverage. Check with your company.

Broad Form Pair and Set Coverage
Additional rating information may be required for this coverage. Check with your company.

Non-Mobile Organ Coverage
Additional rating information may be required for this coverage. Check with your company.

Safe Credit
Identify any property stored in a safe. If a bank vault is used, provide the name and address of the bank.

Breakage Coverage
Use an asterisk (*) to identify each item on the Schedule of Property that has breakage coverage.

ACV Loss Settlement/Replacement Cost Loss Settlement
Indicate if either of these options apply.

Blanket Coverage
If coverage is to be written blanket, check the box and attach a statement of values.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "Yes" response.

1. Any protective devices/systems in use?
Provide the details for the system; include the type of system, whether it is local, central, or directly connected to a central
station, and whether it was professionally installed. For scheduled jewelry kept at home, a copy of the alarm specifications
sheet must be submitted to qualify for a credit.

2. Will any property be exhibited?
This question refers to exhibition away from the insured's premises. Provide information regarding exhibition of the
property. Include what type of property, the location where the property will be exhibited, type of exhibition, type of
security, or security devices that may be used, and the duration of the exhibition.

3. Will any special restriction/endorsements apply?
List the endorsements and/or describe the restrictions. If the endorsements/restrictions do not apply to all property classes
or items, designate the classes or items to which they apply.

4. Will any type of deductible apply?
Provide the amount and type of deductible. Designate which classes or items should have the deductible applied.

5. Is any property used professionally/commercially?
List those items used in this capacity. Also, provide an explanation of how the property is used. Include cameras and
musical instruments.

6. 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. If other insurance is
in force, list types of insurance and provide policy numbers. Indicate whether insurance is commercial or personal.

7. Did any loss occur during the last 3 years?
Describe in detail all losses during the last three years; use the Remarks section. Include data on the applicant, the type
of loss, the amount of the loss, the date and the disposition.

8. Any coverage declined/canceled/non renewed?
If this situation occurred, provide the circumstances under which it happened. This question may not be asked in Missouri.

Prior Insurance & Policy Number
Provide the prior insurance company's name and the complete policy number including any prefix or suffix.

SCHEDULE OF PROPERTY

List those items that are to be covered on the policy in this section. Designate which items should receive additional
coverage or rating consideration. Since a total value for each property class must
be provided, group together all items of the same property class and with the same rating characteristics. When working
with a long list of items, you may attach a list of the items rather than completing this section of the application. When
listing items, provide a full description including serial numbers, if applicable. Appraisals or sales receipts must be
included where required.




Vehicle Form

This form stores your client's vehicles. Each record contains complete information about a vehicle. You can use it to add,
edit, or delete vehicle records. The vehicle information can be used to automatically fill certain forms (Automobile Loss
Notice 2, Business Auto Section 127, Personal Automobile Application 90, Personal Auto Policy Change Request 71,
Insurance Identification Card 50, Personal Umbrella Application 83, Commercial Policy Change Request 175, and the
Vehicle Schedule 129).
Automobile Loss Notice 2
The Automobile Loss Notice has a section for one automobile. If you would like to automatically fill the the section, click
the Add / Edit Vehicle button. A list of vehicles that you have assigned to your client appears. Single-click the vehicle that
you would like to add to the form and click OK. Selected fields on the form will be filled with information from the vehicle
record.
Business Auto Section 127
Page 2 of Business Auto Section has sections for 8 automobiles. If you would like to automatically fill the Page 2, click
Add / Edit Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard
and single-click each vehicle that you would like to add to the form and click OK. The form will be filled with vehicles in
the order they were selected in the grid. You can use Shift instead of Ctrl if you with to select a range of vehicles in the
grid.

Personal Automobile Application 90
If you would like to automatically fill the Vehicle Description / Use section of the Personal Auto App, click Add / Edit
Vehicles. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and
single-click each vehicle that you want to add click OK; you can add up to 4 vehicles. Several fields from the Vehicles
form transfers over to the app. You can use Shift instead of Ctrl if you with to select a range of vehicles in the grid.
Personal Auto Policy Change Request 71
This form has a section for three automobiles. If you would like to automatically fill the the section, click the Add / Edit
Vehicle button. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and
single-click each vehicle that you want to add click OK. You can use Shift instead of Ctrl if you with to select a range of
vehicles in the grid. Selected fields on the form will be filled with information from the vehicle records.
Personal Policy Change Request 175
This form has a section for 2 automobiles. If you would like to automatically fill the the section, click the Add / Edit Vehicle
button. A list of vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-
click each vehicle that you want to add click OK. You can use Shift instead of Ctrl if you with to select a range of vehicles
in the grid. Selected fields on the form will be filled with information from the vehicle records.
Personal Umbrella Application 83
Page 1 of Personal Umbrella Application has sections for 6 automobiles. Three automobiles and three recreation
vehicles. If you would like to automatically fill the Page 1, click Add / Edit Vehicles. A list of vehicles that you have
assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that you would like to
add to the form and click OK. The form will be filled with vehicles in the order they were selected in the grid. You can use
Shift instead of Ctrl if you with to select a range of vehicles in the grid.
Insurance Identification Card 50
If you would like to automatically fill Insurance Identification Cards, click Add / Edit Vehicles. A list of vehicles that you
have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle that needs a
form and click OK. Each vehicle that was selected creates a new Insurance Identification Card record. You can use Shift
instead of Ctrl if you with to select a range of vehicles in the grid. If you wish to create multiple ID Cards using the Vehicle
form but wish to avoid retyping information such as State Title, State, Policy Number, Effective Date, Expiration Date, and
client information, you can create a new record and fill in the information one time. Next, click the Add / Edit Vehicles
button, highlight all the vehicles that you wish to create ID Cards for, and click OK.
Vehicle Schedule 129
This form has sections for 7 vehicles. If you would like to automatically fill these sections, click Add / Edit Drivers. A list of
vehicles that you have assigned to your client appears. Press the Ctrl key on your keyboard and single-click each vehicle
that you want to add click OK. Fields from the Vehicles form transfers over to the form. You can use Shift instead of Ctrl
if you with to select a range of vehicles in the grid.
ENTRY HELP
Veh #
Number assigned by the agent to this vehicle for purposes of tracking in the application process.
Year
Vehicle's model year.
Make
Vehicle's manufacturer (e.g., Buick).
Model
Manufacturer's model name (e.g., Regal).
Body Type
Vehicle's body type (e.g., 4 door sedan).
Vehicle Type
Check the appropriate box. PP (private passenger), SPEC (special), or COML (commercial).
V.I.N.
Full vehicle identification number assigned by the manufacturer.
City, State, Zip where garaged
List the location where this vehicle is normally garaged.
Terr
Enter the rating territory in which the vehicle is principally garaged.
GVW/GCW
These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly.
GVW
Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer.
GCW
Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which
the truck-tractor is designed as specified by the manufacturer.
Class
This is the primary industry classification code found in rating manuals for commercial vehicles as determined by:
If this is a fleet or non-fleet policy
Commercial autos by size, business use, radius of operation and whether truck or trailer type
Public autos by type of vehicle, radius or seating capacity
S.I.C.
This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating
manuals.
Factor
This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you
are not rating this application.
Seating Capacity
Used for public vehicles and livery vehicles. Enter the number of passenger seats available.

Sym/Age
Enter the age of the vehicle in years, as follows:
1 = Current model year
2 = First preceding model year
3 = Second preceding model year
4 = Third preceding model year
5 = Fourth preceding model year
6 = All other autos

Cost New
If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and
equipment.
Radius
Enter the appropriate radius code as follows:
L Local
Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging.
I Intermediate
Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging.
LD Long Distance
Regularly and frequently operated beyond a radius of 200 miles.
Farthest Term
For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of
this vehicle, that this vehicle travels to.
Drive to Work/School
If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are:
Drive to Work or School under 15 miles one way
Drive to Work or School 15 miles or over one way
Use
Check the appropriate box for the primary use of this vehicle. Options are:
Pleasure ¾ Private passenger vehicles or pickups/vans not used for business purposes
Farm ¾ Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch
Retail ¾ Pick up or delivery of property to individual households
Service ¾ Transportation of personnel, tools, equipment or supplies to or from a job site
Commercial ¾ The transportation of property in vehicles other than those defined as retail or service
Check Coverages
Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the
symbols indicated in the coverage section of ACORD 137.

Abbreviations are:
Liab ¾ Liability
PIP ¾ Personal Injury Protection ("No Fault" coverage)
Add'l PIP ¾ Additional Personal Injury Protection
Med Pay ¾ Medical Payments
Unins. Mot ¾ Uninsured Motorist
Underins Mot ¾ Underinsured Motorist
Towing & Labor ¾ Towing and Labor
Spec C of L ¾ Specified Cause of Loss
F ¾ Specified Cause of Loss by Fire
F & T ¾ Specified Causes of Loss by Fire and Theft
F ,T, & W ¾ Specified Causes of Loss by Fire, Theft and Windstorm
LSP ¾ Limited Specified Perils
Comp. ¾ Comprehensive Coverage
Coll. ¾ Collision Coverage

Deductibles
Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount, or ST Amt ¾ Stated Amount
basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if
the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the collision
deductible in the space provided.




Personal Umbrella Application 83 (7/2001)

Personal Umbrella or Personal Excess insurance policies are personal lines insurance contracts that provide for
indemnification of third parties as a result of damages and/or injuries sustained due to the insured's negligence with
respect to personal acts. Coverage for negligence arising out of any professional activities and nearly all business pursuits
conducted by the insured is normally excluded. It is important to note that personal umbrellas normally provide personal
injury in addition to bodily injury coverage. While the latter coverage deals solely with physical injuries, the former includes
"injuries" sustained as a result of libel, slander, defamation of character, false arrest and other "non-physical" perils.

Personal umbrellas typically operate in excess of or "overlay" the primary
liability coverage contained in other personal lines insurance contracts such as private passenger auto, homeowners and
watercraft. Coverage limits are written on a combined single limit (CSL) basis. In some cases, Personal umbrellas may
provide basic or "first dollar" coverage for certain types of negligence for which there is no primary coverage. Personal
umbrellas can also overlay coverages afforded under certain commercial insurance contracts such as owners, landlords
and tenants liability policies. They also provide that the insurer will pay legal defense costs on a first-dollar basis in
addition to the policy limits. The majority of personal umbrellas contain a provision for a retained limit which effectively
operates as a per occurrence deductible.

Although insurance coverage afforded by a personal umbrella is typically
operative "worldwide" and specific units at risk (such as automobiles) may be related to locations in varying geographical
locations (rotary territories), premiums are developed on the basis of unique personal umbrella rates applicable at the
insured's primary residence. No known requirement for allocating premiums back to other exposure locations exists.

The underwriting process for any personal lines policy begins with the
submission of a completed application. The generic sections of each personal lines form are explained in the Personal
Lines Generic section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD
website, (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS.

UMBRELLA INFORMATION

Policy Amount
Limit of liability.

Retention
The amount of liability retained by the insured. Retention is generally expressed in whole dollars but can be a percentage.
Optional Coverages to Apply
Insurance companies often provide options or special coverages. Examples:
     •   Professional
     •   Business
     •   Major medical
     •   Uninsured/underinsured motorists

Specifically note each option desired and provide all the information necessary for underwriter review and policy issuance.

In Florida, Indiana, Louisiana, Ohio, Vermont and West Virginia, Uninsured Motorists coverages must be offered in
umbrella policies up to the liability limit of the policy when auto liability coverage is included. In Florida, auto supplement
ACORD 61 FL should be used with umbrella policies. Refer to the instructions for use of this form in the State Forms
section of this guide. In the other states mentioned above, no supplement is required, but the insured must initial the
appropriate statement at the bottom of the back of this form, indicating selection or rejection of UM coverage.

Premiums
Methods for calculating the policy premiums differ by company, but usually include a basic amount. Any additional autos,
residences, watercraft or special options involve additional premiums based on an established schedule.

Calculations
The insurance company may require use of specific multipliers or factors which can be shown here.

PAYMENT PLAN

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.

PRIMARY POLICY INFORMATION

Type of Policy
The most common coverages are pre-printed on the application. Space for additional primary policies in force is provided.

Company/Policy Number
Provide the name of the insurance company and the full policy number including any alphabetical prefix and/or suffix. Be
sure to list all primary policies for all insureds in the household such as children with their own auto policies.

Policy Period
Effective and expiration dates for each primary policy in force.

Limits of Liability
Limits for each policy. Some policies may offer different limits for specific hazards (fire, legal liability or waterskiing) which
must be identified. Use the blank spaces to provide this information.

REAL ESTATE

Location
Address of all owned, leased, rented or occupied residences, buildings, farms and vacant land.

Description
Differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the
number of acres if farm land.

Interest
Show the interest of the applicant (owner, lessor, lessee, occupier, etc.) for each described location.

Yr Built
Year the dwelling was built, use four digits (e.g., 1952).

Occupancy
Identify the occupants of the premises (self, self and tenant, tenant, three families, doctor's office). Indicate if the
occupancy is seasonal.

AUTOMOBILES

Year and Make and Model
List all automobiles owned, leased or furnished for regular use.

RECREATIONAL VEHICLES

Year and Type, Make and Model
Provide the same information as for automobiles; be specific regarding the type of vehicle. Specify if it is a dirt bike, van,
scooter, etc. Include size of engine in cubic centimeter displacement and/or horsepower.

WATERCRAFT

Year
Model year of the unit in YYYY format. If built at home, the year built.

Motor Type, Manufacturer and Model
Indicate type of motor (inboard, outboard, etc.), manufacturer and model.

Length
Overall length measured in feet from bow to stern.

Horsepower
Total horsepower of the watercraft.

Max Speed
Enter the maximum speed of the craft. State if measured in knots or miles per hour.

Value
Companies may require either one or both dollar amounts. Indicate in the corresponding box whether cost new or current
value applies. If two amounts are required, enter the cost new first.

Waters Navigated
Body of water or geographical area navigated (e.g., Atlantic, Great Lakes, Inland Waterways, Pacific, Rivers). Specific
names (Hudson River, San Francisco Bay) can also be provided.

OPERATOR INFORMATION

Name
Names of all household members and all operators of vehicles or watercraft, even if they are not members of the
household. The listing should include children at home or relatives/friends who may use a vehicle or watercraft.

Sex/Mar Stat

Sex and marital status of each driver and household member..

Date of Birth
Date of birth of each driver and household resident (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44.)

Drivers License #/Licensed State
Complete drivers license number and license state for each licensed operator. Copy directly from license if possible.

Social Security #

Social security number for each driver.

Vehicle, % Use
The vehicle operated by each of those named above, the percentage of use of the vehicle attributed to that operator, and
annual mileage or any other information required by the insurance company.

Craft, % Use
The watercraft operated by each of those named above, the percentage of use of the craft attributed to that operator, and
annual mileage or any other information required by the insurance company.

EMPLOYMENT

Occupation
Some job titles are not very specific (Manager, Analyst). Expand upon the title as necessary (e.g., Department Manager of
Plastics Manufacturer).

Employer's Name and Address
Name of the employer and the address of the location where employed.

Yrs Empl
Number of years the applicant(s) has been with the employer indicated above. If less than 3 years, provide the number of
years in the same or other career field or industry in the Remarks area.

PRIOR EXPERIENCE
Losses
Follow the company guidelines for required information on prior losses.

Prior Carrier and Policy Number
Provide the prior insurance company's name and the complete policy number, including prefix and suffix.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any of the questions below answered with a "Yes"
response.

1. Any aircraft owned, leased, chartered or furnished for regular use?
This does not include scheduled commercial airlines. If the applicant is a licensed pilot, the company may require
additional information.

2. Any operators convicted for any traffic violations?
Provide the name of driver involved, the date and nature of the violation and/or conviction.

3. Any operator have physical /mental impairment?
Provide the name of the driver and the details. Determine if the operator's impairment (e.g., amputation or epilepsy) could
hinder the safe operation of a vehicle. Provide a description of any special equipment installed and treatment or
medication being administered.

4. Any swimming pool on premises?
If there is a swimming pool on any covered premises, indicate whether the pool is above/in ground and whether there is
an approved fence.

5. Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes?
Describe all commercial or business use.

6. Any real estate, vehicles watercraft, aircraft owned, hired, leased or regularily used, not covered by primary
policies?
If yes, explain why no primary coverage exists.

7. Do you engage in farming operation?
Describe all farming operations performed by the applicant including custom farming. Include size of the farm, its acreage
and annual sales.

8. Do you hold any non-compensated positions?
List any unsalaried or other philanthropic position the insured holds. Examples:
      •   Corporation's board of directors
      •   Master of a lodge
      •   Commodore of yacht club

9. Any full-time employees?
If the applicant employs any full or part time employees, provide information on whether they work inside or outside,
number of employees, duties, number of hours worked per week and total payroll (e.g., housekeeper, gardener).

10. Any non-owned property exceeding $1,000 in value in your custody?
If the applicant is responsible for the property of others, list the type of property. Examples:
      •    Firearms
      •    Art
      •    Computers

11. Any business and/or professional activities included in primary policies?
Provide the nature of such professional or commercial activities and whether or not income is produced.

12. Any primary policy have reduced limits of liability?
Include any primary policy endorsed to limit, restrict, exclude or otherwise modify coverage provided by the basic policy
form (e.g., liability may be reduced when the applicant is using watercraft for waterskiing, or for a youthful operator when
operating a motor vehicle).

13. Any coverage declined, cancelled, non-renewed?
If any policy had this action taken, provide the reasons and circumstances. This question cannot be asked in Missouri.

14. Does applicant or tenants have any animals or exotic pets?
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.
15. Has insurance been transferred within agency?
Indicate if prior carrier information shown on the front of the application represents a policy being transferred within the
agency. Give reason for transfer.

16. Any pending litigation, court proceedings or judgement?
If yes, describe in detail.




Policy Certification Log 26 (9/93)

Use the Policy Certification Log (ACORD 26) with the Certificate of Property Insurance (ACORD 24), the Certificates of
Liability Insurance (ACORD 25-N & 25-S) and the Evidence of Property Insurance (ACORD 27). Its purpose is to keep a
manual record or to prepare a hard copy of a computer record of all certifications issued for a single insured. The form
summarizes the information contained in the above forms and identifies several key items to check when issuing
renewals.
IDENTIFICATION SECTION
Producer
Producer's name and address.
Insured
Name and mailing address of the insured as found on the declarations page of the policy.
Companies Affording Coverage
Names of the companies affording coverage to the insured for which a Certificate of Insurance or Evidence of Property
Insurance form has been issued.
Policy Period
Effective and expiration dates for the referenced policies.
CERTIFICATES/EVIDENCE
Certificate/Evidence Holder
ACORD 25-S and ACORD 27.
Mailing Address
Mailing address for the corresponding certificate holder(s) or additional interest(s).
Line of Business
Enter appropriate abbreviations for the coverages indicated on the Certificate of Insurance or Evidence of Property
Insurance. Examples:
WC = Workers Compensation
GL = General Liability
Auto = Automobile
HO = Homeowner
Co Ltr
Company Letter from the Companies Affording Coverage Section for the company providing the corresponding coverage.
Sched Auto
Check this box if the Certificate of Insurance or Evidence of Property Insurance was issued for a specific auto that is
scheduled on a policy.
Word Change
Indicate if the wording that appears on the Certificate of Insurance or Evidence of Property Insurance has been changed.
Add Ins
If the Certificate/Evidence Holder has been added to the policy as an Additional Insured, mark "X " in this field.
Perm
Indicate if a new Certificate/Evidence is to be issued annually.
Date Issued
Month/day/year the Certificate/Evidence was issued.
# Days Canc
Indicate the number of days given within the Cancellation portion of the Certificate of Insurance or Evidence of Property
Insurance.
Month/Year Certification Expires
Month and year the certification expires.
Property Loss Notice 1 (2/2001)

Use the ACORD Property Loss Notice (ACORD 1) for reporting commercial and personal lines property losses including
Homeowners, Dwelling Fire, Inland Marine, Commercial Property, Flood, Wind and others.

