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ACORD Form 125 Commercial Insurance
Application Applicant Information Section Instructions

 

 
ACORD 125 (2009/05) rev. 06-30-2009 1 of 33
Section Name Field Name Field and/or Section Description
The title of the form. ACORD 125, Commercial Application - Applicant Information Section, is used in the underwriting process for any commercial account submission. The following instructions will provide assistance in the completion the ACORD Commercial Insurance Applicant Information Section.
TITLE ACORD 125 (2009/05) Commercial Insurance Application - 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 (MM/DD/YYYY) Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
Enter text: The name of the individual at the producer's establishment that is the primary
IDENTIFICATION SECTION Contact Name contact.
Enter number: The producer's contact person's phone number. If applicable, include the
IDENTIFICATION SECTION Phone (A/C, No, Ext) area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address Enter text: The producer's contact person e-mail address.
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
IDENTIFICATION SECTION Code firm) by the insurer.
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
IDENTIFICATION SECTION Subcode person) within a producer's office (e.g. agency or brokerage).

ACORD 125 (2009/05) rev. 06-30-2009 2 of 33

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Carrier Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Company Policy or Program Name Enter text: The description of an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Program Code Enter code: The product code of the insurer for the policy.
IDENTIFICATION SECTION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Underwriter Enter text: The company underwriter (or other company staff person) that this form should be directed to.
IDENTIFICATION SECTION Underwriter Office Enter identifier: The company underwriting office that this application should be directed to.
STATUS OF TRANSACTION Quote (checkbox) Check the box (if applicable): Indicates the response expected from the company is a quote.
STATUS OF TRANSACTION Issue Policy (checkbox) Check the box (if applicable): Indicates the response expected from the company is an issued policy.
STATUS OF TRANSACTION Renew (checkbox) Check the box (if applicable): Indicates the response expected from the company is a renewed policy.
STATUS OF TRANSACTION Bound (checkbox) Check the box (if applicable): Indicates the coverage has been bound.
STATUS OF TRANSACTION Change (checkbox) Check the box (if applicable): Indicates the policy is being submitted for a policy change.
STATUS OF TRANSACTION Cancel (checkbox) Check the box (if applicable): Indicates the policy is being submitted for cancellation.
STATUS OF TRANSACTION Date Enter date: The date the policy status becomes effective. This date is used for policy statuses of bound, change, and cancel.
STATUS OF TRANSACTION Time Enter time: The time the policy status becomes effective. The time is used for policy statuses of bound, change, and cancel.

