ACORD 125 (2014/12) - COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION

ACORD 125 (2014/12) - COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION
ACORD 125, Commercial Insurance Application, Applicant Information Section, is used in the underwriting process for any commercial account
submission.
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 Medical Professional Liability, and no commercial application is complete without it.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date (MM/DD/YYYY)
Enter date: The date 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.
IDENTIFICATION SECTION
Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION
Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the 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's e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
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.
ACORD 125 (2014/12) rev. 04-29-2014
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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 assigned by 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. (MM/DD/YYYY)
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.
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 application.
SECTIONS ATTACHED
Accounts Receivable /
Valuable Papers Premium
Enter amount: The premium amount for the Accounts Receivable / Valuable Papers line of
business.
SECTIONS ATTACHED
Boiler & Machinery
(checkbox)
Check the box (if applicable): Indicates the Boiler & Machinery section is attached to this
application.
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SECTIONS ATTACHED
Boiler & Machinery Premium
Enter amount: The premium amount for the Boiler & Machinery line of business.
SECTIONS ATTACHED
Business Auto (checkbox)
Check the box (if applicable): Indicates the Business Auto section is attached to this application.
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 Business Owners section is attached to this
application.
SECTIONS ATTACHED
Business Owners Premium
Enter amount: The total estimated 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 application.
SECTIONS ATTACHED
Commercial General
Liability Premium
Enter amount: The total premium amount for the commercial general liability line of business.
SECTIONS ATTACHED
Crime (checkbox)
Check the box (if applicable): Indicates the Crime section is attached to this application.
SECTIONS ATTACHED
Crime Premium
Enter amount: The premium amount for the Crime line of business.
SECTIONS ATTACHED
Cyber and Privacy Coverage
(checkbox)
Check the box (if applicable): Indicates the Cyber and Privacy Coverage Section is attached to
this application.
SECTIONS ATTACHED
Cyber and Privacy Coverage
Premium
Enter amount: The premium amount for the Cyber and Privacy line of business
SECTIONS ATTACHED
Dealers (checkbox)
Check the box (if applicable): Indicates the Dealers section is attached to this application.
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 application.
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
application.
SECTIONS ATTACHED
Equipment Floater Premium
Enter amount: The premium amount for the Equipment Floater line of business.
SECTIONS ATTACHED
Fiduciary Liability Coverage
(checkbox)
Check the box (if applicable): Indicates the Fiduciary section is attached to the application.
SECTIONS ATTACHED
Fiduciary Liability Coverage
Premium
Enter amount: The premium amount for the Fiduciary Liability line of business.
ACORD 125 (2014/12) rev. 04-29-2014
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SECTIONS ATTACHED
Garage and Dealers
(checkbox)
Check the box (if applicable): Indicates the Garage and Dealers section is attached to this
application.
SECTIONS ATTACHED
Garage and Dealers
Premium
Enter amount: The premium amount for the Garage and Dealers line of business.
SECTIONS ATTACHED
Glass and Sign (checkbox)
Check the box (if applicable): Indicates the Glass and Sign section is attached to this
application.
SECTIONS ATTACHED
Glass and 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
application.
SECTIONS ATTACHED
Installation / Builders Risk
Premium
Enter amount: The premium amount for the Installation / Builders Risk line of business.
SECTIONS ATTACHED
Liquor Liability (checkbox)
Check the box (if applicable): Indicates the Liquor Liability section is attached to the application.
SECTIONS ATTACHED
Liquor Liability Premium
Enter amount: The premium amount for the Liquor Liability line of business.
SECTIONS ATTACHED
Open Cargo (checkbox)
Check the box (if applicable): Indicates the Open Cargo section is attached to this application.
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 application.
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 application.
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
application.
SECTIONS ATTACHED
Truckers / Motor Carriers
Premium
Enter amount: The premium amount for the Truckers / Motor Carrier line of business.
SECTIONS ATTACHED
Umbrella (checkbox)
Check the box (if applicable): Indicates the Umbrella section is attached to this application.
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 application.
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 other than those listed is attached to this
application.
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SECTIONS ATTACHED
Other Description
Enter text: The type of section being attached to this application.
SECTIONS ATTACHED
Other Premium
Enter amount: The premium amount the for the other line of business.