IDENTIFICATION SECTION

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

Producer
Producer's name and address.

Phone (A/C, No, Ext)
Producer's telephone number.

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

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

Agency Customer ID
Customer's identification number assigned by the agency.

Miscellaneous Info
Use this field for large accounts to list site and location codes or to enter the claim number on a phone-in report.

Date & Time of Loss
Date and approximate time that the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g., 01/11/94 -
12:15 A.M.).

Previously Reported
Indicate if this is the first report on the loss that has been given to the company; whether written or by telephone. If not, list
in the Remarks section when other report(s) have been made.

Policy Type
Complete the company name and policy number for the types of policies written. Do not repeat the property/homeowners
company name and policy number unless flood and/or wind coverages are written on separate policies.

Property/Home
For commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies.

Flood
For monoline flood policies.

Wind
For monoline wind/hail policies.

Company
Name of the applicable insurance company and the company's NAIC number. Use the actual name of the company within
the group to which you are sending the loss notice. Do not use group names.

Policy Number
Number assigned by the insurance company for the policy.

Effective Date
Date on which the terms and conditions of the policy commenced.

Expiration Date
Date on which the terms and conditions of the policy will or have expire(d).

INSURED

Name and Address of Insured and Spouse
Name and mailing address of the insured and spouse (if applicable) as found on the declarations page of the policy.

Date of Birth, Soc. Sec. # or FEIN
Date of birth and social security number or Federal Employer Identification Number for both the insured and spouse (if
applicable).

Residence Phone
For an individual, the home telephone number, including area code of the insured.

Business Phone
Business telephone number, including area code and extension of the insured.

CONTACT

Contact Insured
If the individual to contact for information is the same as the named insured, check this box and leave blank the areas for
contact name, address and phone numbers.

Person to Contact
Name and address of the individual to be contacted as a representative of the insured on all subsequent business relating
to this incident. No entry is needed if the 'Contact Insured' option is checked.

Residence Phone
Enter the home phone number, including area code, of the contact named above. If it is the insured, leave this field blank.

Business Phone
Business telephone number, including area code and extension of the contact. If it is the insured, leave this field blank.

Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).

When to Contact
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).

LOSS

Location of Loss
Give the physical location of the loss. If the insured has multiple locations on the policy, include the policy location number
and building number (e.g., insured's home or Loc 3, Bld 2; 151 Main St).

Police or Fire Dept. to Which Reported
Name of the municipal or county police or fire department to which the loss was reported, including the precinct or station
number if available.

Kind of Loss
Indicate the type of loss. Check any appropriate box that may apply to the type of loss. If the loss is different from the pre-
printed options, check the "other" option and list the loss type in the available space.

Probable Amount Entire Loss
Estimate the dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available,
provide a description such as "small" or "substantial".

Description of Loss & Damage
Briefly describe the cause of the loss and resulting damage, including the areas of buildings which were damaged.

Note: If the loss resulted in bodily injury to individuals or damage to the property of others, indicate in the Remarks
Section and complete the appropriate additional claim form.

POLICY INFORMATION

Mortgagee
Name and address of all mortgagees on the property that incurred the loss. If there is more than one, use the Remarks
Section if necessary. If there is no mortgagee, check the appropriate box.

HOMEOWNER POLICIES SECTION 1 ONLY
Use this section for Homeowner and Dwelling Fire policies only. For Homeowner, it is limited to the property coverages of
section 1. Use ACORD 3 for reporting liability losses.

Coverage A Dwelling
Coverage amount provided for the dwelling on the policy. If wind coverage is excluded, check the box below.

Coverage B Other Structures
Coverage amount provided for appurtenant private structures on the policy.
Coverage C Personal Property
Coverage amount provided for unscheduled personal property on the policy.

Coverage D Loss of Use
Coverage amount provided for loss of use/additional living expenses on the policy.

Deductibles
Indicate any deductibles that apply to the policy.

Describe Additional Coverages Provided
Describe and give amount for any additional property-related coverages on the policy.

Subject to Forms
Enter all attached policy form numbers and edition dates that affect the policy coverages. For manuscript endorsements,
briefly describe the endorsement.

FIRE, ALLIED LINES AND MULTI-PERIL POLICIES
This section outlines the coverages written on commercial lines policies.

Item
Building number or Inland Marine item number for this subject of insurance.

Subject of Insurance
Indicate whether the corresponding "amount" applies to the coverage of building, contents/personal property, or some
other subject of insurance by marking X in the appropriate box. For other than building or contents subjects of insurance,
list the subject's name in the available space next to the option box. Examples of other subjects of insurance include
business interruption and combined building and contents.

Amount
Dollar amount of insurance provided on the policy for this subject of insurance.

% Coins
Percent of coinsurance that applies to this subject of insurance.

Deductible
Indicate the deductibles that apply to this subject of insurance.

Coverage and/or Description of Property Insured
Describe the coverages written for this subject of insurance and briefly describe the property
insured.

Subject to Forms
Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe
the endorsement.

FLOOD POLICY
This section outlines the coverages issued on a separate flood policy.

Building/Contents
Appropriate building and contents policy limits.

Deductible
Deductible amounts for the building and contents parts of the policy.

Zone
Flood rating zone.

Pre Firm/Post Firm
Check whether the policy was issued based on a Flood Insurance Rate Map (Post Firm) or prior to a map being released
(Pre Firm).

Diff in Elev
Difference in Elevation - Indicate the approximate distance above or below sea level.

Form Type
Indicate whether the flood policy is issued on a general, dwelling or condominium form.

WIND POLICY
This section outlines the coverages issued on a separate wind policy.
Building
Building policy limits.

Deductible
Deductible for the building limit.

Contents
Contents policy limit.

Zone
Wind rating zone if appropriate.

Form Type
Indicate whether the wind policy is issued on a general, dwelling or condominium form.

REMARKS/OTHER INSURANCE
Explain any other property insurance in force at the time of loss. Include company, policy number, coverages and amount
of coverages. Provide any other information that will assist in properly reporting and settling this claim. (For New York
only, provide the previous address of the insured, and the wife's maiden name, if applicable.)

CAT #
If a catastrophe number has been assigned by the Property Claim Service or other industry organization, enter it here.
This is the number assigned to the event which caused the claim being described.

FICO #
If a flood number has been assigned by the Flood Insurance Coordinating Office, enter it here. This is the number
assigned to the flood that caused the claim being described.

Adjuster Assigned
If known, enter the name and telephone number, including area code and extension, of the adjuster assigned to this loss.

Adjuster #
Control number assigned to the adjuster.

Date Assigned
Date the adjuster was assigned to this loss.

Reported by
Indicate the name of the individual who reported the loss.

Reported to
Indicate the name of the individual within the agency or company to whom this loss was reported.

Signatures of Producer and Insured
This form should be signed by the producer and the insured.

Note: Important state information is on the second side of this form.




Property Section 140 (8/2001)

This guide provides the user with basic instructions for completing the
ACORD Property Section Application. The Property Section has been
designed to handle the basic underwriting and rating needs for
commercial property exposures.

The Property Section accommodates two locations, with coverage and
rating information recorded separately for each location.

This form was designed to be used in conjunction with the
CommercialInsurance Application - Applicant Information Section
(ACORD 125). Please turn to the chapter on the ACORD 125 for
information on that form.

IDENTIFICATION SECTION
Much of the information for the Identification Section should match the data found within the
Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it.
Many companies separate the applications by line of business for rating purposes. Not completing
this portion of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address fax and telephone number.

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.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

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

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

Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
40-30-30).

Audit
Use this field to indicate the audit term for policies that are subject to periodic audit. If the
audit period is known, enter the code:

A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other

PREMISES INFORMATION

Complete the front of the form for a single building on a premises, and the back of the form for a
second building or a second premises. Use additional forms for additional buildings or premises.


Premises #
Enter the premises location number as it appears on the ACORD 125 Premises Information
Section.

Building #
Enter the building number(s) associated with this location.

Street Address
Enter the street address as shown on ACORD 125.

Subject of Insurance
Enter all units at risk/coverages that are to be insured at this particular location
number/building number combination. Examples:
    •   Building
    •   Personal Property
    •   Extra Expense
    •   Business Income

Amount
Enter the amount of insurance required for the corresponding subject of insurance.

Coins %
The Coinsurance Percentage is the percentage of the total value of the subject of insurance
being insured. If the amount of insurance falls below this percentage, the insured must share
in the amount of the loss. This field should be completed even when writing agreed amount
coverage.

Valuation
Indicate the method which will be used to determine the amount paid on a claim. Valuation
methods are:

ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value
RC. . . . . . . . . . . . . . . . . . . . . . . . . . . Replacement Cost
AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount
MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value

Causes of Loss
Enter the causes of loss the subject of insurance is to be covered for. Examples:
     •    Basic
     •    Broad
     •    Special excluding theft
     •    Earthquake

Inflation Guard %
The inflation guard percentage gives an automatic increase in the amount of coverage based
on a percentage over time. List both the percentage amount and the period of time during
which it applies (e.g., 4% per year).

Deductible
Enter the deductible amount that is to apply to this subject of insurance.

Blkt Cov

Check this column for each subject of inusrance that is to be included in thecalculation of an average blanket rate.

Forms and Conditions to Apply
Enter all form numbers and special conditions that apply to this subject of insurance. Also
indicate here if coverage is blanket or average rated.

Additional Information - Business Income/Extra Expense
Enter information relating to Business Income and/or Extra Expense coverage that is not
provided above. Check the appropriate box for Business Income/Extra Expense, Business
Income without Extra Expense, or Extra Expense alone.

Type of Business
Check the appropriate box depending on the insured's type of business (e.g., non-manufacturing,
manufacturing or mining).

% Coins
Enter the coinsurance percentage.

Ord Pay
If Ordinary Payroll Exclusion option is selected, check the appropriate box to indicate
either the number of days or the dollar amount of ordinary payroll that is to be excluded. If
no payroll is to be excluded, show "none" for Ordinary payroll.

Power/Heat
If a Power, Heat and Refrigeration deduction is to apply, check the box and show the dollar
amount of the deduction.

Elec Media
If the period of coverage for electronic media and records is to be extended, check the box
and show the number of days of extension.

Ord or Law
If the Ordinance or Law coverage option is to be provided, check the box and show the
number of days applicable.

Ext Period
If the Extended Period of Indemnity option is to apply, check the box and indicate the
number of days selected, and, if applicable, the monthly period of indemnity limit, and the
maximum period of indemnity limit.

Tuition Fees
If this coverage applies, check the box and show the dollar amount applicable to coverage
for student's tuition fees, and the dollar amount applicable to coverage for other educational
services or income.

Off Prem Power
If the Off Premises Power option applies, check the box and indicate if coverage relates to
power, water and/or communications utilities. Describe the utilities and show their
addresses in the space provided.

Depend Prop
If coverage for Dependent Property applies, check the box and indicate the applicable
coinsurance percentage. This percentage may be different from the percentage applicable to
basic Business Income coverage. Also check the box(es) to indicate if coverage applies to
Contributing Locations, Recipient Locations, Manufacturing Locations and/or Leader
Locations. Refer to the ISO Commercial Lines Manual for definitions of these terms.
Describe the dependent property locations and show their addresses in the space provided.

Extra Exp
If Extra Expense coverage applies, check the box and indicate the period of restoration, in
days, selected. If the Limit on Loss Payment option is to apply, show the percentage
limitations selected.

Additional Coverages, Options, Restrictions, Endorsements, Rating
Information
Use this space to enter information on any endorsements or options not provided for above.
Also provide rating information required for these options, or by individual company
programs.

Provide any other coverage information that pertains to this location such as:
     •   Class Rate
     •   Rate Reference
     •   Sales
     •   Earnings

Construction Type
Enter the construction of the premises. Common construction classifications are:
     •    Frame
     •    Joisted Masonry
     •    Non-Combustible
     •    Masonry Non-Combustible
     •    Modified Fire Resistive
     •    Fire Resistive

Distance to Hydrant
Distance (in ft.) from the nearest hydrant that supports the protection class used.

Distance to Fire Station
Distance in miles from the nearest fire station that supports the protection class used.

Fire District/Code Number
The property's fire district name and corresponding code number which can be found in the
individual states manual pages.

Prot Cl
Enter the fire rating protection class for this location.
# Stories
Not including any basement, enter the number of stories for this building.

# Basm'ts
Enter the number of basements.

Yr Built
Enter the year in which the building was first constructed.

Total Area
The number of square feet of the building or area occupied at this location for which
insurance is being requested.

Building Improvements
Indicate if any building improvements have been made since the original construction.
Check all applicable improvements, and list the year the improvement was made after the
improvement name.

Bldg Code Grade
Enter the ISO Building Code Grade, if applicable.

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

Roof Type
Enter the material used to construct the roof. Examples:
     •    Composition (fiberglass, asphalt, etc.)
     •    Metal
     •    Poured
     •    Slate
     •    Tile
     •    Wood Shake/Shingle

Wind Class
Check the applicable box.

Other Occupancies
List any other occupancies located in the building not operated by the insured and not
listed in the Description of Operations section on the ACORD 125. If no other occupancy,
enter None.

HEATING BOILER
If there is a heating boiler on the premises, indicate if insurance is placed elsewhere.

Right/Left/Rear Exposure and Distance
Describe the buildings, structures, activities conducted, or use of property adjacent to the
insured premises and provide the distance from the insured premises.

Burglar Alarm Type
Describe any burglar alarm protecting the building or contents. Descriptive terms such as
safe, premises, perimeter, or ultrasonic may be suitable.

Certificate Number
Enter the Underwriters Laboratories or other testing organization Certificate Number, if
applicable. Attach a copy of the certificate to the application.

Expiration Date
Enter the expiration date of the Certificate.

Extent
Specify the designated extent of protection as described in the ISO crime rating manual.

Grade
Enter the alarm grade as described in the ISO crime rating manual (e.g., AA, A, B, C).

Central Station/With Key
Check all alarm options that apply:

Central Station
The burglar alarm rings at an alarm company or police department.
With Keys
The alarm company, located off the insured's premises, has keys to the applicant's property.

Burglar Alarm Installed and Service by
Enter the name of the alarm company.

# Guards/Watchmen
Enter the number of guards and or watchmen employed or contracted for by the insured.

Clock Hourly
Place an "X" in the box to indicate whether the guard/watchman is required to make hourly
rounds using a special time recording device or in connection with the central station
service. If other than hourly, indicate the time interval in the Other box.

Premises Fire Protection
If the premises is sprinklered, indicate the percentage of the area covered by the system,
whether wet/dry system, if valve monitors are included and if connected to central station.
Cooking facilities, or other special hazards, are often protected by automatic carbon dioxide
or chemical systems or other similar devices. Provide a description. Indicate if the risk
qualifies as a HPR (Highly Protected Risk). Other devices would include smoke detectors.

Fire Alarm Manufacturer
Enter the name of the firm, and if it is UL listed.

Central Station/Local Gong
Check all fire alarm options that apply:

Central Station
The fire alarm rings at an alarm company, police department or fire department.

Local Gong
The fire alarm rings on an audible gong located outside of the building.

ADDITIONAL INTEREST

This section should be used to collect information on any additional interest.

Interest
Check the appropriate box to indicate if the additional interest in the property is a loss
payee or a mortgagee.

Rank
If there is more than one additional interest, indicate who is first mortgagee, second
mortgagee, etc.

Name and Address
List the additional interests' name and address.

Evidence
Indicate if a Certificate of Property Insurance or an Evidence of Property Insurance is
required.

VALUE REPORTING INFORMATION

This section contains information for Reporting Forms. It can also be used to enter policy amounts
for business personal property at locations other than those designated in the Policy Declarations.

Subject of Insurance
Enter the subjects of insurance that are to be covered on a reporting form basis.

Premise 1, 2

If a reporting form is to be used, provide the average values for each premises location for
the prior twelve months.

Any Other Location Declared at Inception
Enter the amount and provide a list of the locations as required. (Available only with
multiple location average rating.)
Any Other Locations Acquired After Inception
Enter the amount of insurance desired. Companies will require that you report new
locations in accordance with policy terms. These locations usually must be reported within
30 days after the end of the month. If not, coverage reverts back to its level at end of
previous report. This may create coinsurance problems.

Premises Not Owned or Acquired Limit
If the policy provides coverage for business personal property at locations not owned, leased
or operated by the insured, enter the premises location limit and aggregate amounts. Also
referred to as Incidental Locations.

REMARKS
Add any additional rating information, comments or other items that will assist in the
classification and rating of this risk.




Small Commercial Acct. Pkg. App 165 (11/2000)

The Small Commercial Account Package Application is a stand-alone application designed to collect a variety of rating
and underwriting information for smaller commercial packages. This application collects information for Property, Inland
Marine, Crime, General Liability, Workers Compensation, Automobile and Umbrella coverages. Agents should check with
their carriers to verify any special limitations applicable when using this application. Complex risks should be requested
using the full commercial lines application series.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Code
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.