ACORD 125 (2009/05) rev. 06-30-2009 3 of 33

Section Name Field Name Field and/or Section Description
STATUS OF TRANSACTION AM (checkbox) Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm.
STATUS OF TRANSACTION PM (checkbox) Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or later.
SECTIONS ATTACHED Accounts Receivable/Valuable Papers (checkbox) Check the box (if applicable): Indicates the Accounts Receivable Valuable Papers section is attached to this policy.
SECTIONS ATTACHED Accounts Receivable/Valuable Papers Premium Enter amount: The premium amount for the Accounts Receivable line of business.
SECTIONS ATTACHED Boiler & Machinery (checkbox) Check the box (if applicable): Indicates the Boiler And Machinery section is attached to this policy.
SECTIONS ATTACHED Boiler & Machinery Premium Enter amount: The premium amount for the Boiler And Machinery line of business.
SECTIONS ATTACHED Business Auto (checkbox) Check the box (if applicable): Indicates the Business Auto section is attached to this policy.
SECTIONS ATTACHED Business Auto Premium Enter amount: The premium amount for the Commercial Vehicle (Business Auto) line of business.
SECTIONS ATTACHED Business Owners (checkbox) Check the box (if applicable): Indicates the type of policy is business owners.
SECTIONS ATTACHED Business Owners Premium Enter amount: The premium amount for the business owners (BOP) line of business.
SECTIONS ATTACHED Commercial General Liability (checkbox) Check the box (if applicable): Indicates the Commercial General Liability section is attached to this policy.
SECTIONS ATTACHED Commercial General Liability Premium Enter amount: The total premium amount for the commercial general liability line of business.
SECTIONS ATTACHED Crime / Miscellaneous Crime (checkbox) Check the box (if applicable): Indicates the Crime or Miscellaneous Crime section is attached to this policy.
SECTIONS ATTACHED Crime / Miscellaneous Crime Premium Enter amount: The premium amount for the Crime line of business.
SECTIONS ATTACHED Dealers (checkbox) Check the box (if applicable): Indicates the Dealers section is attached to this policy.
SECTIONS ATTACHED Dealers Premium Enter amount: The premium amount for the Dealers line of business.
SECTIONS ATTACHED Electronic Data Processing (checkbox) Check the box (if applicable): Indicates the Electronic Data Processing section is attached to this policy.
SECTIONS ATTACHED Electronic Data Processing Premium Enter amount: The premium amount for the Electronic Data Processing (EDP) line of business.
SECTIONS ATTACHED Equipment Floater (checkbox) Check the box (if applicable): Indicates the Equipment Floater section is attached to this policy.
SECTIONS ATTACHED Equipment Floater Premium Enter amount: The premium amount for the Equipment Floater line of business.
ACORD 125 (2009/05) rev. 06-30-2009 4 of 33
Section Name Field Name Field and/or Section Description
SECTIONS ATTACHED Garage & Dealers (checkbox) Check the box (if applicable): Indicates the Garage and Dealers section is attached to this policy.
SECTIONS ATTACHED Garage & Dealers Premium Enter amount: The premium amount for the Garage and Dealers line of business.
SECTIONS ATTACHED Glass & Sign (checkbox) Check the box (if applicable): Indicates the Glass and Sign section is attached to this policy.
SECTIONS ATTACHED Glass & Sign Premium Enter amount: The premium amount for the Glass and Sign line of business.
SECTIONS ATTACHED Installation / Builders Risk (checkbox) Check the box (if applicable): Indicates the Installation - Builders Risk section is attached to this policy.
SECTIONS ATTACHED Installation / Builders Risk Premium Enter amount: The premium amount for the Installation / Builders' Risk line of business.
SECTIONS ATTACHED Open Cargo (checkbox) Check the box (if applicable): Indicates the Open Cargo section is attached to this policy.
SECTIONS ATTACHED Open Cargo Premium Enter amount: The premium amount for the Open Cargo line of business.
SECTIONS ATTACHED Property (checkbox) Check the box (if applicable): Indicates the Property section is attached to this policy.
SECTIONS ATTACHED Property Premium Enter amount: The premium amount for the Commercial Property line of business.
SECTIONS ATTACHED Transportation / Motor Truck Cargo (checkbox) Check the box (if applicable): Indicates the Transportation - Motor Truck Cargo section is attached to this policy.
SECTIONS ATTACHED Transportation / Motor Truck Cargo Premium Enter amount: The premium amount for the Transportation / Motor Truck Cargo line of business.
SECTIONS ATTACHED Truckers / Motor Carriers (checkbox) Check the box (if applicable): Indicates the Truckers - Motor Carrier section is attached to this policy.
SECTIONS ATTACHED Truckers / Motor Carriers Premium Enter amount: The premium amount for the Truckers line of business.
SECTIONS ATTACHED Umbrella (checkbox) Check the box (if applicable): Indicates the Umbrella section is attached to this policy.
SECTIONS ATTACHED Umbrella Premium Enter amount: The premium amount for the Commercial Umbrella line of business.
SECTIONS ATTACHED Yacht (checkbox) Check the box (if applicable): Indicates the Yacht section is attached to this policy.
SECTIONS ATTACHED Yacht Premium Enter amount: The premium amount for the Yacht line of business.
SECTIONS ATTACHED Other (checkbox) Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy.
SECTIONS ATTACHED Other Description Enter text: The type of section being attached to the policy.
SECTIONS ATTACHED Other Premium Enter amount: The premium amount the for the section / line of business.
SECTIONS ATTACHED Other (checkbox) Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy.
SECTIONS ATTACHED Other Description Enter text: The type of section being attached to the policy.
ACORD 125 (2009/05) rev. 06-30-2009 5 of 33
Section Name Field Name Field and/or Section Description
SECTIONS ATTACHED Other Premium Enter amount: The premium amount the for the section / line of business.
SECTIONS ATTACHED Other (checkbox) Check the box (if applicable): Indicates that a section that is not listed specifically on the form is attached to this policy.
SECTIONS ATTACHED Other Description Enter text: The type of section being attached to the policy.
SECTIONS ATTACHED Other Premium Enter amount: The premium amount the for the section / line of business.
ATTACHMENTS Additional Interest (checkbox) Check the box (if applicable): Indicates an ACORD 45, Additional Interests Schedule is attached.
ATTACHMENTS Additional Premises (checkbox) Check the box (if applicable): Indicates an additional premises schedule is attached.
ATTACHMENTS Apartment Building Supplement (checkbox) Check the box (if applicable): Indicates an apartment building supplement is attached.
ATTACHMENTS Condo Association By Laws (For D&O Cov Only) (checkbox) Check the box (if applicable): Indicates the condominium association by laws are attached.
ATTACHMENTS Contractors Supplement (checkbox) Check the box (if applicable): Indicates the contractors supplement is attached.
ATTACHMENTS Coverages Schedule (checkbox) Check the box (if applicable): Indicates a coverages schedule is attached.
ATTACHMENTS Driver Information Schedule (checkbox) Check the box (if applicable): Indicates the Driver Information Schedule section is attached to this policy.
ATTACHMENTS International Liability Exposure Supplement (checkbox) Check the box (if applicable): Indicates an international liability exposure supplement is attached.
ATTACHMENTS International Property Exposure Supplement (checkbox) Check the box (if applicable): Indicates an international property exposure supplement is attached.
ATTACHMENTS Loss Summary (checkbox) Check the box (if applicable): Indicates that a loss summary report is attached to the policy.
ATTACHMENTS Premium Payment Supplement (checkbox) Check the box (if applicable): Indicates a premium payment supplement is attached.
ATTACHMENTS Professional Liability Supplement (checkbox) Check the box (if applicable): Indicates a professional liability supplement is attached.
ATTACHMENTS Restaurant / Tavern Supplement (checkbox) Check the box (if applicable): Indicates a restaurant / tavern supplement is attached.
ATTACHMENTS Statement / Schedule of Values (checkbox) Check the box (if applicable): Indicates a statement / schedule of values is attached.
ATTACHMENTS State Supplement (if applicable) (checkbox) Check the box (if applicable): Indicates that a state supplement is attached to the policy.
ATTACHMENTS Vacant Building Supplement (checkbox) Check the box (if applicable): Indicates a vacant building supplement is attached.