SECTIONS ATTACHED
Other (checkbox)
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
SECTIONS ATTACHED
Other Description
Enter text: The type of section being attached to this application.
SECTIONS ATTACHED
Other Premium
Enter amount: The premium amount the for the other line of business.
SECTIONS ATTACHED
Other (checkbox)
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
SECTIONS ATTACHED
Other Description
Enter text: The type of section being attached to this application.
SECTIONS ATTACHED
Other Premium
Enter amount: The premium amount the for the other line of business.
ATTACHMENTS
Additional Interest
(checkbox)
Check the box (if applicable): Indicates ACORD 45, Additional Interest 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 bylaws 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 application.
ATTACHMENTS
Hotel / Motel Supplement
(checkbox)
Check the box (if applicable): Indicates the Hotel / Motel Supplement is attached to the
application.
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.
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ATTACHMENTS
Loss Summary (checkbox)
Check the box (if applicable): Indicates that a loss summary report is attached to the application.
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 application.
ATTACHMENTS
Vacant Building Supplement
(checkbox)
Check the box (if applicable): Indicates a vacant building supplement is attached.
ATTACHMENTS
Vehicle Schedule
(checkbox)
Check the box (if applicable): Indicates the Vehicle Schedule section is attached to this
application.
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.
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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.
POLICY INFORMATION
Proposed Eff. Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY) 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. (MM/DD/YYYY)
As used here, this is the proposed expiration date.
POLICY INFORMATION
Billing Plan - 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.
ACORD 125 (2014/12) rev. 04-29-2014
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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.
APPLICANT 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.
APPLICANT 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.
APPLICANT 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 the 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 other than
those listed on the form.
ACORD 125 (2014/12) rev. 04-29-2014
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APPLICANT INFORMATION
Other Description
Enter text: The description of the other legal entity.
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.
APPLICANT 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.
APPLICANT 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.
APPLICANT 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 the limited liability corporation.
ACORD 125 (2014/12) rev. 04-29-2014
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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 other than
those listed on the form.
APPLICANT INFORMATION
Other Description
Enter text: The description of the other legal entity.
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.
APPLICANT 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.
APPLICANT 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.
APPLICANT 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.
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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 the 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 other than
those listed on the form.
APPLICANT INFORMATION
Other Description
Enter text: The description of the other legal entity.
Form Page 2
Section Name
Field Name
Description
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.
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 secondary phone number of the contact.
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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 secondary phone number of the contact.
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.
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 or province code of the commercial structure.
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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 in the building is as its
tenant.
PREMISES INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the named insured's interest in the building is other than
those listed.
PREMISES INFORMATION
Other Description
Enter text: The description of the insured's interest in the building when it is other than those
listed.
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 space in the building that is occupied by the
named insured.
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 to others?.
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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 or province code 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 in the building is as its
tenant.
PREMISES INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the named insured's interest in the building is other than
those listed.
PREMISES INFORMATION
Other Description
Enter text: The description of the insured's interest in the building when it is other than those
listed.
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 space in the building that is occupied by the
named insured.
PREMISES INFORMATION
Open to Public Area
Enter number: The area, in square feet, of the building that is open to the public.
ACORD 125 (2014/12) rev. 04-29-2014
Page 14 of 31
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 to others?.
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 or province code 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 in the building is as its
tenant.
ACORD 125 (2014/12) rev. 04-29-2014
Page 15 of 31
PREMISES INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the named insured's interest in the building is other than
those listed.
PREMISES INFORMATION
Other Description
Enter text: The description of the insured's interest in the building when it is other than those
listed.
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 space in the building that is occupied by the
named insured.
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 to others?.
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 or province code of the commercial structure.
PREMISES INFORMATION
Zip
Enter code: The postal code of the commercial structure.
ACORD 125 (2014/12) rev. 04-29-2014
Page 16 of 31
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 in the building is as its
tenant.
PREMISES INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the named insured's interest in the building is other than
those listed.
PREMISES INFORMATION
Other Description
Enter text: The description of the insured's interest in the building when it is other than those
listed.
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 space in the building that is occupied by the
named insured.
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 to others?.
ACORD 125 (2014/12) rev. 04-29-2014
Page 17 of 31
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.
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 other nature / type of business.