Subcode
If your agency uses a sub-code identification system with the company, enter the appropriate code.
Companies
Name of the applicable insurance company and its NAIC code. Do not use group names, but use the actual name of the
company within the group in which you wish to have the policy issued.
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 where the line of business will be placed.
Proposed Eff. Date
Enter the Effective date on which the terms and conditions of the policy will commence.
Proposed Exp. Date
Enter the Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., 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, so indicate and include the date coverage began and attach a copy of the binder. If more than one option applies,
check off multiple boxes.
APPLICANT INFORMATION
Name (First Named Insured & Other Named Insureds)
Enter the 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 are not legal entities.
Mailing Address (including Zip Code)
Address at which the First Named Insured is to receive all correspondence regarding their insurance.
Form of Business Organization
Identify the applicant as an Individual, Partnership, Corporation, Limited Corporation, Joint Venture or Other. If other,
provide a description such as Professional 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.)
SIC Code
Enter the Standard Industry Classification code applicable to the business of the applicant.
Contact for Inspection (Name/Phone #)
Name and 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.
Yrs. In Busin.
Number of years the applicant has been in business. This is important. It helps the underwriter determine the expertise
and business success of the applicant.
PRIOR POLICY(IES)/LOSS HISTORY
Company
Indicate the carrier name, line of business, coverages and policy term.
Losses
Describe any losses, the loss date and amount paid.
Corrective Action
List any action taken to correct losses from reoccurring.
Cancelled, Non-Renewed, Declined
Indicate if the applicant has been cancelled, non-renewed, declined or placed in a non-standard market over the past
three years.
LOCATION
Address (Include county and zip)
Enter the physical street address (not P.O. Box) where the applicant is located. Address should include:
Street number, if any
Pre-direction, if any (example: 150 N Central Ave)
Street name, if any
Street type (examples: st, rd, ave)
Post-direction, if any (example: 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.
Interest
Indicate the interest the applicant has at this location.
Year Built
Enter the year the building was originally constructed.
Area Occup.
Enter the percentage of the building the applicant occupies.
Sq. Ft.
Enter the square footage of the building.
Surrounding Exposures and Other Occupancies
Describe the buildings, structures, activities conducted, or use of property adjacent to the insured premises and provide
the distance from the insured premises. Also include any other occupancies not operated by the insured within the
building where the insured is located.
NATURE OF BUSINESS
Indicate the primary nature of the applicant's operation. Options available are:
Office
Apartments
Service
Condominiums
Retail
Contractors
Wholesale
Other (describe)
DESCRIPTION OF OPERATIONS/OCCUPANCY
This section is designed to tell the underwriter 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.
The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do
not use the classification phraseology from the Commercial Lines Manual or Workers Compensation Manual; it does not
provide adequate detail.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The
overview below lists the expected information that should be added to the remarks section for "Yes" responses.
Do operations involve storing, treating, discharging, applying, disposing, or transporting of hazardous material?
If so, indicate how they are controlled, stored or disposed of. Indicate if the applicant owns or operates any landfills or fuel
tanks.
Are athletic teams sponsored?
Indicate if the teams are composed of employees or others such as Little League.
Are Certificates of Insurance required from sub contractors?
Indicate who checks them, and if coverages are equal to or greater than the applicants.
During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode
Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up
to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.
Describe any location or business interest owned or operated by insured but not listed
List any location or risk that is not to be covered within this package policy.
Annual Sales/Receipts
List the projected sales over the next 12 months.
Total Payroll
List the projected payroll over the next 12 months.
PROPERTY
For each unit at risk list the following:
Amount
The coverage limit.
Valuation Type
Replacement Cost (RC) or Actual Cash Value (ACV).
Infl. %
The Inflation Guard Percentage that is to apply.
Coins
The Coinsurance percentage that is to apply.
Ded
The Deductible limit that is to apply.
Cause of Loss
The cause of loss that is to apply, such as Basic, Broad, Special, or All Risk.
Construction
Indicate the building's construction type.
Fire District/Code Number
The property's fire district name and corresponding code number, which can be found in the individual states manual
pages.
Pr. CL.
Enter the fire rating protection class for this location.

Total Area
The area in square feet that the applicant occupies.
Roof Type
The construction of the roof.
# Stories
Not including any basement, enter the number of stories for this building.
# Units
The number of rental units if this is an apartment or condominium.
Percentage of Building Sprinklered
The percent of the building that is protected by a fire sprinkler system.
Building Improvements
Indicate if any building improvements have been made since the original construction. Check all applicable improvements
and list the year the improvement was made after the improvement name.
Bldg Code Grade
Enter the ISO Building Code Grade, if applicable.
Tax Code
Enter the city, county or state tax code, if required.
Wind Class
Check the applicable box.
OPTIONAL COVERAGES
This section is used to collect information on additional Property, Inland Marine, Crime and Boiler and Machinery
coverages.
Glass
By ground floor and above ground floor panes indicate the following:

# Panes
The number of like size panes
Area
The total area per pane
Length
The horizontal measurement per pane in inches
Type
The use of the pane such as display window
Value
The cost per pane
Deductible
The deductible for glass coverage
Add'l. Info
Any additional underwriting or rating data that may be beneficial.
Property/Inland Marine Options
Enter the limit, coinsurance percentage, and deductible for the following Property or Inland Marine options.

Extra Expense
Loss of Income
Valuable Papers
Accounts Receivable
Signs
Crime
Enter the limits and deductibles for the following Crime coverages.

Employee Dishonesty (include the number of employees)
Burglary/Robbery of Stock
Burglary/Robbery of Money
Boiler and Machinery
Enter the limit and deductible based on Basic or Broad Coverage. If Spoilage is requested, also enter that limit and
deductible. State if there is a separate heating boiler.
Bailees
List the total value of customers' goods stored on the insured premises. If the applicant operates a seasonal storage
operation, enter "yes" for the question about stored beyond normal handling time.
Transit
For Transit coverage, provide the requested values.
CRIME
Complete this section in regards to the location and protection systems for this risk. Information on the classification of
safes, vaults and alarm systems can be found in the Crime Section of the ISO Commercial Lines Manual.
Alarm Type
Indicate the type of alarm(s) protecting this premises, safe or vault. Available options are:

Hold-Up The presence of a manual or semiautomatic control which can transmit an alarm in the event of a hold-up
Burglar - A sensing device installed on premises which transmits an alarm in the event of unauthorized entry
Central Station - An alarm system that protects the safe or vault and is connected to an outside central station
Alarm Description
Indicate any applicable features of the alarm

Local Gong - A bell located outside the premises
Police Connect - Indicate if alarms (hold-up and burglar) are transmitted to Police Headquarters rather than to a private
  control station
With Keys - Indicate if security service or police have Keys to respond to alarms
Grade
Enter the GRADE or class (e.g., A, B, C, etc.). This indicates the time required to respond to a signal from the alarm
system. Please refer to company manual.
Extent of Protection for Safe/Vault
Indicate the extent of the alarm protection for the safe or vault.

Partial - Alarm covers around door only
Complete - Alarm covers sides, top walls, floor, and ceiling
Extent of Protection for Premises
Indicate the extent of the premises alarm as defined in the ISO Commercial Lines Manual.
Alarm Certificate #/Expiration Date
Alarms which are approved by the Underwriters Laboratories (UL) or other testing organizations are evidenced by a
certificate. Record the certificate number and its expiration date.
Safe/Vault/Receptacle Manufacturer
List the manufacturer's name of the applicant's safe, vault or other secured receptacle.
Label
Check the appropriate box to indicate if the rating is based on the Underwriters Laboratories, Inc. (U.L.) or the Safe
Manufacturers National Association (SMNA).
Class
Record the construction classification which represents the extent of burglary protection for this safe or vault. Be sure to
use the classification from the Burglary label and not the Fire label located on the safe or vault. For industry definitions of
the classifications refer to the Commercial Lines Manual.
Maximum Cash on Premises
Indicate the maximum amount of cash kept on the premises during normal business hours.
Maximum Cash With Messenger
Indicate the maximum amount of cash messengers are allowed to carry for the applicant.
Money on Premises Overnight
Indicate the maximum amount of cash left on the premises overnight.
Frequency of Deposits
Indicate the frequency with which deposits are made to the bank (e.g., daily, twice a week).
Dbl. Cyl. Door Locks
Indicate if all doors leading into and out of the applicant's premises have double cylinder door locks.
Other Protection
List any other protection device that the applicant uses.
GENERAL LIABILITY
As part of the package policy, the General Liability section must be completed.
Limits
List all limits as they are to appear on the policy. For Combined Single Limit (CSL) policies list "CSL" and the appropriate
limit in the "Other" coverage and limit section.
Territory
Enter the rating territory code from the appropriate state exception page for each described exposure, based on location.
Class Code
Enter the general liability Class Code that corresponds to the class description shown in the next field. (The class codes
for Premises/Operations and Products/Completed Operations should be the same).
Class Description
Classify the applicant's liability exposures using the ISO Classification Table or other industry organization rules by
location. Enter the appropriate class description from the table in this field.
Exposure Base
Enter the basis for how this class code is rated. Common exposure bases are:
Gross Sales - per $1,000
Payroll - per $1,000 of pay
Area - per 1,000 square feet
Total cost - per $1,000 of cost
Unit - per unit

Exposure
Enter the full exposure for the class.
WORKERS COMPENSATION
Complete this section for Workers Compensation coverage. The Workers Compensation information used on this
application is the same data as included on the Workers Compensation Application (ACORD 130). Please refer to the
chapter on the
ACORD 130 for specific element descriptions.
AUTOMOBILE
Use the appropriate ACORD state-specific commercial auto forms to apply for auto coverage.
UMBRELLA
Complete this section for Umbrella coverage. The Umbrella information used on this application is based on the data
included on the Umbrella Section (ACORD 131-S). Please refer to the chapter on the ACORD 131-S for specific element
descriptions.
SPECIFIC PROGRAM QUESTIONS
Use the Remarks section to provide additional information for any questions answered with a "Yes" response. The
overview below lists the expected information that should be added to the remarks section for "Yes" responses.
APTS/CONDOS
Are there any swimming pools?
List the number of pools and if there are any diving boards.
Is aluminum wiring used?
Indicate the date when wiring was done, and indicate if there is also copper wiring.
# Units in Building or Fire Division
If the building is divided into fire divisions, provide the number of apartment units in the largest fire division. If not, provide
the number of apartments in the building.
Coverage applies to
Indicate if the coverage applies to bare walls or finished walls.
Smoke Detectors
Indicate if smoke detectors are provided in each apartment unit, and whether they are battery operated, or wired into the
building's electrical system.
ADDITIONAL INTEREST
Complete this section for any additional interests to the package policy.
Name & Address
Give the additional interest's name and mailing address.
Interest
Indicate what the interest item is and the interest type. Example:
Building Mortgagee
Vehicle Number 2, Loss Payee
Evidence
Indicate if a Certificate of Insurance or Evidence of Property Insurance is required.
REMARKS
Use this section to provide any additional information required for underwriting or rating.




Statement / Schedule of Values 139 (7/2000)

This form was developed to assist in the collection of information when multiple locations owned or operated by the same
insured will be included in an average or blanket rated property insurance policy, or will be shown in a property schedule.

This form is not intended to replace specific ACORD applications, such as ACORD 140, Property Section, or ACORD
160, Business Owners Application.
Use this space for your notes.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.

Producer
Producer's name, address and telephone number.
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
The company code assigned by the National Association of Insurance Commissioners.
Page
If more than one ACORD 139 form is required because of the number of properties to be included, indicate the page
number applicable and the total number of pages (e.g., Page 1 of 5, Page 2 of 4).
Insured/Applicant
Show the name of the insured or applicant as it will appear on the policy.
Effective Date
Enter the effective date that will apply to the average or blanket rate, or will apply to the policy if the form is used to
provide a schedule.
Coins %
Check the applicable coinsurance percentage, 80%, 90% or 100%.
Applicable Cause of Loss
Indicate the causes of loss for the subject of insurance.
Specific Average Rate/Blanket Rate/Other
Check the appropriate box. If a specific average rate or a blanket rate is not being requested, check the "other" box and
state why the form is being used.
Applicable Form Numbers
Use this space to provide information about endorsements, options, and any information affecting rates or loss costs that
cannot be shown in the schedule on the form.
Class Code
Enter the ISO or Company Class Code, if applicable.
Location #/Bldg. #/Description and Location of Property
For each building, enter the location number, building number and address as shown on the application or change request
that was used when the building was first insured. Provide a description of the property where necessary. Use more than
one line if additional space is required.
ACV/RC
Indicate "ACV" if actual cash value valuation is to apply. Enter "RC" if replacement cost valuation is to apply. If another
valuation basis applies, provide the necessary information.
Subject
Enter the appropriate code to identify the subject of insurance as shown in the instructions on the bottom of the form.
100% Values
Provide the value for each property in accordance with the valuation method and the subject of insurance.
Rate or Loss Cost
For class rated property, attach class rate information or equivalent information for each location. For specifically rated
property, attach specific rate or loss cost information if known.
Premium
Enter the premium for each property in this column.




Supplemental Property Application 190 (1/96)

The Supplemental Property Application is a uniquely designed ACORD application. "Yes" responses to the underwriting
questions on the front side should be explained in detail in corresponding sections on the back of the application. Both
sides of this application must be completed. The instruction information below is formatted by sections; it does not deal
with the front side first and then the back.
IDENTIFICATION SECTION
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
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.
Insured/Applicant
First Named Insured and mailing address as it appears on the Commercial Applicant Information Section, Dwelling Fire
Application or Homeowners Application.
Policy Number
If a policy number has already been assigned to this insured/applicant, enter the number exactly as it will appear on the
policy, including prefixes and suffixes.
Location of Property
Give the location of the property if it is different than the mailing address, or if the mailing address is not sufficiently
descriptive.
UNDERWRITING INFORMATION
A. Ownership Information
List the name, address, position and interest percentage of all major owners for risks other than individuals or
partnerships.
B. Mortgage Payments/Tax Liens Mortgage Payments
For late payments list the Mortgagee's name and address, the date the late payment was due and the amount due. Also,
list any other encumbrances that may be on the property.
Tax Liens/Overdue Taxes
Check if this is a tax lien or overdue tax. List the lienholder or who the tax is owed to in the space under the check-off
boxes. Enter the date and the amount that was due in the available spaces.
C. Violations
Give the date the violation was issued and briefly describe the violation.
D. Convictions/Losses Convictions
Date, description and name of the individual convicted of arson, fraud or property related crime.
Losses
List all fire and explosion losses exceeding $1,000 by date of loss, amount of loss, location and description.
E. Lender
List the lender's name and explain its relationship to the insured.

F. Vacancy/Unoccupancy Season When Unused
For seasonal property and risks when vacancy or unoccupancy is planned, enter the time span when the property is not in
use.
Total # of Apartment Units
List the number of apartments in the building or complex.
# Unoccupied Apartment Units
List the number of units that are currently unoccupied.
Other Buildings, % Vacant
For buildings excluding apartments, list the percentage of the building that is vacant (unoccupied and no furniture).
Other Buildings, % Unoccupied
For buildings excluding apartments, list the percentage of the building that is unoccupied (furnished but no residents).
Anticipated Date of Occupancy
If any tenants are scheduled, list the occupancy date.
Reason for Vacancy/Unoccupancy
List any reasons for the vacancy or unoccupancy, such as seasonal rental property or building renovation.
How is Building Protected from Entry?
List any security measures to protect the building from unlawful entry.
Is there a government order to vacate or destroy the building, or has the building been classified as
uninhabitable or structurally unsafe?
If any of these conditions exist check the "Yes" box.
Are any utilities out of service?
If the electrical, water or gas services have been shut off, explain circumstances in the available space.
Is there unrepaired damage or have items been stripped from building?
If the building is in any form of disrepair or under renovation, describe the damage or process in the available space.
Is the building up for sale?
Enter the listing date.
G. Other Insurance
For other property insurance list the Status (bound, submitted, in force), the effective date, amount of insurance, company
and policy number.
BUILDING INFORMATION
H. Purchase Date
Date of purchase, all transaction dates and seller information over the past three years.
Purchase Price
Amount the insured paid for the property.
Rental Income
Expected annual rental income.
Approximate Cost of Subsequent Improvements
Costs of improvements to the property since first purchased.
Approximate Replacement Costs
Estimated cost to rebuild the building in case of total loss.
Approximate Fair Market Value (Exclusive of Land)
Cost to purchase a similar building without the land.
Insurance Value
Indicate the price used to determine the insurance limit.

Value Determination
Check all methods used to determine the property value and attach copies of any appraisals performed. List the
appraiser's name and any other additional appraisal.
Transportation Section 143 (9/91)

This chapter provides the user with basic instructions for completing the ACORD Transportation Section (ACORD 143).
The section addresses the basic underwriting and rating needs for monoline or package policies with the Inland Marine
coverages of Transportation and Motor Truck Cargo Legal Liability. Applicant Information Section (ACORD 125) and the
Vehicle Schedule (ACORD 129). Refer to the chapters on these forms for specific information on completing them.
IDENTIFICATION SECTION
Much of the information for this section should match the data found within the Applicant Information Section of ACORD
125. Nevertheless, it is still important to complete it. Since many companies separate the applications by line of business
for rating purposes, not completing this part of the application makes it difficult to keep track of the full account.
Date
Month/day/year on which the form is completed.
Producer
Producer's name, address and telephone number.
Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.
Proposed Eff. Date
Effective date on which the terms and conditions of the policy will commence.
Proposed Exp. Date
Expiration date on which the terms and conditions of the policy will terminate unless renewed.
Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30).
Audit
Indicate the audit term for policies that are periodically audited. If the audit period is known, enter the code:
A = annual
S = semi-annual
Q = quarterly
M = monthly
O = other

INTEREST
This part of the form applies to both Transportation Insurance and Motor Truck Cargo Legal Liability. The balance of the
front of this application is used to request Transportation Coverage, and the entire reverse for Motor Truck Cargo Legal
Liability. Indicate the relationship of the applicant to the property being shipped.
Common Carrier
General right to operate as a carrier for any shipper over certain routes and for types of non-exempt commodities.
Contract Carrier
Right to haul interstate for certain customers. The trucker is limited to no more than 10 contracts.
Shipper of Owned Property
Indicate if an insurable interest in the property has been shipped on owned vehicles or other vehicles while in transit by
virtue of ownership.
Other
List any other trucking relationship(s) in detail.
TYPE
Indicate the type(s) of Insuring Agreement desired.
Transportation
Applies when insurance is desired on property owned by the applicant, whether the property is shipped in the applicant's
vehicles or in public conveyances. Provides no Legal Liability coverage.
Motor Truck Cargo Legal Liability
Applies when insurance is desired on property in the care, custody or control of the applicant, and for which the applicant
is responsible as a carrier for hire.
Open or Annual
Indicate if policy is being written on an Open or Annual basis.
Open
Continuous monthly reporting policy. The values change monthly, as reported.
Annual
Policy written with a specified term limit.
Other
Provide pertinent information regarding coverages or explain the applicant's other interest.
TRANSPORTATION
This section should be used to request Transportation Insurance, or coverage on goods owned by the applicant, whether
the goods are shipped in the applicant's own vehicles or on public conveyances. This insurance covers property only and
does not provide coverage for Legal Liability.
OPERATIONS
Property Shipped
Specifically describe the property to be insured while in transit, and indicate if the property is also produced by the
applicant. Attach a supplemental page if necessary.
Points of Origin
Origination point of the property to be shipped.
Points of Destination
Destination to which the property is to be shipped.
Territory
Area of operations for transported merchandise. This may be specific (e.g., a certain city, state or route); or general (e.g.,
eastern states from Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the territory should
also be provided, as well as the number of drivers within the territory.