ACORD 125 (2009/05) rev. 06-30-2009 6 of 33

Section Name Field Name Field and/or Section Description
ATTACHMENTS Vehicle Schedule (checkbox) Check the box (if applicable): Indicates the Vehicle Schedule section is attached to this policy.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.

ACORD 125 (2009/05) rev. 06-30-2009 7 of 33

Section Name Field Name Field and/or Section Description
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
ATTACHMENTS Other Check the box (if applicable): Indicates there is an attachment other than those listed on the application.
ATTACHMENTS Other Description Enter text: The description of the type of other attachment.
POLICY INFORMATION Proposed Eff. Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, this is the proposed effective date.
POLICY INFORMATION Proposed Exp. Date Enter date: The date on which the terms and conditions of the policy will expire. As used here, this is the proposed expiration date.
POLICY INFORMATION Direct Bill (checkbox) Check the box (if applicable): Indicates if the policy is to be direct billed.
POLICY INFORMATION Agency Bill (checkbox) Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
POLICY INFORMATION Payment Plan Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -Quarterly, etc.).
POLICY INFORMATION Method of Payment Enter text: The method the invoice will be paid.
POLICY INFORMATION Audit Enter code: 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 Deposit Enter amount: The amount of the premium received as a deposit.
POLICY INFORMATION Minimum Premium Enter amount: The minimum premium amount for the policy.
POLICY INFORMATION Policy Premium Enter amount: The estimated total cost amount of the policy.
APPLICANT INFORMATION Name (First Named Insured) & Mailing Address (Including Zip+4) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Mailing Address Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION Enter code: The named insured's mailing address postal code.

ACORD 125 (2009/05) rev. 06-30-2009 8 of 33

Section Name Field Name Field and/or Section Description
POLICY INFORMATION GL Code Enter code: The code identifying the general liability nature of business for the insured. The source of this code list is the Insurance Services Office Commercial Lines Manual (CLM) or individual insurer rate manuals.
POLICY INFORMATION SIC Code Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.
POLICY INFORMATION NAICS Code Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known).
APPLICANT INFORMATION FEIN or Social Security Number Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Business Phone Number Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Website Address Enter text: The primary website address for the named insured.
APPLICANT INFORMATION Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation".
APPLICANT INFORMATION Individual (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual".
APPLICANT INFORMATION Joint Venture (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture".
APPLICANT INFORMATION LLC (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation".
APPLICANT INFORMATION No. of Members and Managers Enter number: The number of members and managers for a limited liability corporation.
APPLICANT INFORMATION Not For Profit Organization (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Not For Profit Organization".
APPLICANT INFORMATION Partnership (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership".
APPLICANT INFORMATION Subchapter "S" Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation".
APPLICANT INFORMATION Trust Check the box (if applicable): Indicates the legal entity code for the named insured is "Trust".
APPLICANT INFORMATION Other (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form.
ACORD 125 (2009/05) rev. 06-30-2009 9 of 33
Section Name Field Name Field and/or Section Description
APPLICANT INFORMATION Other Description Enter text: The description of the legal entity if not listed on the form.
APPLICANT INFORMATION Name (Other Named Insured) & Mailing Address (Including Zip+4) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Mailing Address Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION Enter code: The named insured's mailing address postal code.
POLICY INFORMATION GL Code Enter code: The code identifying the general liability nature of business for the insured. The source of this code list is the Insurance Services Office Commercial Lines Manual (CLM) or individual insurer rate manuals.
POLICY INFORMATION SIC Code Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.
POLICY INFORMATION NAICS Code Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known).
APPLICANT INFORMATION FEIN or Social Security Number Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Business Phone Number Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Website Address(es) Enter text: The primary website address for the named insured.
APPLICANT INFORMATION Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation".
APPLICANT INFORMATION Individual (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual".
APPLICANT INFORMATION Joint Venture (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture".
ACORD 125 (2009/05) rev. 06-30-2009 10 of 33
Section Name Field Name Field and/or Section Description
APPLICANT INFORMATION LLC (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation".
APPLICANT INFORMATION No. of Members and Managers Enter number: The number of members and managers for a limited liability corporation.
APPLICANT INFORMATION Not For Profit Organization (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Not For Profit Organization".
APPLICANT INFORMATION Partnership (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership".
APPLICANT INFORMATION Subchapter "S" Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation".
APPLICANT INFORMATION Trust Check the box (if applicable): Indicates the legal entity code for the named insured is "Trust".
APPLICANT INFORMATION Other (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form.
APPLICANT INFORMATION Other Description Enter text: The description of the legal entity if not listed on the form.
APPLICANT INFORMATION Name (Other Named Insured) & Mailing Address (Including Zip+4) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Mailing Address Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION Enter code: The named insured's mailing address postal code.
POLICY INFORMATION GL Code Enter code: The code identifying the general liability nature of business for the insured. The source of this code list is the Insurance Services Office Commercial Lines Manual (CLM) or individual insurer rate manuals.
POLICY INFORMATION SIC Code Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.