ACORD 125 (2014/12) rev. 04-29-2014
Page 18 of 31
APPLICANT INFORMATION
Date Business Started
Enter date: The date the applicant began in business. This is important because it helps the
underwriter determine the expertise and business success of the applicant.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS
Description of Primary
Operations
Enter text: The description of the operations of this risk or insured. As used here, this is the
description of primary operations.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS
Installation, Service or
Repair Work Percent
Enter percentage: The percentage of total sales of a retail store or service operation attributed
to installation, service or repair work.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS
Off Premises Installation,
Service or Repair Work
Percent
Enter percentage: The percentage of total sales of a retail store or service operation attributed
to installation, service or repair work completed off premises.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS
Description of Operations of
Other Named Insureds
Enter text: The description of the operations of this risk or insured. As used here, this 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.
ADDITIONAL INTEREST
Employee As Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as 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.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Reason for Interest
Enter text: The description for the interest in the item.
ADDITIONAL INTEREST
Rank:
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ACORD 125 (2014/12) rev. 04-29-2014
Page 19 of 31
ADDITIONAL INTEREST
Evidence - Certificate
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
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.
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 code: 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.
ACORD 125 (2014/12) rev. 04-29-2014
Page 20 of 31
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.
Form Page 3
Section Name
Field Name
Description
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 the applicant 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.
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 any subsidiaries?.
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 operation?.
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 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?.
ACORD 125 (2014/12) rev. 04-29-2014
Page 21 of 31
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is any exposure to flammable, explosive or
chemicals.
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 identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Any policy or coverage
declined, cancelled or
non-renewed during the
prior three (3) years for any
premises or operation?
(Missouri Applicants - Do
not answer this question)
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.
ACORD 125 (2014/12) rev. 04-29-2014
Page 22 of 31
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 any past losses or claims relating to sexual abuse or molestation
allegations, discrimination or negligent hiring.
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?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any applicant has been indicted or convicted of fraud or
any arson related crime in connection with a property with in the last five (5) years.
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 occurrence date of any uncorrected fire code violations.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether there are any uncorrected fire code violations.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any fire code violations.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with the fire code violation.
GENERAL INFORMATION
Occurrence Date
Enter date: The occurrence date of any uncorrected fire code violations.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether there are any uncorrected fire code violations.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any fire code violations.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with the fire code violation.
ACORD 125 (2014/12) rev. 04-29-2014
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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 occurrence date associated with the applicants foreclosure ,repossession,
bankruptcy or bankruptcy filing during the last mandated number of years.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether the applicant has had a foreclosure, repossession,
bankruptcy or filed for bankruptcy during last mandated number of years.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any bankruptcy filings within the last mandated
number of years.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with any bankruptcy filings within the last mandated
number of years.
GENERAL INFORMATION
Occurrence Date
Enter date: The occurrence date associated with the applicants foreclosure ,repossession,
bankruptcy or bankruptcy filing during the last mandated number of years.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether the applicant has had a foreclosure, repossession,
bankruptcy or filed for bankruptcy during last mandated number of years.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any bankruptcy filings within the last mandated
number of years.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with any bankruptcy filings within the last mandated
number of years.
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 judgment or lien during the past specified number of years?.
GENERAL INFORMATION
Occurrence Date
Enter date: The occurrence date associated with the applicant's judgement or lien during the last
mandated number of years.
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether the applicant has a judgement or lien during the last
mandated number of years.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any judgement or lien during the last mandated
number of years.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with any judgement or lien during the last mandated
number of years.
GENERAL INFORMATION
Occurrence Date
Enter date: The occurrence date associated with the applicant's judgement or lien during the last
mandated number of years.
ACORD 125 (2014/12) rev. 04-29-2014
Page 24 of 31
GENERAL INFORMATION
Explanation
Enter text: An explanation as to whether the applicant has a judgement or lien during the last
mandated number of years.
GENERAL INFORMATION
Resolution
Enter text: The resolution associated with any judgement or lien during the last mandated
number of years.
GENERAL INFORMATION
Resolution Date
Enter date: The resolution date associated with any judgement or lien during the last mandated
number of years.
GENERAL INFORMATION
Has business been placed
in a trust?
Enter Y for a Yes response. Input N for No response. Indicates the response to the 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.
GENERAL INFORMATION
Any foreign operations,
foreign products distributed
in USA, or US products sold
/ distributed in foreign
countries?
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 sold/distributed in
foreign countries?.