Annual Gross Sales
Estimated annual amount of sales.
Conveyances Used
Complete sections that apply next to the mode of transportation used to transport the property to be insured.
Annual Value Shipped at Applicant's Risk
Specify per classification, the total annual dollar amount of incoming, outgoing or interplant cargos shipped or received by
the applicant.
Incoming
Dollar value of all yearly incoming shipments.
Outgoing
Dollar value of all yearly outgoing shipments.
Interplant
Dollar value of all yearly shipments sent between the applicant's plants.
Average Value per Shipment
Average value of shipments on any type of conveyance used by the applicant.
Limit of Liability
Limits should be 100 percent of the maximum value carried.
Bill of Lading
Written document explaining the terms of shipment. Specify the released Bill of Lading for the property shipped per
conveyance type (e.g., 60 cents per pound. If full value is insured, indicate on the appropriate line).
Perils
Indicate the perils the coverage is to be written on. Options are All Risk, Named Perils and Named Perils Including Theft.
Deductible
Deductible for the transportation coverage.
Number Operated
Specify the exact number of vehicles used or operated by the applicant for each of the groups listed. Vehicle types are:
Trucks
Tractors
Trailers
Tank Trucks
Refrigerated Units
Special Units Owned/Operated
List all other vehicles owned or operated by the applicant for which this insurance applies (e.g., extra-wide or extra-long or
large tank trucks, mobile cranes, tandem trailers and house movers).
VEHICLE SCHEDULE
Use this section to identify vehicles which transport property of the applicant. The section can be supplemented by the
ACORD Vehicle Schedule (ACORD 129) which highlights important features in the ACORD Vehicle Schedule related to
this coverage line. Not all information found in the ACORD Vehicle Schedule is necessary to complete this application.

Number
Number assigned by the agent to this vehicle to track during the application process.
Model Year
Vehicle's model year.
Vehicle Type
Manufacturer's name, their model name and vehicle body type.
ID#/Serial Number
Vehicle identification number (vin) or serial number assigned by the manufacturer.
Date Purchased
Date the vehicle was purchased.
New/Used
Indicate if the vehicle was purchased new or used.
Radius of Operations
Average radius in miles that this vehicle travels.
F.O.B.
If materials are shipped F.O.B. (Free on Board) point of destination, the seller is liable for damages caused during
transportation. If materials are shipped F.O.B. point of departure, the buyer is liable for damages. Indicate if contingent
coverage is desired on F.O.B. shipments. Contingent coverage is either "in excess of" or "in lieu of" coverage provided by
the shipper and affords protection when the shipper's insurance is incorrect or inadequate, or when differences in
conditions (DIC) exist. Enter the percentage of annual gross sales represented by F.O.B. shipments.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered "Yes." The overview below lists
information that should be added to the Remarks section for "Yes" responses.
1. Is there a vehicle maintenance program in operation?
Explain the type of program and if maintenance records are kept on file.
2. Does applicant obtain MVR verification for drivers?
Indicate if applicant reviews MVRs on all assigned drivers and frequency. Indicate if review is upon hiring
only. If no, explain.
3. Does applicant have a driver recruiting method?
Describe the recruiting method and indicate if written and/or road tests are conducted.
4. Do drivers receive a regular physical?
Indicate the frequency of the physical.
5. Any waterborne shipments to be covered?
Specify the body of water and the method of transportation.
6. Are vehicles equipped with theft alarms?
List the type of alarm installed.
7. Are vehicles left unlocked when unattended?
If yes, give circumstances.
8. Are vehicles left loaded overnight?
If yes, give circumstances. Indicate where trucks are parked, describe any security provided, and who is responsible.
9. Does applicant back haul property of others?
Indicate contract terms.
REMARKS
Use this section to provide any additional information required for underwriting or rating.
MOTOR TRUCK CARGO LEGAL LIABILITY
This section is used to request Motor Truck Cargo Legal Liability insurance, or coverage on property in the care, custody
or control of the applicant, for which the applicant is responsible as a carrier for hire.
OPERATIONS
Property Hauled
Specifically describe the property of others that the applicant hauls.
Gross Receipts Last 12 Months
Amount of gross receipts for shipments handled the past 12 months.
Gross Receipts Next 12 Months
Estimated amount of gross receipts for next 12 months of shipments.
Territory
Area of operations for transported merchandise. This may be specific (e.g., a certain city, state or route); or general (e.g.,
Eastern states from Vermont to Maryland, West Coast states, Midwest, etc.). Major cities covered in the territory should
also be provided as well as the number of drivers within the territory.
Average Distance
State in miles the average distance the applicant hauls.
Maximum Distance
State in miles the farthest distance the applicant hauls.
List Target Commodities Carried
List all property hauled which might be exposed to additional risk, including pharmaceuticals, stereos, computers, meat,
seafoods, televisions, audio-visual equipment, alcoholic beverages, cigarettes, explosives, flammables, auto parts,
clothing and furs.
Percent of Gross Revenues
Percent of gross revenues earned from transporting each target commodity.
Maximum Value per Vehicle
Maximum value of each target commodity carried on any one vehicle.
State Filings Required
List all states requiring filings for the regulation of the trucking industry. Indicate if a P.U.C. (Public Utility Commission),
P.S.C. (Public Safety Commission) or I.C.C. (Interstate Commerce Commission) fileing is required. Enter all known docket
numbers for these filings.
Limit of Liability
Amount of insurance required for each applicable category. If different limits exist for different vehicles, show the limits of
liability per vehicle in the Remarks section or on a separate sheet of paper.
Per Single Conveyance
Amount of insurance required per conveyance which is the aggregate limit being moved by a motorized unit (e.g., Truck
with Semi-Trailer or Full Trailer).
Per Disaster
Specify the overall disaster limit required.
Loading/Unloading
If loading or unloading coverage is desired, place an "X" in the box, and indicate the limit of liability and deductible
desired.
Perils
Indicate the perils the coverage is to be based on. Options are: All Risk, Named Perils, Named Perils including Theft and
Loading/Unloading.
Deductible
Deductible for the chosen perils coverage.
Number Operated
Specify the exact number of vehicles used or operated by the applicant for each of the groups listed. Vehicle types are:
Trucks
Tractors
Trailers
Tank Trailers
Refrigerated Units
Special Units Owned/Operated
List all other vehicles owned or operated by the applicant for which this insurance applies (e.g., extra wide trailers, large
tank trucks, mobile cranes, tandem trailers and house movers).
TERMINALS
Terminal locations are buildings (or enclosed areas) owned or used by the applicant and operated as points of holding,
distribution, warehousing, or layovers for property off vehicles.
Location #
Assign a number to each terminal location. If locations are the same as shown on the Applicant Information Section
(ACORD 125), use the same number in the space provided.
Address
Give the address of each terminal for each location.
Average Value At Terminal
Average value of goods held at each terminal location.
Maximum Value
Maximum value of goods held at each terminal location.
Limit of Liability
Limit required for each terminal location. The limits should be 100 percent of the maximum value carried.
VEHICLE SCHEDULE
Use this section to identify vehicles used by the applicant to transport property of others. This section can be
supplemented by the ACORD Vehicle Schedule (ACORD 129), and highlights important features found in the ACORD
Vehicle Schedule related to this line of coverage. Not all information found in the ACORD Vehicle Schedule is necessary
to complete this application.
#
Number assigned by the agent to this vehicle to track during the application process.
Model Year
Vehicle's model year.
Vehicle Type
Manufacturer's name, model name and the body type for this vehicle.
ID#/Serial Number
Vehicle identification number (vin) or serial number assigned by the manufacturer.
Date Purchased
Date the vehicle was purchased.
New/Used
Indicate if the vehicle was purchased new or used.
Radius of Operations
Indicate the average radius in miles that this vehicle travels.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered "Yes." The overview below lists
information that should be added to the Remarks section for "Yes" responses.
1. Is there a vehicle maintenance program in operation?
Explain the type of program and if maintenance records are kept on file.
2. Does applicant obtain MVR verification for drivers?
Indicate if applicant reviews MVRs on all assigned drivers and frequency. Indicate if the review is upon hiring only. If no,
explain.
3. Does applicant have a driver recruiting method?
Describe the recruiting method and indicate if written and/or road tests are conducted.
4. Do drivers receive a regular physical?
Indicate the frequency of the physical examinations.
5. Are vehicles equipped with theft alarms?
List the type of alarm installed.
6. Are vehicles left unlocked when unattended?
If yes, give circumstances.
7. Are overages, shortages and damage claims pending?
Enter the amount of any such outstanding claims.

8. Are any vehicles operated for the applicant by others?
Indicate if any vehicles are owned, leased or operated solely for the applicant by private or contract carriers. Give
agreement conditions.
9. Do terminals have fire protection (sprinklers, hoses, etc.)?
Describe all such fire protection devices.
10. Do terminals have security systems (guards, alarms, fences, lights, dogs, etc.)?
Describe all such security systems.
11. Are vehicles left loaded overnight?
Indicate where trucks are parked and describe any security provided.
12. Is applicant an owner operator?
Complete vehicle section.
13. Does the applicant hire owner operators?
Give the conditions of all agreements with owners and indicate if an insurance certificate is required.
14. Does the applicant triplease to others?
Give the conditions of all agreements with owners and indicate if an insurance certificate is required.

15. Does the applicant back haul property of others?
Give the conditions of all agreements with owners and indicate if an insurance certificate is required.
REMARKS
Use this section to provide any additional information required for underwriting or rating.




Truckers/Motor Carriers Section 132 (3/2001)

This guide provides the user with basic instructions for completing the
ACORD Truckers/Motor Carriers Section. This Section has been designed to
handle the basic underwriting and rating needs for liability and physical
damage coverages for trucking or motor carrier operations. If a transportation
or motor truck legal liability exposure exists, the Transportation Section,
ACORD 143 (9/91), may also need to be completed.

Insurance coverages, "no fault" and uninsured/underinsured motorists
coverages in particular, vary widely from state to state. In addition, there are
numerous state-specific requirements that apply to Truckers or Motor Carrier
applications. ACORD 132 cannot address these various unique specifications.
Therefore, state specific forms, ACORD 137, have been developed to respond
to these requirements. Use the ACORD 137 for your state to provide
coverages/limits information, as well as the required disclosure and other data
unique to the state. See the State Forms section of this Guide for more
information.

This form was designed to be used in conjunction with the Commercial
Insurance Application - Applicant Information Section (ACORD 125) and
the Vehicle Schedule (ACORD 129). Please turn to the chapters on these
forms for specific information on completing them.

Many states require supplements to all auto applications, to provide specific
coverage explanations or to allow applicants to accept or reject certain
coverages. In some cases, the applicant must be allowed to select among
various options. In others, laws or regulations require disclosure of information
pertinent to auto insurance.

ACORD has provided the necessary supplements in all states. Refer to the State Forms
section of this Guide.

IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the
Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it.
Many companies separate the applications by line of business for rating purposes. Not completing
this portion of the application makes it difficult to keep track of the full account.

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

Producer
Producer's name, address and telephone number.
Phone (A/C, No, Ext)
Producer's telephone number.

Code
Identification code assigned to the agency or brokerage firm by the Insurance Company
receiving this form.

Sub Code
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.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

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

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

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

Payment Date
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.

Audit
Use this field to indicate the audit term for policies that are subject to periodic audit. If the
audit period is known, enter the code:

A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other

REGULATION

This section is used to indicate the relationship between the applicant and the property being
shipped and to indicate any regulatory filings required. Indicate the method of operation by
checking the applicable box(es). Also attach ACORD 194, Request for State/Federal Filing
Action, to provide the necessary filing information.

Common Carrier
Has the general rights to operate as a carrier for any shipper over certain routes and for types
of non-exempt commodities.

Contract Carrier
Has the rights to haul interstate for certain specific customers. The trucker is limited to no
more than 10 contracts.

Private Carrier
Indicates an insurable interest in the property being shipped on owned vehicles or other
vehicles while in transit by virtue of ownership.

DOT Rating, Docket #, ICC Filing
Provide this information if applicable.

Other
List any other trucking relationship in detail in the Remarks Section.

COVERAGE/LIMITS
Covered Auto Symbols
Truckers policies use numeric symbols on the policy declarations to indicate the type(s) of
vehicles for which coverage is in effect. Be sure to place an X in the appropriate box for
each type of coverage. Only those symbols specified for a coverage may be used. Symbols 41
through 45 provide Fleet Automatic coverage. Symbol 41 includes Hired and Non-Owned
auto coverage. If symbol 41 is not used and Hired Auto (symbol 47) or Non-Owned Auto
(symbol 50) coverage is desired, those symbols must be checked.

The symbols indicate the automobiles to which each coverage applies. The symbol
"triggers" the coverage. For exact policy definitions of the symbols, please refer to the
company's policy declarations page.

Symbol 41 - Any Auto
Can only be used for Liability insurance. Its use provides coverage for any auto with which
the insured will have contact, including owned and non-owned and hired vehicles. It
includes coverage for non-owned autos, no-fault, uninsured motorists or physical damage
insurance.

Symbol 42 - Owned Autos Only
Provides coverage for owned autos only and includes automatic coverage for autos you
newly acquire.

Symbol 43 - Owned Commercial Autos Only
Provides coverage for owned commercial autos only and includes automatic coverage for
commercial autos you newly acquire.

Symbol 44 - Owned Autos Subject to No-Fault Laws
Applies to owned autos where no-fault is required by law, including automatic coverage for
autos you newly acquire.

Symbol 45 - Owned Autos Subject to Compulsory Uninsured Motorist
Laws
Applies to owned autos where there is a compulsory Uninsured Motorists law including
automatic coverage for autos you newly acquire where rejection of UM is not permitted by
law.

Symbol 46 - Specifically Described Autos
Provides coverage for scheduled autos only, with no automatic coverage for autos you newly
acquire.

Symbol 47 - Hired Autos Only
Provides coverage only for autos leased, hired, rented or borrowed by the named insured.
This does not include autos owned by employees or members of their families.

Symbol 48 - Trailers in Your Possession Under a Trailer Interchange
Agreement
Provides for trailers listed under a trailer interchange that are left in the applicant's
possession.

Symbol 49 - Trailers in the Possession of Another Trucker Under a Trailer
Interchange Agreement
Provides coverage for your trailers when listed under a trailer interchange that are in the
possession of another trucker.

Symbol 50 - Non-Owned Autos Only
Provides liability coverage for autos not owned by the named insured but used in
connection with the trucking business. This includes autos owned by employees.

Coverage/Limits - Use ACORD 137

RECEIPTS, MILEAGE UNITS

For each of the past three years, enter the gross receipts, total mileage for all vehicles, and the total
number of power units. Also enter estimates for next year.

Commodities
Describe each of the major commodities transported. Enter the percent of total revenues
and the estimated value per truckload.
TERMINALS
This section is used to collect information on the terminal locations that the trucker uses.
#
Assign a number to identify each terminal location. If this location corresponds to one
listed in the Applicant Information Section of ACORD 125, use that number.

Name and Address of Terminals
Enter the name and address of each terminal used.

# Veh
Specify the number of vehicles regularly using or garaged at each terminal.

Dist. From Garage
Enter the appropriate distance between each terminal and the place of principal garaging.

DRIVER INFORMATION

This section is used to collect information on all the drivers that will be covered under this
account. The driver list should include any family member that will be driving company vehicles
and employees who regularly drive their own vehicles for company business.

Driver #
Indicate driver number assigned by the agency/agency-vendor system used for tracking
purposes.

Name
Enter driver's full name. If the company requires the address, enter it as well.

Sex
Enter F for female, M for male.

Mar Stat
Enter the marital status for each listed driver. Examples:

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

Date of Birth
Enter driver's birth date.

Yrs Exp
Enter the number of years of driving experience for each driver.

Year Licensed
Enter year in which the driver was first licensed.

Driver's License Number/Soc. Sec. #
Enter complete driver's license number. If a license number is unavailable, enter the driver's
social security number.

State Lic.
Enter the state in which the license was issued.

Date Hire
Enter the date of hire for each listed driver (MM/DD/YY).

Use Vehicle #
Enter the vehicle number that this driver primarily uses.

% Use
Indicate the percentage of driving done by this driver in the primary vehicle that this driver
uses.

EQUIPMENT
Use this section to summarize information on the trucks and tractors used by the applicant.
Individual specifics on each truck or tractor should be completed in the Vehicle Section, ACORD
129. List the number of vehicles falling into each category.
Company Owned
Specify the number of vehicles, per type, owned by the applicant.

Non-Owned
Specify the number of non-owned vehicles, per type, operated by the applicant.

Long Term Leased
Specify the number of long termed leased vehicles operated by the applicant.

Trip Lease
Specify the number of vehicles operated on a trip lease basis by average number per month.

Radius (miles)
By vehicle type, indicate the number of vehicles that fall within the categories of local,
intermediate, and long distance, in accordance with the companies' manual rules.

TERRITORY/ZONE

Specify the territory in which the applicant normally operates. This may be a certain city, county or
state. If the applicant has any special routes or areas of confined operation, so indicate. List any
specific geographic areas that the applicant may operate out of such as Mid-western States or East
Coast.

For zone rated risks, provide the appropriate numbers or identification information. Zone rating is
designed for trucks, tractors and trailers regularly operated at a distance exceeding 200 miles from
the point of principal garaging. It does not apply to light trucks or trailers used with light trucks.

GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes"
response. The overview below lists the expected information that should be added to the remarks
section for "Yes" responses.

1. Is there a vehicle maintenance program in operation?
Explain type of program and if maintenance records are kept on file.

2. Does the applicant obtain MVR verifications on drivers?
Indicate if applicant reviews MVRs on all assigned drivers and how often. Indicate if review
is upon hiring only. If No, provide explanation as to why MVRs are not reviewed.

3. Does the applicant have a driver recruiting method?
Describe the recruiting method. Indicate if written and/or road tests are conducted.

4. Are any drivers not covered by Workers Compensation?
Provide the names of all drivers not covered.

5. Does applicant own or operate equipment not listed here?
List all equipment not to be covered and explain why. Indicate where coverage is placed for
this equipment.

6. Does applicant haul any dangerous, caustic, radioactive or flammable
cargo?
Specify the type of cargo hauled, the percentage of business involved in this cargo and the
estimated annual revenue derived from hauling this cargo.

7. Does applicant haul target commodities?
Indicate if the applicant hauls any property subject to high incidence of theft. Specify the
type of cargo hauled, the percentage of business involved in this cargo and the estimated
annual revenue derived from hauling this cargo.

8. Do drivers receive a regular physical?
List the frequency of the physical examinations. Example: annual or semi-annual.

9. Does applicant hire equipment from others?
List the source and kind of equipment.

10. Does applicant rent or lease vehicles or equipment to others
with/without operators?
List the vehicles or equipment, drivers name (if any), and who is carrying the primary
coverage.
11. Does applicant haul for other truckers?
Identify the work done for others and the percentage of estimated annual revenue involved
in working for others.

12. Do other truckers operate under the permit of the applicant?
Specify the percentage of the total number of vehicles operated by others under the permit
of the applicant.

13. Is coverage required for travel in Canada or Mexico?
List countries where coverage is required.

14. Are drivers compensated per trip?
Indicate how the drivers are paid: per trip, by mile, by salary, or by contract. Give terms of
agreement for remuneration.