ACORD 125 (2009/05) rev. 06-30-2009 11 of 33

Section Name Field Name Field and/or Section Description
POLICY INFORMATION NAICS Code Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known).
APPLICANT INFORMATION FEIN or Social Security Number Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Business Phone Number Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Website Address(es) Enter text: The primary website address for the named insured.
APPLICANT INFORMATION Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation".
APPLICANT INFORMATION Individual (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual".
APPLICANT INFORMATION Joint Venture (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture".
APPLICANT INFORMATION LLC (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Limited Liability Corporation".
APPLICANT INFORMATION No. of Members and Managers Enter number: The number of members and managers for a limited liability corporation.
APPLICANT INFORMATION Not For Profit Organization (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Not For Profit Organization".
APPLICANT INFORMATION Partnership (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership".
APPLICANT INFORMATION Subchapter "S" Corporation (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is "Subchapter S Corporation".
APPLICANT INFORMATION Trust Check the box (if applicable): Indicates the legal entity code for the named insured is "Trust".
APPLICANT INFORMATION Other (checkbox) Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form.
APPLICANT INFORMATION Other Description Enter text: The description of the legal entity if not listed on the form.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
CONTACT INFORMATION Contact Type Enter text: The type of contact being described (e.g. accounting, claims, etc.).
CONTACT INFORMATION Contact Name Enter text: The full name of the contact.
CONTACT INFORMATION Primary Phone Number Enter number: The primary phone number of the contact.
ACORD 125 (2009/05) rev. 06-30-2009 12 of 33
Section Name Field Name Field and/or Section Description
CONTACT INFORMATION Home Check the box (if applicable): Indicates the contact's primary phone is a home phone.
CONTACT INFORMATION Business Check the box (if applicable): Indicates the contact's primary phone is a business phone.
CONTACT INFORMATION Cell Check the box (if applicable): Indicates the contact's primary phone is a cell phone.
CONTACT INFORMATION Secondary Phone Number Enter number: The contact's secondary phone number.
CONTACT INFORMATION Home Check the box (if applicable): Indicates the contact's secondary phone number is a home phone.
CONTACT INFORMATION Business Check the box (if applicable): Indicates the contact's secondary phone number is a business phone.
CONTACT INFORMATION Cell Check the box (if applicable): Indicates the contact's secondary phone number is a cell phone.
CONTACT INFORMATION Primary E-Mail Address Enter text: The contact's primary e-mail address.
CONTACT INFORMATION Secondary E-Mail Address Enter text: The contact's secondary e-mail address.
CONTACT INFORMATION Contact Type Enter text: The type of contact being described (e.g. accounting, claims, etc.).
CONTACT INFORMATION Contact Name Enter text: The full name of the contact.
CONTACT INFORMATION Primary Phone Number Enter number: The primary phone number of the contact.
CONTACT INFORMATION Home Check the box (if applicable): Indicates the contact's primary phone is a home phone.
CONTACT INFORMATION Business Check the box (if applicable): Indicates the contact's primary phone is a business phone.
CONTACT INFORMATION Cell Check the box (if applicable): Indicates the contact's primary phone is a cell phone.
CONTACT INFORMATION Secondary Phone Number Enter number: The contact's secondary phone number.
CONTACT INFORMATION Home Check the box (if applicable): Indicates the contact's secondary phone number is a home phone.
CONTACT INFORMATION Business Check the box (if applicable): Indicates the contact's secondary phone number is a business phone.
CONTACT INFORMATION Cell Check the box (if applicable): Indicates the contact's secondary phone number is a cell phone.
CONTACT INFORMATION Primary E-Mail Address Enter text: The contact's primary e-mail address.
CONTACT INFORMATION Secondary E-Mail Address Enter text: The contact's secondary e-mail address.
PREMISES INFORMATION Loc # Enter number: The location number for the premises.
PREMISES INFORMATION Bld # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street Enter text: The first address line of the commercial structure.
PREMISES INFORMATION Enter text: The second address line of the commercial structure.
ACORD 125 (2009/05) rev. 06-30-2009 13 of 33
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION City Enter text: The city of the commercial structure.
PREMISES INFORMATION County Enter text: The county of the commercial structure.
PREMISES INFORMATION State Enter code: The state of the commercial structure.
PREMISES INFORMATION Zip Enter code: The postal code of the commercial structure.
PREMISES INFORMATION City Limits Inside (checkbox) Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION City Limits Outside (checkbox) Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates if the building is not inside or outside city limits. For example, unincorporated.
PREMISES INFORMATION Other Description Enter text: The description of the risk location if not inside or outside the city limits.
PREMISES INFORMATION Interest Owner (checkbox) Check the box (if applicable): Indicates the named insured's interest in the building is as its owner.
PREMISES INFORMATION Interest Tenant (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is as its tenant.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is other than as its owner or tenant.
PREMISES INFORMATION Other Description Enter text: The description of the insured's interest is the building when it is other than as its owner or tenant.
PREMISES INFORMATION # Full Time Employees Enter number: The number of full time employees.
PREMISES INFORMATION # Part Time Employees Enter number: The number of part time employees.
PREMISES INFORMATION Annual Revenues Enter amount: The annual revenue amount for this location.
PREMISES INFORMATION Occupied Area Enter number: The area, in square feet, of the building the named insured occupies.
PREMISES INFORMATION Open to Public Area Enter number: The area, in square feet, of the building that is open to the public.
PREMISES INFORMATION Total Building Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Description of Operations Enter text: The description of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location (e.g., location #1 is a sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include number of leased and owned premises outside of the United States. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C.".
PREMISES INFORMATION Any area leased to others? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any area leased in building?".
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Loc # Enter number: The location number for the premises.
PREMISES INFORMATION Bld # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street Enter text: The first address line of the commercial structure.
PREMISES INFORMATION Enter text: The second address line of the commercial structure.
PREMISES INFORMATION City Enter text: The city of the commercial structure.
PREMISES INFORMATION County Enter text: The county of the commercial structure.
PREMISES INFORMATION State Enter code: The state of the commercial structure.
PREMISES INFORMATION Zip Enter code: The postal code of the commercial structure.
PREMISES INFORMATION City Limits Inside (checkbox) Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION City Limits Outside (checkbox) Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates if the building is not inside or outside city limits. For example, unincorporated.
PREMISES INFORMATION Other Description Enter text: The description of the risk location if not inside or outside the city limits.
PREMISES INFORMATION Interest Owner (checkbox) Check the box (if applicable): Indicates the named insured's interest in the building is as its owner.
PREMISES INFORMATION Interest Tenant (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is as its tenant.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is other than as its owner or tenant.
PREMISES INFORMATION Other Description Enter text: The description of the insured's interest is the building when it is other than as its owner or tenant.
PREMISES INFORMATION # Full Time Employees Enter number: The number of full time employees.
PREMISES INFORMATION # Part Time Employees Enter number: The number of part time employees.
PREMISES INFORMATION Annual Revenues Enter amount: The annual revenue amount for this location.
PREMISES INFORMATION Occupied Area Enter number: The area, in square feet, of the building the named insured occupies.
PREMISES INFORMATION Open to Public Area Enter number: The area, in square feet, of the building that is open to the public.
PREMISES INFORMATION Total Building Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.