GENERAL INFORMATION
Does applicant have other
business ventures for which
coverage is not requested?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant have other business ventures for which coverage is not requested?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any other business ventures for which coverage is not requested.
GENERAL INFORMATION
REMARKS / PROCESSING
INSTRUCTIONS
Enter text: The commercial policy general remarks.
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 general liability insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The general liability policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the general liability line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior general liability policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous general liability coverage.
PRIOR CARRIER
INFORMATION
Automobile Liability Carrier
Enter text: The name of the previous automobile insurer.
ACORD 125 (2014/12) rev. 04-29-2014
Page 25 of 31
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The automobile policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the automobile line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior automobile policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous automobile coverage.
PRIOR CARRIER
INFORMATION
Property Carrier
Enter text: The name of the previous property insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The policy number of the previous property coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the property line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior property policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous property coverage.
PRIOR CARRIER
INFORMATION
Other Line of Business
Enter text: The line of business used in the other section of prior coverage.
PRIOR CARRIER
INFORMATION
Other Carrier
Enter text: The name of the previous insurer for the other line of business.
PRIOR CARRIER
INFORMATION
Other Policy Number
Enter number: The policy number of the previous coverage for the other line of business.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for other lines of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior policy for the other line of business.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous coverage for the other line of business.
Form Page 4
Section Name
Field Name
Description
ACORD 125 (2014/12) rev. 04-29-2014
Page 26 of 31
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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 general liability insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The general liability policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the general liability line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior general liability policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous general liability coverage.
PRIOR CARRIER
INFORMATION
Carrier
Enter text: The name of the previous automobile insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The automobile policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the automobile line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior automobile policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous automobile coverage.
PRIOR CARRIER
INFORMATION
Carrier
Enter text: The name of the previous property insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The policy number of the previous property coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the property line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior property policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous property coverage.
ACORD 125 (2014/12) rev. 04-29-2014
Page 27 of 31
PRIOR CARRIER
INFORMATION
Other Line of Business
Enter text: The line of business used in the other section of prior coverage.
PRIOR CARRIER
INFORMATION
Other Carrier
Enter text: The name of the previous insurer for the other line of business.
PRIOR CARRIER
INFORMATION
Other Policy Number
Enter number: The policy number of the previous coverage for the other line of business.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for other lines of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior policy for the other line of business.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous coverage for 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 general liability insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The general liability policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the general liability line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior general liability policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous general liability coverage.
PRIOR CARRIER
INFORMATION
Carrier
Enter text: The name of the previous automobile insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The automobile policy number of the previous coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the automobile line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior automobile policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous automobile coverage.
ACORD 125 (2014/12) rev. 04-29-2014
Page 28 of 31
PRIOR CARRIER
INFORMATION
Carrier
Enter text: The name of the previous property insurer.
PRIOR CARRIER
INFORMATION
Policy Number
Enter number: The policy number of the previous property coverage.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the property line of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior property policy.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous property coverage.
PRIOR CARRIER
INFORMATION
Other Carrier
Enter text: The name of the previous insurer for the other line of business.
PRIOR CARRIER
INFORMATION
Other Policy Number
Enter number: The policy number of the previous coverage for the other line of business.
PRIOR CARRIER
INFORMATION
Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for other lines of business.
PRIOR CARRIER
INFORMATION
Effective Date
Enter date: The effective date of the prior policy for the other line of business.
PRIOR CARRIER
INFORMATION
Expiration Date
Enter date: The expiration date of the previous coverage for 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.
(MM/DD/YYYY)
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. (MM/DD/YYYY)
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
ACORD 125 (2014/12) rev. 04-29-2014
Page 29 of 31
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.
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.
LOSS HISTORY
Date Of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
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. (MM/DD/YYYY)
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.
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.
LOSS HISTORY
Date Of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
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. (MM/DD/YYYY)
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.
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.
SIGNATURE SECTION
Notice Of Information
Practices
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
SIGNATURE SECTION
Insured Initials
Initial here: The named insured's initials.
ACORD 125 (2014/12) rev. 04-29-2014
Page 30 of 31
SIGNATURE SECTION
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. 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. (MM/DD/YYYY)
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.
ACORD 125 (2014/12) rev. 04-29-2014
Page 31 of 31