15. Any Hold Harmless agreements?
If any are in effect, state the provisions or attach a copy of the agreement.

16. Any Drivers with moving traffic violations?
Give driver name and number, date, type and place for each conviction. Enter the number
of years reviewed, in accordance with the company's and state's requirements.

17. Do any vehicles have special equipment mounted or attached?
Indicate which vehicles have been altered, customized or equipped with special equipment.

18. Does applicant pull double or triple trailers?
If yes, describe the operations, including the percentage of vehicles in each category.

19. Does applicant have tow trucks or perform towing?
Indicate how many tow trucks are owned or used by the applicant and describe towing
operations.

20. Are vehicles left unlocked when unattended?
If yes, describe how vehicles and contents are protected from unauthorized entry.

21. Are any overage, shortage or damage claims pending?
If yes, describe, and provide dollar amounts.

ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS

Use this section for information on any additional interests, employees who should be listed as
additional insureds, and others who require Certificates of Insurance on the automobile portion of
this policy. For additional names attach an ACORD 45.

Interest
Indicate all appropriate options for the individual named.

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

Name and Address
List the additional interests name and address.

Reference #
Indicate the additional interests reference number for this applicant such as the loan or
mortgage number.

Certificate Required
If a Certificate of Insurance is required check this box.

Interest in Item Number
List the item number corresponding with the application for the item of interest for this
additional insured.

Item Description
If needed, further clarify the item of interest in this field. For a vehicle list the make, model
and VIN number. For a scheduled item list the description, such as 3 carat diamond in six
point setting.
REMARKS

Use this section to provide any additional information required for the underwriting or rating of
this risk.




Umbrella Section 131 (8/2001)

An Umbrella is a liability coverage affording high limit excess and/or
extended coverage. It is a separate policy over and above other basic liability
policies the same insured may have. A completed Umbrella Application
consists of both the Applicant Information Section ACORD 125 and the
Umbrella Section ACORD 131. This is necessary because some information
about the applicant is only shown on the Applicant Information Section.

IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the
Applicant Information Section of the ACORD 125. Even though this data matches the data on
the ACORD 125, it is still important to complete it. Many companies separate the applications by
line of business for rating purposes. Not completing this portion of the application makes it difficult
to keep track of the full account.

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

Producer
Producer's name, address fax and telephone number.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

Proposed Eff. Date
Enter the Effective date on which the terms and conditions of the policy will commence.
It is important that the effective dates of the underlying policies are concurrent with those
of the Umbrella policy when aggregate limits are involved. If the effective dates of the
underlying policies and the Umbrella are not concurrent, the full underlying limits may not
be available for losses that occur during the policy period of the Umbrella and a coverage
gap may occur.

Proposed Exp. Date
Enter the Expiration date on which the terms and conditions of the policy will terminate
unless renewed.

Billing Plan
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 (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
40-30-30).

Audit
Use this field to indicate the audit term for policies that are subject to periodic audit. If the
audit period is known, enter the code:
A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other

POLICY INFORMATION
Transaction Type
Indicate by checking the appropriate box if this is New business or a Renewal request.

Expiring Pol #
For renewal requests, indicate the expiring umbrella policy number.

Proposed Retroactive Date
If Claims Made coverage is being requested, enter the proposed retroactive date.

Current Retroactive Date
The current retroactive date should be shown if the Umbrella is over a Claims Made
primary policy. If the current retroactive date is different from the proposed retroactive date,
an explanation must be provided.

Limit of Liability
Liability is generally on a per occurrence basis. Other options are: per accident, total
products liability hazard, aggregate limits, etc. Enter the policy limit and specify the limit
type if it is not on a per occurrence basis.

In Florida, Indiana, Louisiana, Ohio, Vermont, and West Virgina Uninsured Motorists coverages must be offered in
umbrella policies up to the liability limit
of the policy, when auto liability coverage is included. In Florida auto
supplement ACORD 61 FL should be used with Umbrella policies.
Refer to the instructions for use of this form in the State Supplement section of this
guide. In the other states mentioned above, no supplement is required, but the insured must
initial the appropriate statement at the bottom of the back of this form, indicating selection
or rejection of UM coverage.

Retained Limit
The retained limit on an Umbrella policy functions like a deductible. If a loss occurs that is
covered under the Umbrella, but not covered under the primary, the Umbrella policy
responds in excess of the retained limit.

First Dollar Defense
Most Umbrella policies provide first dollar defense coverage. Some insurers may not offer an
alternative. This coverage is generally in connection with self-insured retention. Place an
"X in the "yes" box if the applicant desires first dollar defense.

Primary Location and Subsidiaries
This section is completed to give additional location information not found on the
ACORD 125.

#
Enter the primary location numbers as they appear on the ACORD 125.

Name and Location of Primary and All Subsidiary Companies
Describe the operation of each of the insured's companies. A restatement of the products
classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC"
could include anything from paper clips to bridge girders).

Large industrial concerns, which are involved in many types of operations, may only
indicate exposures from their major division or operation. The real exposure from an excess
standpoint may be a minor portion of the insured's operation (e.g., an insured that owns or
acquires a subsidiary involved in the manufacture of medical diagnostic equipment).

If the locations are not listed on the ACORD 125, be sure to include their addresses.

Annual Payroll
Provide the estimated annual payroll figures for each entity and operation. This information
is useful to underwriters in analyzing the applicant's exposures. It is also useful when writing
Umbrella coverage on an auditable basis. If there are foreign subsidiaries, state only the
domestic sales.

Ann. Gross Sales
Provide the estimated annual gross sales for each entity and operation.

Foreign Sales
Most Umbrellas provide coverage "anywhere," and do not require a suit to be brought
within the CGL territory definition of the U.S., Canada, and Puerto Rico. If no foreign sales
are shown, it would indicate no operations outside the United States. If foreign sales are
shown, attach information on the products sold, countries involved, and the primary
insurers of foreign products coverage. The limits of this coverage should be expressed in
U.S. dollars.

# Empl.
Enter the number of employees at each primary and subsidiary location.

UNDERLYING INSURANCE

List all liability and Worker's Compensation policies in force that you intend to apply as underlying
insurance. The information about underlying insurance should be as complete as possible since it
will be used by the underwriter to price the Umbrella coverage and complete the Schedule of
Underlying Insurance.

Carrier/Policy Number
Enter the name of the insurance company (carrier) and the policy number for each type of
insurance.

Policy Effective/Expiration Dates
Enter the effective and expiration date of each of the underlying policies listed.
* If these dates are not concurrent with the effective and expiration dates for the
Umbrella coverage, it could result in a failure to provide unimpaired, underlying
aggregate limits.

Limits
Enter the limits as found on the policy declarations pages for each listed underlying policy.
Available coverages listed are:

Automobile Liability
             •     Combined Single Limit (CSL)
             •     Bodily Injury (BI)
             •     Property Damage (PD)

General Liability
              •       Each Occurrence
              •       General Aggregate
              •       Personal & Advertising Injury
              •       Products & Completed Operations Aggregate
              •       Fire Damage
              •       Medical Expense

* For General Liability, indicate if the underlying coverage was issued as either an
Occurrence policy or a Claims Made policy.

Employers Liability
             •     Each Accident
             •     Disease Policy Limit
             •     Disease Each Employee

Annual Renewal Premium
Enter the annual premium for the policy period shown for each underlying policy.

Rating Mod
Enter the Combined Rating Modification, and the experience modification debit or credit
as they apply.

* Space is provided in this section to add other liability policies in force.

UNDERLYING GENERAL LIABILITY INFORMATION

This section provides the Underwriter with a more detailed view of the underlying general liability
policies listed above.

Use the Remarks section to provide additional information for any questions answered with a "Yes"
response. The overview below lists the expected information that should be added to the remarks
section for "Yes" responses.

1. Are defense costs
Check the appropriate box to indicate how the general liability policy responds to defense
costs. Options:
                  •   Within Aggregate Limits
                  •   A Separate Limit
                  •   Unlimited

2. Indicate the edition date of the ISO form or similar filing for the
underlying coverage
Policy coverage may vary depending on the edition date of the policy paper. The underlying
general liability coverage forms issued by ISO vary if they are based on the rules of "86" or
the rules of "88." Enter the edition date of the underlying coverage form in the space
provided.

3. Has any product, work, accident, or location been excluded, uninsured or
self insured from any previous coverage?
Explain any such situation in the Remarks section.

4. For Claims Made, indicate the retroactive date of current underlying
policy
Show the retroactive date of the current general liability policy if it is a Claims Made policy.

5. For Claims Made, indicate entry date into uninterrupted Claims Made
coverage
Indicate when uninterrupted Claims Made coverage became effective. This tells the
underwriter where the applicant is in the Claims Made progression, such as year 3 or 4 of
Claims Made coverage.

6. For Claims Made, was "tail" coverage purchased for any previous
primary or excess policy?
Give details and indicate when the Tail was purchased. The proposed retroactive date for
the policy being applied for should not be earlier than the effective date of the Tail.

UNDERLYING COVERAGES/EXPOSURE
Use this section to indicate all underlying coverages and all known liability exposures.

Use the box to the left of the coverage listing to indicate that the applicant has standard insurance
coverage for the item. The limits must equal or exceed the limits indicated in the Underlying
Insurance section above. If the limits are less, an exposure exists so the exposure box on the right
should also be checked.

Use the box on the right of each coverage listing to indicate if a known exposure exists.

Additional known coverages or exposures should be indicated in the available space.

Known exposures should be elaborated on in the Additional Exposures section on the reverse side
of the application and within the Remarks section.

Underlying Insurance Coverage Information
List all underlying coverage forms, endorsements, subrogation waivers and extensions of
coverages.

Previous Experience
List the loss history over the past five years involving liability claims exceeding $10,000 or
occurrences that may give rise to claims. If there are no such claims or occurrences, "X" the
available box.

CARE, CUSTODY, CONTROL

Many Umbrella policies include coverage for property of others in the applicant's care, custody, and
control, even though such coverage is excluded by the underlying insurance. It is important to
consider and describe this exposure when it exists. Some potential exposures in the applicant's care,
custody, and control include:
                •   Rented or leased equipment
                •   Personal property of others
                •   Leased premises
                •   Goods on consignment
                •   Property of others used or borrowed by the applicant
                •   Each location that has a care, custody, and control exposure should be indicated

Loc
Enter the location number if applicable to the ACORD 125.

Real Property/Personal Property
Check if the "value" listed is a building (real property) or personal property within the care,
custody or control of the applicant.

Value
For real property, include the value of the entire building, not just the portion occupied. For
personal property list the appropriate personal property value.

A, B, C, D
Indicate all of the following that apply in relation to the applicant's liability for the
described premises:
A . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant is held harmless in the lease.
B . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant has a waiver of subrogation.
C . . . . . . . . . . . . . . . . . . . . . . . . . . . . Applicant is a named insured in the fire policy.

D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other. Specify within the Occupancy/Description section.

Sq Ft/Bld Occ
Provide the total square footage of the premises occupied by the applicant.

Occupancy/ Description of Personal Property
Provide a description of the building occupancy or of the property held by the applicant in
his care, custody and control.

ADDITIONAL EXPOSURES

This section gives the underwriter insight on exposures which may have been identified in the
Underlying Insurance section or other exposures which may exist. Complete all sections with
known exposures.

Use the Remarks section to provide additional information for any questions answered with a "Yes"
response. The overview below lists the expected information that should be added to the remarks
section for "Yes" responses.

Advertising Liability
If advertising is required by the applicant, complete this section.

1. Media used, annual costs
Specify the media used for advertising such as newspaper or radio and the annual cost for all
advertising.

2. Services of advertising agency used?
Provide the name and address of the advertising agency used.

3. Any coverage provided under agency's policy?
If advertising liability coverage is provided to the applicant by the ad agency, give the
insurer, policy number and limits of liability.

Aircraft Liability
Complete this section for aircraft exposures.

4. Does applicant own, lease or operate aircraft?
Provide a copy of the Aircraft Liability Application and description of aircraft to be insured.

Auto Liability
If automobiles or other vehicles are owned or operated by the applicant, complete this
section.

5. Are explosives, caustics, flammables or other dangerous cargo hauled?
Identify the type(s) of all such cargo (e.g., dynamite, acid).

6. Are passengers carried for a fee?
Identify vehicles and circumstances. Indicate if vehicles are used to transport the general
public or charter groups.

7. Any units not insured by underlying policies?
Identify vehicles not covered under the underlying policies.
8. Are any vehicles leased or rented to others?
Provide description of the nature of rental or lease agreement.

9. Is Hired and Non/Owned coverage provided?
List the estimated cost of hire and to whom the non/owned coverage applies.

Contractors Liability
Complete this section if contracting is performed.

10. Is bridge, dam or marine work performed?
Specify duties and hazards involving water exposures.

11. Describe typical jobs performed
Give a brief description of the type of work performed for which this policy applies.

12. Describe agreement
Explain all contractual agreements pertaining to the work performed.

13. Does applicant own, rent, or otherwise use cranes?
Specify type of equipment used and the length of the boom.

14. Do subcontractors carry coverages or limits less than applicant?
Indicate if certificates are required.

Employers Liability
Complete this section for Employers Liability exposures.

15. Is applicant self-insured in any state?
Specify the states involved and give the amount of the self insured retention. Indicate if self
insurance adequately satisfies state requirements.

16. Regulation:
Place an "X" in the appropriate box to indicate if any employees are subject to one or more
of the following programs:
                •    Jones Act
                •    Federal Employers Liability Act (FELA)
                •    Stop Gap

Incident Malpractice Liability
If applicant provides medical aid, complete the following questions.

17. Hospital or first aid facility maintained?
Describe the facility and services provided.

18. Coverage provided for doctors/nurses?
List carrier and policy number for coverage provided to doctors or nurses. Identify those
covered.

19. Indicate # of doctors, nurses, beds.
Give the count for the listed items.

Pollution Liability
Complete this section if the applicant has any exposure to hazardous materials.

EPA #
Provide the number assigned by the Environmental Protection Agency.

20. Do current or past products, or their components, contain hazardous
materials that may require special disposal methods?
Specify the methods of hazardous material disposal.

21. Indicate the coverages carried:
Check the appropriate boxes for the underlying general liability coverages.

Product Liability
Complete this section if the applicant produces or sells any product. List all products in the
remarks section.

22. Are missiles, engines, guidance systems, frames or any other product
used/installed in aircraft?
Identify the systems or parts produced or installed.

23. Are foreign products distributed in U.S?
Identify any foreign products that the applicant sells or distributes in the United States.

24. Are U.S. products sold or distributed in foreign countries?
Identify the products involved and the nature of the applicant's operation.

25. Product liability loss in past 3 years?
Provide details of all product losses, items involved, amounts paid and reserves established.

26. Gross sales from each of the last three years.
List the gross sales or receipts for all products manufactured or sold in the past three years
beginning with the most current receipts.

Protective Liability
Complete this section if contractors are hired by the applicant.

27. Describe independent contractors
Identify all independent contractors and explain the agreements involved. Give nature of
business and work performed.

Watercraft Liability
If the applicant owns, operates or uses watercraft, complete this section.

28. Does applicant own or lease watercraft?
Give the number owned, length and horsepower of watercraft owned or leased.

Apartments/Condominiums/Hotels/Motels
Complete this section if the applicant rents any of the above units. List the number of
stories, number of units, number of swimming pools and number of diving boards.

VEHICLES

Use this section to provide specific information on the number and type of Auto units. The three
distance columns should be used to indicate the radius of operations for each vehicle type. If over
200 miles, enter the approximate distance.

REMARKS

Use this section to explain all "Yes" responses to any of the questions in the Additional Exposures
section. Provide enough detail to enable the underwriter to fully understand the exposures
indicated and the degree of risk involved. Attach additional pages if necessary.




Vehicle Schedule 129 (8/2001)

This form is to be used in conjunction with the following ACORD forms to
individually schedule vehicles:

ACORD 127 - Business Auto Section
ACORD 128 - Garage and Dealers Section
ACORD 132 - Truckers/Motor Carriers Section
ACORD 143 - Transportation Section

Within the Remarks section of the above forms, a note should be made to "see
attached vehicle schedule."

IDENTIFICATION SECTION

Much of the information for the Identification Section should match the data found within the
Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it.
Many companies separate the applications by line of business for rating purposes. Not completing
this portion of the application makes it difficult to keep track of the full account.
Date
Month/day/year on which the form is completed.

Producer
Producer's name, address and telephone number.

Phone (A/C, No, Ext)
Producer's telephone number.

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.

Applicant (First Named Insured)
First Named Insured as it appears on the ACORD 125.

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

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

Billing Plan
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. (e.g., Prepaid, Annual, Semi-annual, Bi-monthly,
40-30-30).

Audit
Use this field to indicate the audit term for policies that are subject to periodic audit. If the
audit period is known, enter the code:

A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual
Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly
O . . . . . . . . . . . . . . . . . . . . . . . . . . . . other

VEHICLE DESCRIPTION

This section is used to collect pertinent information on the vehicles that are to be insured,
including what they are, how they are used and what coverage applies to them.

Veh #
Number assigned by the agent to this vehicle for purposes of tracking in the application
process.

Year
Vehicle's model year.

Make
Vehicle's manufacturer (e.g., Buick).

Model
Manufacturer's model name (e.g., Regal).

Body Type
Vehicle's body type (e.g., 4 door sedan).
Vehicle Type
Check the appropriate box. PP (private passenger), SPEC (special), or COML (commercial).

V.I.N.
Full vehicle identification number assigned by the manufacturer.

Sym/Age
Enter the age of the vehicle in years, as follows:
     •    1-Current model year
     •    2-First preceding model year
     •    3-Second preceding model year
     •    4-Third preceding model year
     •    5-Fourth preceding model year
     •    6-All other autos

Cost New
If actual cash value coverage is desired, indicate the original retail cost the original
purchaser paid for the vehicle and equipment.

City, State, Zip where garaged
List the location where this vehicle is normally garaged.

Lic State
Enter the state in which the vehicle is licensed.

Territory
Enter the rating territory in which the vehicle is principally garaged.

GVW/GCW
These terms identify the size class of commercial vehicles. The weights must be indicated to
classify the vehicle correctly.

GVW
Gross Vehicle Weight. Maximum loaded weight for which a single vehicle is designed by
the manufacturer.

GCW
Gross Combined Weight. Maximum loaded weight for a combination truck-tractor and
semi-trailer or trailer for which the truck-tractor is designed as specified by the
manufacturer.

Class
This is the primary industry classification code found in rating manuals for commercial
vehicles as determined by:
     •     If this is a fleet or non-fleet policy
     •     Commercial autos by size, business use, radius of operation and whether truck or
     •     trailer type
     •     Public autos by type of vehicle, radius or seating capacity

S.I.C.
This is the secondary Special Industry Class code which applies to commercial vehicles as
determined by industry rating manuals.

Factor
This is the sum of the rating factors from the primary and secondary classification tables.
This field may be left blank if you are not rating this application.