ACORD 125 (2009/05) rev. 06-30-2009 14 of 33 ACORD 125 (2009/05) rev. 06-30-2009 33 of 33

ACORD 125 (2009/05) rev. 06-30-2009 15 of 33
Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Description of Operations Enter text: The description of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location (e.g., location #1 is a sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include number of leased and owned premises outside of the United States. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C.".
PREMISES INFORMATION Any area leased to others? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any area leased in building?".
PREMISES INFORMATION Loc # Enter number: The location number for the premises.
PREMISES INFORMATION Bld # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street Enter text: The first address line of the commercial structure.
PREMISES INFORMATION Enter text: The second address line of the commercial structure.
PREMISES INFORMATION City Enter text: The city of the commercial structure.
PREMISES INFORMATION County Enter text: The county of the commercial structure.
PREMISES INFORMATION State Enter code: The state of the commercial structure.
PREMISES INFORMATION Zip Enter code: The postal code of the commercial structure.
PREMISES INFORMATION City Limits Inside (checkbox) Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION City Limits Outside (checkbox) Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates if the building is not inside or outside city limits. For example, unincorporated.
PREMISES INFORMATION Other Description Enter text: The description of the risk location if not inside or outside the city limits.
PREMISES INFORMATION Interest Owner (checkbox) Check the box (if applicable): Indicates the named insured's interest in the building is as its owner.
PREMISES INFORMATION Interest Tenant (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is as its tenant.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is other than as its owner or tenant.
PREMISES INFORMATION Other Description Enter text: The description of the insured's interest is the building when it is other than as its owner or tenant.
PREMISES INFORMATION # Full Time Employees Enter number: The number of full time employees.
PREMISES INFORMATION # Part Time Employees Enter number: The number of part time employees.

ACORD 125 (2009/05) rev. 06-30-2009 16 of 33

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Annual Revenues Enter amount: The annual revenue amount for this location.
PREMISES INFORMATION Occupied Area Enter number: The area, in square feet, of the building the named insured occupies.
PREMISES INFORMATION Open to Public Area Enter number: The area, in square feet, of the building that is open to the public.
PREMISES INFORMATION Total Building Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Description of Operations Enter text: The description of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location (e.g., location #1 is a sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include number of leased and owned premises outside of the United States. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C.".
PREMISES INFORMATION Any area leased to others? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any area leased in building?".
PREMISES INFORMATION Loc # Enter number: The location number for the premises.
PREMISES INFORMATION Bld # Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street Enter text: The first address line of the commercial structure.
PREMISES INFORMATION Enter text: The second address line of the commercial structure.
PREMISES INFORMATION City Enter text: The city of the commercial structure.
PREMISES INFORMATION County Enter text: The county of the commercial structure.
PREMISES INFORMATION State Enter code: The state of the commercial structure.
PREMISES INFORMATION Zip Enter code: The postal code of the commercial structure.
PREMISES INFORMATION City Limits Inside (checkbox) Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION City Limits Outside (checkbox) Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates if the building is not inside or outside city limits. For example, unincorporated.
PREMISES INFORMATION Other Description Enter text: The description of the risk location if not inside or outside the city limits.
PREMISES INFORMATION Interest Owner (checkbox) Check the box (if applicable): Indicates the named insured's interest in the building is as its owner.
PREMISES INFORMATION Interest Tenant (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is as its tenant.

ACORD 125 (2009/05) rev. 06-30-2009 17 of 33

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Other (checkbox) Check the box (if applicable): Indicates the named insured's interest is the building is other than as its owner or tenant.
PREMISES INFORMATION Other Description Enter text: The description of the insured's interest is the building when it is other than as its owner or tenant.
PREMISES INFORMATION # Full Time Employees Enter number: The number of full time employees.
PREMISES INFORMATION # Part Time Employees Enter number: The number of part time employees.
PREMISES INFORMATION Annual Revenues Enter amount: The annual revenue amount for this location.
PREMISES INFORMATION Occupied Area Enter number: The area, in square feet, of the building the named insured occupies.
PREMISES INFORMATION Open to Public Area Enter number: The area, in square feet, of the building that is open to the public.
PREMISES INFORMATION Total Building Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PREMISES INFORMATION Description of Operations Enter text: The description of what business each applicant performs and the way it is conducted by premises. Operations which may not be apparent in a general description of operations may be segmented by location (e.g., location #1 is a sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include number of leased and owned premises outside of the United States. The section should be completed in enough detail to enable the underwriter to understand and classify each operation. Do not use the classification wording from the Commercial Lines Manual or Workers Compensation Manual. They do not provide adequate detail. Example: a manufacturer of pulley wheels used in sewing machines should be described as such and not as "Metal Goods Mfg. N.O.C.".
PREMISES INFORMATION Any area leased to others? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any area leased in building?".
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Apartments Check the box (if applicable): Indicates the nature of business is apartments.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Condominiums Check the box (if applicable): Indicates the nature of business is condominiums.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Contractor Check the box (if applicable): Indicates the nature of business is a contractor.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS Institutional Check the box (if applicable): Indicates the nature of business is institutional.
ACORD 125 (2009/05) rev. 06-30-2009 18 of 33
Section Name Field Name Field and/or Section Description
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Manufacturing Check the box (if applicable): Indicates the nature of business is manufacturing.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Office Check the box (if applicable): Indicates the nature of business is an office.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Restaurant Check the box (if applicable): Indicates the nature of business is a restaurant.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Retail Check the box (if applicable): Indicates the nature of business is retail.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Service Check the box (if applicable): Indicates the nature of business is service.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Wholesale Check the box (if applicable): Indicates the nature of business is wholesale.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Other Check the box (if applicable): Indicates the nature of business is other than those listed.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS Other Description Enter text: The description of the nature/type of business.
Enter date: The date the applicant began in business. This is important because it helps
APPLICANT INFORMATION Date Business Started the underwriter determine the expertise and business success of the applicant.
NATURE OF
BUSINESS/DESCRIPTION Enter text: The text description of the operations of this risk or insured. As used here, this
OF OPERATIONS Description Primary Of Operations is the primary description of operations.
NATURE OF
BUSINESS/DESCRIPTION Installation, Service or Repair Enter percentage: The percentage of total sales of a retail store attributed to installation,
OF OPERATIONS Work Percent service or repair work.
NATURE OF
BUSINESS/DESCRIPTION Off Premises Installation, Service Enter percentage: The percentage of total sales of a retail store attributed to installation,
OF OPERATIONS or Repair Work Percent service or repair work completed off premises.
ACORD 125 (2009/05) rev. 06-30-2009 19 of 33
Section Name Field Name Field and/or Section Description
NATURE OF
BUSINESS/DESCRIPTION Description of Operations of Other Enter text: The text description of the operations of this risk or insured. As used here, this
OF OPERATIONS Named Insureds is the description of operations for other named insureds.
ADDITIONAL INTEREST Interest Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST Breach of Warranty Check the box (if applicable): Indicates the additional interest type is a breach of warranty.
ADDITIONAL INTEREST Co-Owner Check the box (if applicable): Indicates the additional interest type is a co-owner.
Check the box (if applicable): Indicates the additional interest type is an employee as
ADDITIONAL INTEREST Employee As Lessor lessor.
ADDITIONAL INTEREST Leaseback Owner Check the box (if applicable): Indicates the additional interest type is a leaseback owner.
ADDITIONAL INTEREST Lienholder Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST Loss Payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST Owner Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST Registrant Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST Trustee Check the box (if applicable): Indicates the additional interest type is a trustee.
Check the box (if applicable): Indicates the additional interest is not any of the types listed
ADDITIONAL INTEREST Other on the form.
ADDITIONAL INTEREST Other Description Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST Reason for Interest Enter text: The description for the interest in the item.
Enter number: The ranking of 'this' additional interest when multiple additional interests
ADDITIONAL INTEREST Rank: are associated with the same item.
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
ADDITIONAL INTEREST Evidence - Certificate Insurance,
ADDITIONAL INTEREST Evidence - Policy Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST Evidence - Send Bill Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST Name And Address Enter text: The additional interest's full name.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST Enter code: The additional interest's mailing address postal code.