Seating Capacity
Used for public vehicles and livery vehicles. Enter the number of passenger seats available.

Radius
Enter the appropriate radius code as follows:

L - Local . . . . . . . . . . . . . . . . . . . . Up to 50 miles. Not frequently operated
beyond a 50- mile radius from the point of
principal garaging.
I -Intermediate . . . . . . . . . . . . . . .Operation beyond 50 miles, but not regularly
operated beyond a 200-mile radius from the
point of principal garaging.
LD - Long Distance . . . . . . . . . . Regularly and frequently operated beyond a
radius of 200 miles.

Farthest Term
For zone-rated vehicles, enter the town name and state of the terminal farthest away from
the normal garaging location of this vehicle, that this vehicle travels to.

Drive to Work/School
If this vehicle is used for commuting purposes to work or school, check the box that applies.
Options are:
       •    Drive to Work or School under 15 miles one way
       •    Drive to Work or School 15 miles or over one way

Use
Check the appropriate box for the primary usage of this vehicle. Options are:
     •     Pleasure-Private passenger vehicles or pickups/vans not used for business
     •     purposes
     •     Farm/Private passenger vehicles or pickups/vans principally garaged and used on
     •     a farm or ranch
     •     Retail-Pick up or delivery of property to individual households
     •     Service-Transportation of personnel, tools, equipment or supplies to or from a
     •     job site
     •     Commercial-Transportation of property in vehicles other than those defined as
service or retail

Check Coverages
Use this section to indicate the coverages applicable to this individual vehicle. These
coverages should correspond to the symbols indicated in the coverage section of ACORD
137. Abbreviations are:

Liab . . . . . . . . . . . . . . . . . . . . . . . . . . . Liability
No-Fault . . . . . . . . . . . . . . . . . . . . . . ."No-Fault" coverage available in the state
Add'l No-Fault . . . . . . . . . . . . . . . . . Additional "No-Fault" coverage available in the state
Med Pay . . . . . . . . . . . . . . . . . . . . . . Medical Payments
Uninsd. Mot . . . . . . . . . . . . . . . . . . . Uninsured Motorist
Underins Mot.. . . . . . . . . . . . . . . . . . Underinsured Motorist
Tow & Labor. . . . . . . . . . . . . . . . . . . Towing and Labor
Spec C of L . . . . . . . . . . . . . . . . . . . . Specified Cause of Loss
F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Specified Cause of Loss of Fire
F & T. . . . . . . . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss of Fire and Theft
F, T, & W . . . . . . . . . . . . . . . . . . . . . . .Specified Causes of Loss of Fire, Theft and Windstorm
LSP . . . . . . . . . . . . . . . . . . . . . . . . . . . .Limited Specified Perils
Comp. . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive Coverage
Coll. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Collision Coverage

Deductibles
Indicate if the deductible is based on an ACV - Actual Cash Value, AA - Agreed Amount,
or ST Amt - Stated Amount basis by checking the appropriate box. For Agreed Amount or
Stated Amount basis enter the applicable limit.

Indicate if the other than collision deductible is for comprehensive coverage or some sort of
specified cause of loss coverage, along with listing that deductible amount.

Enter the collision deductible in the space provided.

Net Veh Dr/Cr
Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level.
Provide under Remarks a description of each debit or credit used in the calculation of the net rating factor.

Tot Prem
Enter the total premium for the vehicle.




Watercraft Application 82 (2/2001)
The underwriting process for any personal lines policy begins with the
submission of a completed application. This guide will provide assistance in completing the ACORD Watercraft
Application.

This form can be used either as a stand-alone application or as a supplement to the Homeowners Application (ACORD
80) if physical damage on watercraft is being written under the Homeowners policy. Check with the company to determine
whether physical damage can be written on the Homeowners policy.

If coverage will be provided under a yacht policy, do not use this form. Use ACORD 210, Yacht Section.

The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of
the Personal Lines Section of the Forms Instruction Guide. On the ACORD website, this information appears under the
title PERSONAL LINES GENERIC SECTIONS.

BOAT HULL

Provide hull number if more than one hull is to be insured.

Power
Indicate the method of propulsion. Sailboats can be powered by an auxiliary engine, therefore, please check SAIL in
addition to the auxiliary type of propulsion for sailboats.

Type of Hull
Indicate the type of watercraft to be insured. "Personal WC" refers to "personal watercraft".

Hull Material
If the hull material is not fiberglass, metal or wood, please indicate the material type in the remarks area.

Hull Design
Indicate the type of hull to be insured.

Fuel Tank
Indicate whether the fuel tank is made of fiberglass or metal.

Year
Model year of the unit in YYYY format. If built at home, enter the year built.

Manufacturer/Model
Name of the manufacturer and the model (e.g., Chris Craft Tournament Fisherman, Pacemaker Runabout).

Length
Overall length measured in feet from bow to stern.

Max Speed
Enter the maximum speed of the craft. State if measured in knots or miles per hour.

Date Purchased
Date the watercraft was purchased by the insured in MMYY format.

Cost New
Cost of the boat when it was purchased new, in whole dollar amounts.

Present Value
Boat's present value, stated or agreed, in whole dollar amounts.

Name of Boat
Name in which the watercraft is registered.

Registration Number/Hull Identification Number
Enter the registration number and the serial number of the watercraft.

Waters Navigated
Identify the primary area of operation (e.g., San Francisco Bay Area, Hudson River).

Territory
This is typically the navigation territory. However, use company manuals to determine territory.

Berth/Storage Location
Physical address where the boat is stored; no P.O. boxes.
Lay-Up Period
Specify the period when the boat is not in operation (e.g., October through March). Also, state if the boat is stored afloat
or in a dry dock. If the boat is stored afloat, indicate the devices used to prevent ice damage (e.g., bubble system).

ENGINE/MOTOR

Use this section to provide information about all engines and motors used to propel the boat.

Year
Model year of the engine/outboard motor in YYYY format.

Manufacturer/Model/Serial Number
Enter the name of the manufacturer, the model (e.g., Mercury Mark 50, Evinrude 200), and the serial number.

Horsepower
Enter the horsepower. There is a method for determining the maximum safe horsepower for a specific boat based on
length and width. If the company employs this formula, it may be helpful to make note of the width in the space labeled
"other".

Fuel
Indicate the fuel used to power the engine.

For Outboard Motors Only
Provide the date purchased, cost when new and present value.

TRAILER
If boat trailer insurance is to be included on the watercraft policy (usually only available for stand-alone watercraft
policies), enter all pertinent information regarding the boat trailer: year, manufacturer, serial number, number of axles,
capacity, date purchased, cost.

COVERAGES/LIMITS OF LIABILITY

Indicate the limit of insurance, deductible and coverage premium for each applicable coverage. List any additional
coverages, including their limit and premium in the other coverage section.

Hull
Amount of coverage for boat damage; this may include collision liability.

Outboard Motor
Amount of coverage for damage to the outboard motor. Limits may be entered for three motors.

* Coverage for inboard motors is included in the hull coverage.

Portable Accessories
Coverage amount for those items not permanently attached to the boat. Examples:
    •    Oars
    •    Anchors
    •    Life Preservers
    •    Fire extinguishers

Trailer
Amount of coverage for damage to the trailer.

Liability
Coverage amount for bodily injury and property damage. May be called protection and indemnity.

Medical Payments
Amount of coverage for medical expenses for bodily injury to occupants of the boat.

Uninsured Boaters Liability
Coverage amount for bodily injury caused by an uninsured boat operator. Some companies offer this coverage.

Credit
Total credit amount for the watercraft portion of the policy.

Total
Estimated total premium.

Describe all Credits to Apply to each Boat
List all credit amounts and names for each boat.

PAYMENT PLAN

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 to be used for payment.

ADDITIONAL INTEREST

Provide the following information for each entity having an interest in the motors or the watercraft to be insured: the
interest number or rank (1st, 2nd), whether the additional interest is the lienholder (e.g., bank in which the loan is held) or
other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan
number.

RATING/UNDERWRITING

Provide a description of the equipment on the boat that is of particular interest to the underwriter.
Indicate the number present on the boat and an appropriate description of each piece of equipment.


Bilge Pumps
A bilge pump is a manually operated or automatically activated device used for pumping water from the inner part of the
ship's hull. Using the same principle as the manual pump, the automatic pump is activated by the rise of water within the
hull. Specify the manufacturer and the model (e.g., Dynaflow Pump 304).

Cooking Stove
Indicate the manufacturer, model and fuel type. Also indicate if there is more than one stove.

Fume Detector
A device used for detecting the presence of fuel vapors below deck. Specify the manufacturer and model (e.g., Sniffer
203).

CO2/Chemical System
A built-in fire extinguishing device. Indicate if it is manual or automatic and identify the spaces protected. Include the
manufacturer and model. Use the Remarks section if necessary.

Fire Extinguishers
Indicate the number of fire extinguishers on the boat. Specify the type, size, and the date last weighed, if available.

Depth Sounder
An electronic device for determining the depth of the water beneath the boat. Indicate the manufacturer and model (e.g.,
Moran 6" - 150/SV-300).

Radar
A device for detecting distant objects and determining their position. Specify the manufacturer and model.

Radio Direction Finder
A navigational aid employing a radio signal. Enter the manufacturer and model (e.g., Loran, GSP).

Ship to Shore Radio
Indicate the type of radio. Examples:
     •     SSB-Single Side Band
     •     VHF-FM-Very High Frequency - Frequency Modulation
     •     CB -Citizens Band
     •     Cellular Phones
     •     Marine Radio

Anti-Theft Devices
Special locks, burglar alarms or engine cut-out devices may be employed by the applicant. Marina security may be noted
as well.

Heating
Describe heating system, if any.

Other
Use the blank spaces to list additional equipment. Attach a separate list if necessary.

PORTABLE ACCESSORIES

List the portable accessories that are to be insured.
Include the name of the equipment, year of manufacture, name of manufacturer, and the model and serial number if
applicable. Also provide the limit(s) of insurance required.

OPERATORS

List the name, sex, marital status (S-Single, M-Married, D-Divorced, SEP-Separated, W-Widowed), date of birth
(MM/DD/YY), social security #, auto drivers license number and licensed state if applicable, for each household member
and any other frequent operators.

OPERATORS EXPERIENCE

Indicate if any operator completed courses offered by the United States Coast Guard Auxiliary, the Power Squadron or
other recognized training. The underwriter will also be interested in the number of years of boating experience and the
type of boats operated or owned. Some companies require the percentage of use for each operator. Be sure to cross-
reference the operator number.

HULL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "Yes" response.

1. Is the boat chartered to others?
If the vessel is chartered, describe the type of arrangements, destination, length of time and frequency. Indicate if it is a
bare boat charter where no crew or supervision is furnished, a voyage charter, a time charter, etc. Include the purpose of
the charter (sight-seeing, fishing) and whether alcohol is served.

2. Is the boat used commercially or for business purposes?
Describe the commercial or business use of the vessel. Indicate if the vessel is used for demonstrations, promotions,
fishing, sight-seeing trips, etc.

3. Is the boat used for racing?
If the vessel is used for racing, indicate the frequency of such races during the year, the extent of the race, the waters
navigated, etc.

4. Is the boat used for waterskiing?
Indicate how frequently the vessel is used for waterskiing.

5. Does the applicant employ a paid crew?
Specify the number of crew members, and whether they are full or part time. Be sure to list the crew members in the
Operator section of the application.

6. Any sleeping facilities?
Provide number of beds.

7. Any existing damage to the boat?
If yes, describe in detail.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any question answered with a "yes" response.

1. Has the applicant lived at current address for less than 3 years?
Indicate the previous address of the applicant.

2. Any operator have physical/mental impairment?
Answer "yes" only if the impairment impedes the use of the watercraft. Indicate the impairment and any applicable
medical treatment being used.

3.Any drivers license suspended/revoked during the last 3 years?
Indicate if the drivers license of any operator was suspended or revoked and explain the circumstances.

4. Has any operator had an accident/conviction during the last 3 years?
Indicate accidents/convictions for both driving and boating records.

5. Any other insurance with this company?
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 along with any policy numbers available.

6. Any losses occur during the last 3 years?
Describe in detail, all losses during the last three years. Include data on the operator, the type of loss, the amount of the
loss, the date and the disposition.
7. Any coverage declined, cancelled, or non-renewed?
Provide the circumstances surrounding this situation. This question cannot be asked in Missouri.

8. During the last five years(ten in RI), has any applicant been convicted of any degree of the crime of arson?
In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one
year of imprisonment.




Workers Comp First Report of Injury or Illness 4 (2/2001)


ACORD, in conjunction with the IAIABC (International Association of Industrial Accident Boards & Commissions)
developed this standard First Report. The form tracks with the IAIABC and ANSI X12 EDI standard for reporting Workers
Compensation losses.

The form is designed as a first notice of a claim for injury or illness by an employee. In nearly all cases, the form is
completed by the employer and sent directly to the insurer or the state workers compensation board. It contains
information about the employer, insurance carrier, employee, the occurrence leading to the injury or illness, and the
nature of injury or illness. Instructions to the employer regarding completion of the form are contained on the third and
fourth pages of the form.

Each jurisdiction mandates the form to be used within that state. The new version of ACORD 4 is accepted in many
jurisdictions. It is anticipated that this number will continue to increase significantly as states adopt the IAIABC and ANSI
X12 EDI Standard.

As of November 1, 1998, the following states are reported to accept ACORD 4. Consult your company about use in other
states.

Connecticut
Florida
Idaho
Illinois
Maryland
Mississippi
New Mexico
Ohio
Rhode Island
South Carolina.

In addition, Wisconsin accepts ACORD 4WI, Wisconsin Employer's First Report of Injury or Illness.




Workers Compensation Application 130 (8/2000)

ACORD's Workers Compensation Application is a self-contained Commercial Lines application that does not require the
completion of the Applicant Information Section (ACORD 125). Therefore, complete the entire Identification section of this
form. The Workers Compensation Application provides for workers' compensation, employer's liability, and voluntary
compensation coverages. The Policy Information and Rating Information sections have been designed to follow workers'
compensation rules published by the National Council on Compensation Insurance (NCCI). Other plans may be used with
this form as well. Please refer to the NCCI manual for coverage definitions. This form may not be used in Florida. Refer to
Florida Workers Compensation Application, ACORD 130 FL, in the State Forms section of this guide.
IDENTIFICATION
Date
Month/day/year in which the form is completed.
Producer
Producer's name, address and telephone number.
Code
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
Phone (A/C, no., ext.)
Telephone number where the producer may be reached.
Subcode
If your agency uses a sub-code 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. Use the actual name of the company within the group in which you wish to
have the policy issued. Do not use group names.
Underwriter
Field used to direct the application to a specific company underwriter by name.
Applicant Name
Full name of the applicant as it appears 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, the one intended to receive these rights and
responsibilities is named first.) If joint ownership is claimed, the name used may include both names (e.g., John and Mary
Smith). Phrases such as "et al." or "As their interests may appear" are not legal entities and therefore unacceptable.

Mailing Address
Address at which the First Named Insured is to receive all mail.
Years in Business
Number of years the applicant has been in business.
SIC
Appropriate Standard Industry Class code assigned to the particular type of business (if known).
Form of Business Organization
Identify the applicant as an Individual, Partnership, Corporation, Sub Chapter "S" Corporation, Limited Corporation, or
Other. If Other, provide a description (e.g., Professional Association). If there is more than one Named Insured, list each
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.).
Federal Employer ID Number
FEIN is assigned by the IRS to specifically identify the applicant and is required in most states before a policy can be
issued. A separate FEIN may apply to each entity named as an insured. For individuals with no FEIN, use Social Security
Number.
NCCI ID Number
A nine-digit number assigned to the applicant by the National Council on Compensation Insurance (NCCI). This number is
required in most states before a policy can be issued. It also helps insure timely and accurate calculation of experience
modifications. The NCCI is a rating bureau operating in most states that also provides interstate experience rating for risks
occurring in more than one state.
Other Rating Bureau ID or State Employer Registration Number
A state's rating bureau may assign a separate identification number if the applicant is subject to experience rating in an
independent bureau state. In Minnesota, use this box to record the applicant's unemployment account number, as
required by the state. In New Jersey, use this box to record the applicant's state employer registration number.
SUBMISSION STATUS
Use the Quote/Issue Policy/Bound boxes to indicate whether the response to this application from the company is
expected to be a quote or an issued policy. Also indicate if the risk is bound. Include the date coverage began and attach
a copy of the binder. This application is not a substitute for a binder. You may check more than one box (e.g., if the
underwriter indicated by telephone that the risk is acceptable and coverage can be bound, check both Bound and Issue).
For Assigned Risk business check the "Assigned Risk" box and complete an ACORD 133 Workers Compensation
Insurance Plan Assigned Risk Section. Rules for binding assigned risk policies apply. The Quote, Issue Policy and Bound
options do not apply when submitting an assigned risk application. Please refer to the instructions for the ACORD 133 for
specific uses of the ACORD 130 elements as they apply to assigned risk business.
BILLING/AUDIT INFORMATION
Billing Plan
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. For the Other option, use the company's specific
designation for the plan being used (e.g., Bi-monthly or 40-30-30).
% Down
For bound policies, list the percentage of the total estimated annual premium that has been (or will be) received as a
down payment.
Audit
Indicate the frequency with which audits should be undertaken for this policy.
LOCATIONS
List all usual workplaces of the applicant including the physical address, not post office boxes.
POLICY INFORMATION
Proposed Policy Eff Date
Date on which the terms and conditions of the policy will commence. For assigned risk business being submitted with the
ACORD 133 use the effective date on that form, following state mandated rules.
Proposed Exp.date
Date on which the terms and conditions of the policy will expire. The normal policy period (effective date to expiration
date) is one year. However, a policy may be issued for any length of time up to a maximum of three years. Certain rules
and endorsements must be used if the policy is written for more than one year. It may be necessary to use Effective and
Expiration Dates that do not indicate a one year term, to concur with other policies.
Normal Anniversary Rating Date
Normally, the rates used are in effect on the effective date of the policy. NCCI Manual rules require that the rates apply for
a period of one year. If a policy is cancelled or short-termed, the rating bureau requires the original effective date to be
considered the Normal Anniversary Rating Date for both rates and experience modifications. This is temporary and will
last until the next renewal when the new policy effective date will again determine the rates. The rule is intended to
prevent wholesale cancellations by insureds and companies to take advantage of rate and/or rule changes. For cancelled
or short-termed polices, enter the original effective date.
Participating/Non-Participating
A Participating policy may result in reduced premiums through the payment of policyholder dividends declared by the
insurer. Some policyholder dividends are based on actual experience of the applicant. If such a program is available
through the company in the covered state, indicate whether the policy is to be on a Participating or Non-Participating
basis. Check with your company on the availability of plans.
Retro Plan
Retrospective Rating Plans Permits the adjustment of the final premium based on the actual premiums and losses of the
applicant, subject to the plan's minimum and maximum premium limits. One to three year plans may be available. Check
with your company on the availability of plans.
Part 1 (States)
States in which Part 1 will apply. Part 1 refers to the workers' compensation law and/or occupational disease law in states
where the applicant has operations.
Part 2 - Employers Liability
Requested limits for Part 2 of the policy (Employers Liability Insurance). The basic limits of liability under Part 2 are: Bodily
Injury By Accident - $100,000 per accident; Bodily Injury by Disease - $500,000-policy limit; Bodily Injury by Disease -
$100,000 per employee. Express limits with full dollar amount (all zeros shown) on the application.
Part 3 - Other States Insurance
Indicate the states in which Part 3 will apply. Part 3 refers to states not listed in Part 1 where the applicant has the
potential for operations during the policy term, but none currently exists as of the effective date of the policy.
Deductibles
If a deductible option exists in the state where coverage is being applied for check the appropriate deductible type. (In
Pennsylvania, the deductible is "per claim". The deductible choices are $1,000, $5,000 and $10,000.)
Amount/%
Indicate the amount of the deductible as a whole dollar amount or as a percentage. For percentages indicate the
percentage amount followed by the percent (%) sign.
Other Coverages
Use this space to request optional United States Longshoremen's & Harbor Worker's (USL&H) coverage and Voluntary
Compensation coverages. Exposures for these optional coverages as well as additional coverages should be described in
the Specify Additional Coverages/Endorsements section.
Dividend Plan or Safety Group
Identify the specific plan or safety group of which the applicant is a member. This field is related to the participating plan.
Check with your company on the availability of plans.
Additional Company Information
Any additional company or state specific information should also be listed in this section.
RATING INFORMATION
Information in the Rating section must be entered by state and location. If there are multiple named insureds, information
must be shown by individual entity.
State
State abbreviation for the associated location.
LOC
Location Number for each entry corresponding to the locations listed in the Locations section above.