ACORD 125 (2009/05) rev. 06-30-2009 20 of 33

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST Enter code: The additional interest's country code.
ADDITIONAL INTEREST Reference / Loan Number Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST Interest End Date Enter date: The date the interest holder's interest terminates.
ADDITIONAL INTEREST Lien Amount Enter amount: The amount of the loan.
ADDITIONAL INTEREST Phone Number Enter number: The primary phone number of the additional interest.
ADDITIONAL INTEREST Fax Number Enter number: The primary fax number of the additional interest.
ADDITIONAL INTEREST E-Mail Address Enter text: The primary e-mail address for the additional interest.
ADDITIONAL INTEREST Location: Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST Building: Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST Vehicle: Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST Boat: Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST Airport: Enter identifier: The Federal Aviation Administration's designator for the airport (e.g. ORD -O'Hare International Airport).
ADDITIONAL INTEREST Aircraft: Enter number: The producer assigned number of the aircraft which has an additional interest.
ADDITIONAL INTEREST Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTEREST Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTEREST Item Description: Enter text: The description of the item of interest if needed to further clarify. 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.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION Is the applicant a subsidiary of another entity? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is this company a subsidiary of another entity?".
GENERAL INFORMATION Parent Company Name Enter text: The name of the parent organization.
GENERAL INFORMATION Relationship Description Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION % Owned Enter percentage: The percent of ownership by the parent company.

ACORD 125 (2009/05) rev. 06-30-2009 21 of 33

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Does the applicant have any subsidiaries? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does the applicant have subsidiaries? If yes, explain.".
GENERAL INFORMATION Subsidiary Company Name Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
GENERAL INFORMATION Relationship Description Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION % Owned Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION Is a formal safety program in operation? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is a formal safety Program in existence? If yes, explain.".
GENERAL INFORMATION Safety Manual Check the box (if applicable): Indicates a safety manual is part of the formal safety program.
GENERAL INFORMATION Safety Position Check the box (if applicable): Indicates a safety position is part of the formal safety program.
GENERAL INFORMATION Monthly Meetings Check the box (if applicable): Indicates monthly meetings are is part of the formal safety program.
GENERAL INFORMATION OSHA Check the box (if applicable): Indicates the formal safety program meets OSHA guidelines.
GENERAL INFORMATION Other Check the box (if applicable): Indicates there is a formal safety program other than those listed.
GENERAL INFORMATION Other Description Enter text: The description of the formal safety program.
GENERAL INFORMATION Any exposure to flammables, explosives, chemicals? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any exposure to flammables, explosives, chemicals?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Any other insurance with this company? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any other insurance with this company?".
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION Line of Business Enter code: The line of business of the other policy.
GENERAL INFORMATION Policy Number Enter text: The description of the other policy not listed on the form.
ACORD 125 (2009/05) rev. 06-30-2009 22 of 33
Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operation? (Not Applicable in MO) Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?". As used here, not applicable in Missouri.
GENERAL INFORMATION Non-Payment Check the box (if applicable): Indicates the policy is being cancelled due to non-payment of premium.
GENERAL INFORMATION Non-Renewal Check the box (if applicable): Indicates the policy is being cancelled due to non-renewal.
GENERAL INFORMATION Agent No Longer Represents Carrier Check the box (if applicable): Indicates the policy is being cancelled because the agent is no longer writing business for the insurer.
GENERAL INFORMATION Underwriting Check the box (if applicable): Indicates the policy is being cancelled due to underwriting reasons.
GENERAL INFORMATION Condition Corrected Check the box (if applicable): Indicates the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION Correction Description Enter text: The description of how the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION Other Check the box (if applicable): Indicates the policy is being cancelled due to reasons other than those listed.
GENERAL INFORMATION Other Description Enter text: The description of why the policy is being cancelled or terminated.
GENERAL INFORMATION Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?".
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION During the last five years (ten in RI), has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "During the mandated number of years, has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related crime in connection with this or any other property?".
ACORD 125 (2009/05) rev. 06-30-2009 23 of 33
Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Any uncorrected fire code violations? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any uncorrected fire code violations?".
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Has applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the past five (5) years? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the past specified number of years?".
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Has applicant had a judgement or lien during the past five (5) years? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has applicant had a judgement or lien during the past specified number of years?".
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION Occurrence Date Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION Explanation Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION Resolution Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION Resolution Date Enter date: The resolution date associated with an underwriting question.

ACORD 125 (2009/05) rev. 06-30-2009 24 of 33

Section Name Field Name Field and/or Section Description
Has business been placed in a Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
GENERAL INFORMATION trust? question, "Has business been placed in a trust?".
GENERAL INFORMATION Name of Trust Enter text: The additional interest's full name. As used here, this is the name of the trust.
Any foreign operations, foreign
products distributed in USA, or US products sold / distributed in Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Any foreign operations, foreign products distributed in USA, or US products
GENERAL INFORMATION foreign countries? sold/distributed in foreign countries?".
Does applicant have other Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
business ventures for which question, "Does applicant have other business ventures for which coverage is not
GENERAL INFORMATION coverage is not requested? requested?".
Enter text: An explanation of a response to a general information or underwriting question.
GENERAL INFORMATION Remarks Normally, "Yes" responses require an explanation.
REMARKS/PROCESSING
GENERAL INFORMATION INSTRUCTIONS Enter text: The commercial policy general remarks.
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
PRIOR CARRIER
INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER Enter text: The name of the previous insurer. As used here, this applies to the Commercial
INFORMATION Carrier General Liability policy.
PRIOR CARRIER Enter identifier: The policy number of the previous coverage. As used here, this applies to
INFORMATION Policy Number the Commercial General Liability policy.
Enter amount: The annual modified premium charged (not including taxes or service
PRIOR CARRIER charges) for the specified line of business. As used here, this applies to the Commercial
INFORMATION Premium General Liability policy.
PRIOR CARRIER Enter date: The effective date of the prior policy. As used here, this applies to the
INFORMATION Effective Date Commercial General Liability policy.
PRIOR CARRIER Enter date: The expiration date of the previous coverage. As used here, this applies to the
INFORMATION Expiration Date Commercial General Liability policy.
PRIOR CARRIER Enter text: The name of the previous insurer. As used here, this applies to the Automobile
INFORMATION Automobile Liability Carrier Liability policy.
PRIOR CARRIER Enter identifier: The policy number of the previous coverage. As used here, this applies to
INFORMATION Policy Number the Automobile Liability policy.

ACORD 125 (2009/05) rev. 06-30-2009 25 of 33

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Property Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Section Enter text: The line of business used in the "other" section of prior coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.

ACORD 125 (2009/05) rev. 06-30-2009 26 of 33

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.

ACORD 125 (2009/05) rev. 06-30-2009 27 of 33

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.

ACORD 125 (2009/05) rev. 06-30-2009 28 of 33

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Year Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.

ACORD 125 (2009/05) rev. 06-30-2009 29 of 33

Section Name Field Name Field and/or Section Description
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION Carrier Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION Other Carrier Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Other Policy Number Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Premium Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Effective Date Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION Expiration Date Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
LOSS HISTORY Check if None Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years.
LOSS HISTORY Losses Last Number of Years Enter number: The number of years of loss information required by the insurer.
LOSS HISTORY Total Losses Enter amount: The amount that has been paid on all losses to date.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.

ACORD 125 (2009/05) rev. 06-30-2009 30 of 33

Section Name Field Name Field and/or Section Description
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
ACORD 125 (2009/05) rev. 06-30-2009 31 of 33
Section Name Field Name Field and/or Section Description
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.

ACORD 125 (2009/05) rev. 06-30-2009 32 of 33

Section Name Field Name Field and/or Section Description
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY Date Of Occurrence Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Line Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
Section Name Field Name Field and/or Section Description
LOSS HISTORY Type/Description of Occurrence or Claim Enter text: A brief description of the loss.
LOSS HISTORY Date of Claim Enter date: The date the claim was filed.
LOSS HISTORY Amount Paid Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Amount Reserved Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY Subrogation Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY Claim Status Open Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
GENERAL INFORMATION Notice Of Information Practices Check the box (if applicable): Indicates that a copy of the Notice of Information Practices has been given to the applicant.
SIGNATURE SECTION Producer's Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
SIGNATURE SECTION Producers Name Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE SECTION State Producer License Number Enter identifier: The State License Number of the producer.
SIGNATURE SECTION Applicant's Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION Date Enter date: The date the form was signed by the named insured.
SIGNATURE SECTION National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).