Class Code
Code which best describes the applicant's business. Remember that it is the business of the employer, not the individual
employees, that is being classified. Consult the proper rating manual to determine the code. Rating bureaus may exercise
control over classification assignment.
Company Use
Leave blank. The insurer may use this space for special computer codes to identify the applicable class description
wording.
Categories, Duties, Classifications
Single class code may include several related descriptions of activities/operations. It is extremely important to enter the
specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much
information as necessary to avoid mis-classifying the operations.
No. of Employees, Full Time/Part Time
Number of employees to whom the classification applies. The average number is sufficient when the total number
fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate. Show full
time and part time employees separately.
Estimated Annual Remuneration
Total annual payroll for the class. Payroll means money or substitutes for money, such as the value of meals or lodging if
provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do
not include overtime premium.

Rate
Manual Rate for the classification from the appropriate state manual.
Estimated Annual Premium
The rate is applied (multiplied) to every $100 of remuneration (payroll) and the result is the Estimated Annual Premium for
this classification.
Additional Coverages/Endorsements
Explain the applicant's exposures and payroll for any other coverage requested, including USL&H and Voluntary
Compensation.
RATING COLUMNS
Rating Worksheet
The Factor and Factored Premium columns are used to calculate the total estimated annual premium. Agents completing
the rating process should fill out this section of the application or attach a rating worksheet.
Total
Add the amounts for each class to obtain the total estimated pre-modified premium.
Increased Limits
Enter the factor and modified total premium if limits other than the standard limits for Part 2 Employers Liability are
requested.
Deductible
If a state deductible option is available and chosen, enter the deductible factor and the modified total premium.
Experience Modification
If the applicant is subject to experience rating, enter the experience modification factor and the modified total premium.
Generally the business has to have been in operation for at least two years under present ownership and the premium
must meet or exceed a level which is established by the state to qualify for experience rating. If more than one
modification factor applies to the applicant, explain in the Specify Additional Coverages/Endorsements section. Attach the
most recent experience rating data sheet.
Loss Constant
If a Loss Constant is applicable due to low premium levels enter the flat amount as per the rating manuals.
Assigned Risk Surcharge
Applicable only to assigned risk accounts. A state specific surcharge for placement of business into an assigned risk pool.
ARAP
Assigned Risk Adjustment Program  A state specific adjustment for Assigned Risk policies.
Premium Discount
If a Premium discount is applicable due to large premium levels, enter the discount rate and the modified total premium.
Expense Constant
Enter the flat amount of the expense constant as applicable per state rating manual.
Optional Lines
If any optional factors, charges or credits are required such as a state tax enter the option title, factor (if applicable) and
adjustment amounts in these available spaces.
Total Estimated Annual Premium
Amount resulting from applying all modifications, discounts, taxes and other rating criteria to the total estimated pre-
modified premium.
Minimum Premium
Found on state rate sheets opposite the class code; they apply by policy. If two or more classifications with different
Minimum Premiums are included on one policy, the highest usually applies. Check the appropriate rate manual.
Deposit Premium
Dollar amount due the insurer at inception.
INDIVIDUALS INCLUDED/EXCLUDED
Based on state laws, certain positions within an organization, such as sole proprietors and partners, may not be covered
by the applicable workers' compensation law, and may elect to be brought under such law. Conversely, executive officers
of corporations are usually considered to be employees, but may elect to be excluded from coverage. Refer to the NCCI
or applicable state workers' compensation manual for specific state details. Since the inclusion or exclusion affects
coverage and premium, this section must be fully completed.
Name
Partner, executive officer or relative to indicate whether or not the individual is to be covered by the policy.
Date of Birth
Individual's birthdate.
Title/Relationship
Either the individual's title within the organization or relationship to the organization's owners.
Ownership %
Percentage of ownership the individual has in the organization, if applicable.
Duties
Briefly identify the duties of the individual.

Inc/Exc
Indicate if the individual is to be Included or Excluded under the policy's coverages.
Class Code
For individuals to be included based on the duties described above.
Remuneration
Estimated annual Remuneration for individuals to be included. Minimum or Maximum remunerations may apply based on
state laws. (Enter the class code and remuneration in the Rating Information section of the application for all included
individuals).
PRIOR CARRIER INFORMATION/LOSS HISTORY
Either this section should be completed or a loss history report attached covering the last five years. If a loss history report
is attached, check the appropriate box.
Year
Year or policy period. The most recent policy period should be listed first.

Carrier & Policy Number
Carrier's name and policy number for the corresponding policy.
Annual Premium
For the corresponding policy. Use the final audited premium when available.
Mod.
If the risk was subject to experience rating, enter the Experience Modification in this column for the corresponding policy.
# Claims
Total number of Claims for the corresponding policy term.
Amount Paid
The total dollar amount actually paid for all open or closed claims.
Reserve
Enter the amount in Reserve for any open claims, with the valuation date of the reserves. Estimates are acceptable; enter
zero if none.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS
This section informs the underwriter of each applicant's business and the way it is conducted by premises. Operations,
which may not be apparent in a general description, may be segmented by location. For example, location #1 may be the
general offices while location #2 may be the warehouse. The section should include enough detail to enable the
underwriter to understand and classify each operation. Do not use the classification phraseology from the Commercial
Lines Manual or Workers' Compensation Manual, because they do not provide adequate detail. For example, a
manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods
Mfg.N.O.C."

If the applicant is a manufacturer, describe the:
Raw materials used
Process of 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 it is domestic or foreign product
Services provided
Whether or not the applicant delivers

If the applicant is a service organization, describe the:
Type of service performed
Location
The applicant's clients (e.g., general public, dentists, banks)
GENERAL INFORMATION
Use the Remarks section to provide additional information for any questions answered "Yes".

1. Does applicant own, operate or lease aircraft/watercraft?
Describe any aircraft exposure excluding commercially scheduled flights. Name any employee who is a licensed pilot.
Explain his or her duties and describe the type of license. Describe any watercraft which is owned, leased or operated,
and explain its use.
2. Do operations involve storing, treating, discharging, applying, disposing or transporting of hazardous
material? (E.g., landfills, asbestos, wastes, fuel tanks, etc.)
Explain the exposure and the precautionary measures implemented to handle hazardous materials. Exposures include:
flammables, explosives, radioactivity, caustics or fumes and their storage, disposal or transportation, or any other material
with a known occupational disease exposure.
3. Any work performed underground or above 15 feet?
Detail the frequency and nature of such work, and the number of people involved.
4. Any work performed on barges, vessels, docks or bridge over water?
Describe any work on barges, vessels or docks and the location, frequency and number of people involved.
5. Is applicant engaged in any other type of business?
List all other businesses and the carrier for that business's workers' compensation coverage.
6. Are subcontractors used?
Explain the nature and frequency of any subcontracted work. Give the percent of work subcontracted. Are Certificates of
Insurance required?
7. Any work sublet without certificates of ins.
Describe the nature and frequency of the subcontracted work and indicate if the classifications and remuneration for such
work have been included in the Rating Information section.
8. Is a formal safety program in operation?
Describe the safety program. Does it involve meetings, classes or incentives?
9. Any group transportation provided?
Is a van pool program in effect? Does the employer shuttle employees to job sites? What type of conveyance is used?
How many employees are transported? How often? Over what distance?
10. Any employees under 16 or over 60 years of age?
Specify the number of employees in each category and the duties they perform.
11. Any seasonal employees?
How many employees? How many hours do they work? At what time of the year are they employed? What are their
duties?
12. Is there any volunteer or donated labor?
Explain the circumstances under which volunteer labor is used and the nature of the work.
13. Any employees with physical handicaps?
Describe the nature of the work and explain the circumstances under which physically handicapped workers are
employed. Indicate the number of employees and the type of handicaps. Is the applicant involved in a special community
program for handicapped people? If eligible, has the employee been registered in a second injury fund?
14. Do employees travel out of state?
Describe the nature of the travel and indicate the number of employees, frequency and mode of transportation.
15. Are athletic teams sponsored?
Describe the nature of the athletic activities and indicate the number of employees involved (if any). Indicate whether the
applicant provides an accident and health policy to cover athletic activities. This may include company, school or
community teams or leagues, such as Little League.
16. Are physicals required after offers of employment are made?
Are employees required to undergo a physical examination after they have been made an offer for employment? Describe
the extent of the physical examination and indicate which applicants are required to take them.
17. Any other insurance with this insurer?
If other insurance policies of any kind are in force with this insurer, identify the coverages, policy numbers and terms. You
may also note other submissions for this account being considered.
18. Any prior coverage declined/cancelled/non-renewed (last 3 yrs.)?
The fact that such action occurred is not as important as the reason for the action. Provide all details.
19. Are Employee health plans provided?
Indicate the carrier name and policy number for the health plan.
20. Is there a labor interchange with any other business/subsidiary?
Indicate who the interchange is being done with and their relationship to the insured.
21. Do you lease employees to or from other employers ?
For leasing employees indicate who you are leasing them to. For leased employees indicate who you are leasing them
from and if you have a certificate of insurance from the lessor.
22. Do any employees predominantly work at home?
Indicate who works at home and what their hours of operation are.
CONTACT INFORMATION
Inspection (Phone and Name)
Enter the name and telephone number of the contact person who will assist the insurer in conducting a physical
inspection survey.
Accounting Records (Phone and Name)
The insurer may need to contact the applicant for audit purposes. Provide the name and telephone number of the
individual responsible for such records.
Claims Information (Phone and Name)
Provide the telephone number and name of the person the insurer is to contact regarding any potential claims inquiries.
Remarks
Add any additional rating information, comments or other items that will assist in the classification and rating of this risk.




Young Driver Questionnaire 93 (2/95)

This form is generally completed by drivers under the age of twenty five. The Young Driver Questionnaire provides
additional underwriting information that is usually common to youthful drivers. This form should be completed and signed
exclusively by the young driver with no input from the parents and/or agent.




Personal Auto Policy Change Request 71 (6/2001)
Use this form to request mid-term changes to any personal auto policy. The form should be used instead of individual
turnaround endorsement requests. A copy of the request may be sent to the insured to confirm that the change is
submitted to the company.

The generic fields on this form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines
Section of the Forms Instruction Guide. On the ACORD website (www.acord.org),, this information appears under the title
PERSONAL LINES GENERIC SECTIONS.

For changes to property, mobile home, inland marine, watercraft and umbrella coverages, use ACORD 70, Personal
Policy Change Request (Except Auto). 229

IDENTIFICATION

This section provides essential producer, company and insured information. It should be fully completed for all types of
changes. A copy of the policy's declaration page can be attached to provide additional identification information.

All data fields in this section, except the insured's name and mailing address, should contain existing policy information —
not changed data.

* Most sections begin with a change indicator. Enter either an A-Add, C-Change, D-Delete, or check the appropriate box.
Various combinations of changes are permitted in one submission.

Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an
item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change
coverage limits).

VEHICLE DESCRIPTION/USE

If the request pertains to change of vehicle information, complete this section. The form permits three vehicle
modifications. Obtain information directly from the policy or vehicle registration when possible. Vehicles include
automobiles, motorcycles, vans, recreational vehicles, motor
homes, trailers and pickups. Indicate the type of change being requested.

When adding a vehicle, the entire description section should be completed to assist the company in processing the
request. Also complete questions 1-5 of the General Information section and at least
the comprehensive and collision portion of the Coverage section. Use the Remarks section for any additional information
required by the company.

When requesting a change, enter only the information being changed. All other items on the policy will remain the same. If
deleting an item, provide adequate information to process the request and indicate the reason for the deletion in the
Remarks section.

Veh #
The current vehicle number, before renumbering.

Year
Model year of the vehicle.

Make, Model and Body Type
Manufacturer's trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4 door sedan).

VIN/Registered State
Full vehicle identification number appearing on the title certificate or registration. Enter the state where the vehicle is
registered. If the vehicle is registered in a state other than where it is garaged, explain in the Remarks area.

HP/CC
Amount of horsepower or the number of cubic centimeters of displacement.

DATE LEASED
Year the applicant leased the vehicle in the YYYY format.

Date Purch
Year the applicant acquired the vehicle in YYYY format.

New/Used
Mark "N" if the applicant bought the vehicle new or "U" if the vehicle was used.
Cost New
Original cost of the vehicle.

Symbol Age Grp
If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual.

Terr
Rating territory code where the vehicle is principally garaged. Refer to rating manual.

Mile 1 Way Wk/Schl
Number of miles from the garage location to school or work.

# Days Week
Number of days per week the vehicle is used to commute from the garage location to work or school including driving to
and from a commuter lot or transit station.

# Weeks/Mo.
Number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes
driving to and from a commuter lot or transit station.

Usage
Pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation,
profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of
occupation, profession or business is considered pleasure.

Perform
Vehicle's performance level. Indicate High (H), Intermediate (I) or Sport (S).

Multi-Car
Check box only if multi-car credit applies.

Car Pool
Indicate if any vehicle is used in a car pool for travel to work or school.

Garaged
Indicate if the vehicle is parked in a garage at night. If the vehicle is left on the street, at school or some other equally
exposed place, provide this information in Remarks section. Examples of exposures are:
     •      Off street (driveway)
     •      Off street (at school)
     •      Street (at school)
     •      Street (at residence)

Odometer Reading
Current number of miles on the odometer.

Annual Mileage
Total estimated annual mileage for each vehicle.

Govern Driver
Driver assigned to each vehicle for rating purposes.

Driver Use %
Percentage that each driver uses each vehicle. Usage for each vehicle should total 100 percent.

Class
Rate classification for each vehicle. Refer to manual. Some companies determine class automatically from information
provided in Vehicle Use and Driver Information sections.

Seat Belt
Check box if the vehicle is equipped with automatic seat belts.

Air Bag
Indicate D for driver side air bag; B for vehicle equipped with air bags for both driver and front passenger.

Anti - Lock Brakes 2/4
For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4- wheel anti-lock braking
system.

Anti - Theft Devices
If vehicle is equipped with an anti-theft device, indicate the type.
Credits and Surcharges
Any other credits and/or surcharges that will apply to any vehicles.

GARAGE LOCATION

Indicate the vehicle number and the complete address including the ZIP code for any vehicle not kept at the mailing
address. Provide this information if the mailing address is a P.O. box or rural route address, or when a driver is at school
with one of the vehicles.

VEHICLE COVERAGE/PREMIUMS

For each automobile to be added or changed, enter the vehicle number, year and make on the first row of the Vehicle
Coverage/Premium section. If the vehicle is added, enter all applicable coverage information. If coverages on an existing
vehicle are to be added, changed and/or deleted, enter only coverage information that is different.

Single Limit Liability (CSL)
Desired limit of both bodily injury and property damage. If an entry is made in this field, leave blank the separate Bodily
Injury and Property Damage fields. Show a property damage deductible, if applicable.

Bodily Injury Liability
Desired per person and per accident limits.

Property Damage Liability
Desired limit. Include a property damage deductible, if applicable.

No Fault Coverages
Refer to the applicable state manual for no fault/personal injury protection coverages. Each state where these coverages
are available has a unique mandatory coverage and unique coverage options. Space is provided here to list both
mandatory and optional coverages.

Medical Payments
Desired per person limit.

Uninsured Motorist
Bodily injury (per person and per accident) and property damage (per accident) limits. Circle CSL and enter the limit in the
per accident area for combined single limits. Many companies require supplemental uninsured motorists applications.
Include them when submitting this application.

Underinsured Motorist
Bodily injury (per person and per accident) and the property damage (per accident) limits. Circle CSL and enter the limit in
the per accident area for combined single limits. Many companies require supplemental underinsured motorist
applications. Include them when submitting this application.

Comprehensive
Comprehensive coverage deductible for each vehicle. Enter stated amount, if other than actual cash value (ACV), in the
space to the right and indicate the vehicle to which it applies.

Collision
Collision coverage deductible for each vehicle. If stated amount applies for the type of vehicle being insured, enter the
amount in the space to the right and indicate the vehicle to which it applies.

Towing & Labor
Amount per disablement for each vehicle, if applicable. Some companies provide a verbal limit. Consult company
manuals for cases in which a verbal limit applies.

Transportation Expense/Rental Reimbursement
Amount desired, per day limit and maximum amount.

Additional miscellaneous coverages can be included in the blank spaces, or in the Remarks Section.

GENERAL INFORMATION

Complete this section if a vehicle or driver is being added to the policy. Questions 1-5 pertain to addition of a vehicle.
Questions 6-10 refer to addition of a driver to the policy. Answer only questions pertinent to the change being requested. If
there are any "Yes" responses, explain
completely in the Remarks section. Use an additional sheet of paper if space in the Remarks section is inadequate.

1. Excluding any encumbrances, are any vehicles not solely owned by and registered to the applicant?
Show the vehicle number and name of the vehicle registrant if not the applicant.
2. Any car modified/special equipment?
Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any
customized painting such as murals or pin striping; any equipment installed to overcome a physical handicap. Indicate
vehicle number and describe modifications and the cost of the special equipment.

3. Any existing damage to vehicle, including damaged glass?
Indicate if any vehicle has been damaged and unrepaired as of the application date. Indicate the vehicle number and
completely describe the damage.

4. Any car kept at school?
Identify the household member and name and location of the school. Include the distance between the school and the
residence garage location.

5. Any car parked on street?
Determine if any vehicle is parked on the street or otherwise kept outside an enclosed garage when not in use. (Indicate
vehicle number from the vehicle description area indicating where the vehicle is parked.)

6. Any household member in military service?
Detail branch of service, rank and location of base for any household member in active military service. Determine if any
vehicle is located at the military location.

7. Any driver's license been suspended/revoked?
Indicate the driver number, period of suspension, reason for suspension, and date the license was reinstated.

8. Any driver have physical/mental impairment?
List any operator with a physical or mental impairment which could hinder the safe operation of a vehicle (e.g.,
amputation, epilepsy). If impaired, enter the name of the driver, describe any special equipment installed and treatment or
medication being administered.

9. Any financial responsibility filing?
Indicate the driver's name, reason for the filing and date of original filing.

10. Any coverage declined, cancelled, or non-renewed during
the last three years?
Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within
the last three years. List the person's name and why the action was taken. This question cannot be asked in Missouri.

DRIVER INFORMATION

When adding a driver, complete this entire section, questions 6-10 of the General Information section and the entire
Accidents/Convictions section. Refer to the driver's license for the licensed operator being added to the policy. If more
space is required, use the Remarks section. If a change is
made, enter only the information being changed.

If a driver is being deleted, provide sufficient information to identify and process the request. Indicate reason for the
deletion in the Remarks section.

Driver #
Indicate the current driver number, before renumbering.

Name
Name of the licensed operator appearing on the driver's license. Enter the surname only if it differs from the insured's.

Sex
F for female, M for male.

Mar Stat
Marital status of the driver. Examples:

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

Relation to Applicant
Driver's relationship to the insured. Examples:

I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Insured
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spouse
C . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child
SIB. . . . . . . . . . . . . . . . . . . . . . . . . . . Brother/Sister
P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent
E . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employee.

Date of Birth
Birth date of the driver (e.g., March 7, 1944 should be 3/7/44).

Occupation
Occupation of the driver.

Date Lic
Date (MM/YY) the driver was permanently licensed.

Stdt >> 100
Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section,
show name of institution and address.

Good Stdt
Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a
Good Student Certificate (ACORD 91) for each operator who qualifies.

Drv Train
Indicate if driver training credit applies to the driver, if required by the company. Refer to the company's manual to verify if
a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21
and has successfully completed this training and qualifies for the credit.

ACC Prev Cse Date
Date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a
Course Completion Certificate if the driver qualifies.

Drivers License #/Licensed State
Complete driver's license number and licensed state for the licensed operator. Copy directly from license if possible.

Social Security #
Driver's social security number.

ACCIDENTS/CONVICTIONS

Complete this section only if any driver being added to the policy has had an accident, been convicted of a violation or
had a comprehensive loss. The number of years this information should cover must be in accordance with the company's
and state's requirements. If there have not been
any accidents, convictions or comprehensive losses during the indicated time period, enter "None".

This section must be completed fully and accurately. Many companies verify driving records with state motor vehicle
departments. Discrepancies between the application and the report may result in processing delays and unnecessary
correspondence with the company.

Date of Accident/Conviction
Date the accident or conviction occurred.

Description of Accident or Conviction
Complete description of the accident or conviction including the number of vehicles involved and the type of vehicles
(private passenger or commercial). Convictions constitute a judgement of guilty, plea of nolo contendere or forfeiture of
bail. Use Remarks section or an additional piece of paper if necessary.

Place of Accident/Conviction
City and state of the accident or conviction.

BI or Death
Indicate whether bodily injury or death occurred. Fully describe the accident.

Amount of Property Damage
Total amount of property damage (applicant's and all claimants' combined damages). Refer to company manual.

ADDITIONAL INTEREST

Indicate if Additional Interest (additional insured-lessor, certificate holder) or Loss Payee. Show complete name and
mailing address. This section is often used to delete a lienholder from a policy after the loan is repaid.
PRODUCER'S SIGNATURE / INSURED'S SIGNATURE

Space is provided for signatures of the producer and/or the insured.
Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are
made that are considered significant to the company. Refer to your company rules.

Many companies, or state laws require the insured's signature when auto, liability, no fault, or uninsured motorists
coverage is changed or deleted. Refer to your company or state rules.




Personal Policy Change Request 70 (Except Auto) (5/2001)

Use this form to request mid-term changes to any personal lines policy,
except auto. For auto changes, see ACORD 71, Personal Auto Policy Change Request. This form should be used instead
of individual turnaround endorsement requests. A copy of the request may be sent to the insured to confirm that the
change is submitted to the company. The form provides for property, mobile home, inland marine, watercraft and umbrella
changes.

IDENTIFICATION

This section provides essential producer, company and insured information. It should be fully completed for all types of
changes. A copy of the policy's declaration page can be attached to provide additional identification information.

All data fields in this section, except the insured's name and mailing address, should contain existing policy information,
not changed data.

The generic fields of the Identification section are explained in the Personal Lines Generic Section at the beginning of the
Personal Lines Sections of the Forms Instruction Guide. On the ACORD website (www.acord.org)., this information
appears under the title PERSONAL LINES GENERIC SECTIONS.

Most sections in this form begin with a change indicator. Enter either an A-Add, C-Change, D-Delete, or check the
appropriate box. Various combinations of changes are permitted in one submission.

Use "A" to add an item that was not previously in the policy (e.g., add a
coverage, add a property location). Use "D" to delete an item (e.g., delete a property location). Use "C" to change an item
in the policy (e.g., change a deductible, change coverage limits).

HOMEOWNER COVERAGES/LIMITS OF LIABILITY

This section should be completed for any modification to the coverage amounts on a homeowner policy. If a new
homeowner policy is to be written, the Homeowner Application (ACORD 80) should be used.

When requesting a change, enter only the information being changed. All other items on the policy remain the same. If
deleting an item, provide sufficient information to process the request.

List the anticipated dollar limit amount for each applicable coverage.

HO Form
Policy form number or company form designation for the type of policy/coverage desired. Some ISO form types are:

1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic
2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Broad
3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special
4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenants Contents
5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Comprehensive.

Deductibles
One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage.
Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same
amount or they may differ by coverage.)

Dwelling Fire Coverages/Limits of Liability
List the changed dollar limit amounts for each applicable coverage.

Coverage Abbreviations
Fire . . . . . . . . . . . . . . . . . . . . . . . . . . Fire and Lightning
EC . . . . . . . . . . . . . . . . . . . . . . . . . . . Extended Coverage
VMM. . . . . . . . . . . . . . . . . . . . . . . . . Vandalism and Malicious Mischief

One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage.
Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same
amount or they may differ by coverage.)

Mobile Home Coverages/Limits of Liability
Enter the applicable coverage form and list the changed dollar limit amounts for each applicable coverage.

One or more deductibles may apply, depending on the company, the jurisdiction for the policy and the property coverage.
Enter the appropriate name of the deductible and deductible amount in each field. (Note: Deductibles may be the same
amount or they may differ by coverage.)

HOMEOWNER, DWELLING FIRE AND MOBILE HOME RATING/UNDERWRITING

Provide the information below for each dwelling. Enter only the information being changed.

Construction Type
Check the primary type of building material used to construct the dwelling.

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.

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.

# 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 fire walls.

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.

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
Oil Storage Tank Location
If the fuel type is oil, provide the location of the fuel oil storage tank. Examples:
      •     Indoors completely above ground on a masonry floor
      •     Indoors completely above ground not on a masonry floor
      •     Outdoors and completely above ground
      •     All other (including underground)

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

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.

Dwelling Location
Location of the dwelling within the guidelines listed.

Occupied By
Indicate if the dwelling is occupied by the owner or a tenant.

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.

Housekeeping Condition
Enter the evaluation of the interior upkeep of the dwelling.

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.
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 or approved fence.

Storm Shutters
Check the applicable boxes.

Hurricane Resistant Glass
Check the applicable box.

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.

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

WIND CLASS
Check the applicable box.

Roof Type
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
MOBILE HOME TIEDOWN/FOUNDATION
Check the appropriate box to describe the type of tie down, if any, used to secure the mobile home from wind damage,
and the type of foundation.

ADDITIONAL INTEREST

Provide the following information for the entity having an interest in the dwelling(s) to be insured: the interest number or
rank (1st, 2nd), whether the additional interest is the mortgage holder, (e.g., bank in which the mortgage is held) or other
interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan
number. Space is provided for two additional interests.

PERSONAL INLAND MARINE/SCHEDULE OF PROPERTY

List items that are to be added, changed or deleted on the personal inland marine policy. When working with a long list of
items, you may attach a list of the items rather than complete this section of the application. When listing items, provide a
full description, including serial numbers, if applicable. Appraisals or sales receipts must be included where required.

WATERCRAFT COVERAGES/LIMITS OF LIABILITY

Hull
Amount of coverage for boat damage (this may include collision liability). Limits may be entered for two vessels.

Outboard Motor
Amount of coverage for damage to the outboard motor. Space for 2 motors is provided.
    •    Coverage for inboard motors is included in the hull coverage.

Portable Accessories
Coverage amount for those items not permanently attached to the boat. Examples:
    •    Oars
    •    Anchors
    •    Life preservers
    •    Fire extinguishers

Trailer
Coverage amount for damage to the trailer.
Liability
Coverage amount for bodily injury and property damage (may be called protection and indemnity).

Medical Payments
Coverage amount for medical expenses for bodily injury to occupants of the boat.

Uninsured Boaters Liability
Some states require this coverage for watercraft.

Deductible
Show the deductible if applicable.

PERSONAL UMBRELLA COVERAGES/LIMITS OF LIABILITY

Section may be used to make changes to either the basic policy or individual coverage limits.

Policy Amount
Limit of liability.

Retention
Amount of liability retained by the insured. Retention is usually expressed in whole dollars, but can be a percentage.

Other Coverages, Automobile, Personal Liability, Watercraft, Recreational Vehicles
Complete these boxes as needed.

Producer's Signature / Insured's Signature
Space is provided for signatures of the producer and/or the insured.

Some companies require one or both signatures when limits of insurance are increased or reduced, or other changes are
made that are considered significant to the company. Refer to your company rules.

Many companies, or state laws require the insured's signature when certain types of coverage is changed or deleted.
Refer to your company or state rules.




Workers Comp Insurance Plan 133 (4/96)

The Workers Compensation Insurance Plan Assigned Risk Section (ACORD 133) is designed to be used in conjunction
with the ACORD Workers Compensation Application (ACORD 130). These two forms collect the data necessary for
submitting assigned risk business.

Please answer all questions thoroughly. Any omission may result in delay or denial of coverage. Where space restricts a
complete answer, attach answer on a separate sheet of paper. These applications do not provide coverage.
Refer to the National Council on Compensation Insurance Inc. (NCCI) WCIP State Instruction pages following this section
for state specific instructions on completing the ACORD 133 and ACORD 130 for WCIP business.

All questions regarding the preparation of this form should be referred to the NCCI Service Center shown on the state
instruction pages.
APPLICANT INFORMATION SECTION
Applicant Name
Enter the complete legal name of the employer. Provide all applicable D.B.A.'s (Doing business as). If more than one
named insured, please submit appropriate ERM 14 form(s) "Confidential Request for Information." Contact NCCI for this
form.
Proposed Effective Date
Enter the proposed policy effective date. Such requested effective date shall be the later of the following options.
1. 12:01 a.m. on the date following the receipt by the Plan Administrator of a complete and eligible application,
2. the date of expiration of existing coverage, or
3. a date the application requested.
SUPPLEMENTAL INFORMATION
Payroll Office Name and Address
List the company name, physical address and telephone number where payroll records are maintained. A P.O. box
address only is not acceptable.
State Developing Highest Payroll
Enter the state which generates the highest payroll and follow all specific instructions for this state.
1. Prior Coverage question
If there was no prior coverage, indicate why by checking the appropriate box for either new business, self insured
(independent or group), or insufficient number of employees.
2. Premium Due or in dispute question
Details of any outstanding obligations must be furnished in the available space, in the remarks section or on an attached
separate piece of paper.
3. Year Applicant's Business Began
List the month, day and year the current owners purchased or started the business.
4. Name/Ownership over 5 Years question
A signed ERM-14 form "Confidential Request for Information," must accompany the application if a name or ownership
change has occurred over the past five years, and has not already been reported. Contact NCCI for this form.
5. Related Entities question
List all related entities, providing a detailed explanation of the type of relationship (e.g., management, ownership, etc.).
6. Do you lease workers from a labor contractor?
Refer to the WCIP state instruction sheet for state requirements.
7. Do you lease workers to a client company?
Refer to the WCIP state instruction sheet for state requirements.
8. Are you seeking to cover leased workers?
Refer to the WCIP state instruction sheet for state requirements.
9. Do you provide temporary labor services to other employers?
If yes, give a complete description of type of services provided (e.g., type of work being performed, duration, etc.) and a
copy of the service contract, if available.
10. Do you have a franchise or licensing agreement?
Provide details of agreement including franchiser's name and address.
11. Do trucking classifications apply?
If yes, complete questions 12, 13, and 14.
12. Base Terminal question
List the complete address for each base terminal which is used by the drivers to load, unload, and/or transfer freight on a
regular basis.
13. Driver's State of Majority Driving Time question
If the state of majority driving time can be established for each driver through verifiable logs or records, list the state for
each driver in the appropriate section of question 14.
14. Drivers Listing
The drivers listing should include the following for each driver:
driver name
base terminal (if applicable)
state of majority driving time (if applicable)
state of residence.
INSURANCE COMPANIES WHO HAVE OFFERED/REFUSED INSURANCE
1. Have you received any offers of voluntary coverage?
An offer of voluntary coverage will affect an applicant's eligibility for Plan coverage; therefore voluntary offers of coverage
must be fully and completely described.
2. Refusing Insurance Companies information.
Refer to the state instructions for requirements regarding the number of refusals needed before an applicant is eligible for
the state's WCIP coverage. Refusal must come from non-affiliated insurers who are licensed and actively writing workers
compensation insurance in the state of application. The employer and/or its representative must retain in file the refusing
carrier's name, contact person, address, phone number and date of refusal.
PREMIUM PAYMENT
Several options are available for submitting deposit premium, including:
1. Verbal Check - Submit the complete nine (9) digit ABA number or bank routing number in the boxes provided under
  BANK/ABA #. Submit the complete account number and check number in the boxes provided. Indicate the premium
  amount (in whole dollars) which NCCI, Inc. is authorized to deduct from the account. The funds may be drawn on an
  agency or applicant's account which may be either a commercial or personal account.
2. Electronic Funds Transfer (EFT) - Submit the complete nine (9) digit ABA number or bank routing number, and the
  complete account number in the boxes provided. Indicate the premium payment amount (in whole dollars) which NCCI,
  Inc. is authorized to deduct from the account. The funds may be drawn on an agency or applicant's account. For this
  option, a commercial account must be used.
3. Mail-In Check - Make check payable to NCCI, Inc. or other Plan Administrator, if applicable. The check may be in the
  form of an agency check, applicant's check, cashier's check, certified check, draft, money order, or finance company
  check. Coverage cannot be bound if the required deposit premium is not received. Please refer to the appropriate
  WCIP instructions for deposit premium requirements and premium calculation guidelines.
APPLICANT'S STATEMENT
This application must be signed by a sole proprietor, partner, corporate owner or officer. If a person other than any of
these has signed the application (e.g., spouse, trustee, general manager), attach a copy of the power of attorney. With the
signature, provide the signer's name, title and signature date. The Loss Sensitive Rating Plan acknowledgement applies
only in those jurisdictions where the program has been approved for use.

Reminder: Both the 130 and 133 applications must be signed by the insured and the producer.
PRODUCER'S CERTIFICATION
The following producer information must be completed: Agency FEIN (Federal Employer Identification Number), agency
phone and fax number, resident or non-resident license number with expiration date, and the producer's name, date and
signature.




Agent / Broker of Record Change 36 (1/98)

Use this form to provide authorization from your customer to the customer's current insurance company. The form notifies
the insurer that you have been named as the exclusive representative with respect to policies currently in force.




Statement of No Loss (1/96)


Use this form when:

A policy issued by your agency has been cancelled, or has lapsed, because premium for the policy was not paid in time;

The former insured desires to pay the delinquent premium and reinstate
insurance without a lapse in coverage; and

Your contract with the insuring company, or the company's rules, permit
policy reinstatement. (You may have to contact your company before
proceeding.)

By signing this form, the former insured certifies that there were no losses, or circumstances that might give rise to a claim
under the policy, during the
period coverage had lapsed.

This form is also a receipt for the premium payment you collect at the time
the form is signed. The form is NOT an insurance binder.




General Fraud Statement 63 (10/2001)

The following states have enacted anti-fraud statutes that prescribe specific fraud warning text for disclosure notices to
applicants for insurance and/or claimants.

In the case of claimants, the back of each ACORD loss notice contains the required fraud warning in compliance with
state laws and regulations.

NOTE: When a risk is located in moe than one state, the applicable law is the law in effect for the state in which the
insurance policy is written, or the insurance claim is made.
California:
All claim forms, and auto applications contain the required text.

Colorado:
ACORD 63 CO responds.

Arkansas, Florida, Kentucky,New Mexico, New York:
ACORD has secured agreement among these state regulators to recognize the "standard" fraud warning text included in
all ACORD applications after 1/96.

However, these states will no longer accept supplements such as ACORD 63FL, 63KY, and 63NY, which were withdrawn
as soon as these states accepted our "standard" text.

Companies with unique, program-specific applications should consider inserting ACORD's "standard" text, shown below,
in their applications.

"Any person who knowingly and with intent to defraud any insurance company or another person files an application for
insurance containing any materially false information, or conceals for the purpose of misleading information concerning
any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and
(NY: substantial) civil penalties." (Not applicable in CO, HI, NE, OH, OK, OR, VT, ) In DC, LA, ME, TN and VA, insurance
benefits may also be denied.

Hawaii:
ACORD 63 HI responds.

Idaho, Indiana, Nevada, New Hampshire:
Claim forms only.

District of Columbia, Louisiana, Maine, Tennessee and Virginia
The "standard" ACORD fraud statement has been revised to respond to these states.

Michigan, Minnesota:
Regulators are enforcing law requiring specific fraud text in claim forms, but are not requiring that warnings be included in
applications.

Arizona, New Jersey, Pennsylvania, Tennessee:
Claim forms and Applications. These states also accepted ACORD's "standard" text, and also recognize supplements to
applications.

Although not necessary with respect to ACORD applications, companies should consider using ACORD 63 with their
unique, program-specific applications in these states, unless they have incorporated the "standard" ACORD text.

Ohio, Utah:
Claim forms and applications (Utah- workers compensation only). These states have specific, unique text requirements.
ACORD 63OH, and 63UT meet these requirements, and should be used with ALL applications, ACORD or company-
specific.

Oklahoma:

Claim forms, insurance policies and applications. ACORD 63OK responds.

								
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