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ACORD Form 131 Umbrella/Excess
Section Instructions

 

 
ACORD 131 (2009/02) rev. 02-27-2009 1 of 23
Section Name Field Name Field and/or Section Description
TITLE ACORD 131 (2009/02) Umbrella / Excess Section The title of the form. ACORD 131, Umbrella / Excess Section, captures information about a liability coverage affording high limit excess and/or extended coverage. It is a separate policy over and above other basic liability policies the same insured may have. A completed Umbrella / Excess Application consists of both the Applicant Information Section, ACORD 125 and the Umbrella / Excess Section, ACORD 131. This is necessary because some information about the applicant is only shown on the Applicant Information Section. Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Even though this data matches the data on the ACORD 125, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Date 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 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 Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
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 Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
POLICY INFORMATION Transaction Type - New Check the box (if applicable): Indicates the response expected from the company is a new issued policy.
POLICY INFORMATION Renewal Check the box (if applicable): Indicates the response expected from the company is a renewed policy.
ACORD 131 (2009/02) rev. 02-27-2009 2 of 23
Section Name Field Name Field and/or Section Description
POLICY INFORMATION Umbrella Check the box (if applicable): Indicates the type of policy is umbrella.
POLICY INFORMATION Excess Check the box (if applicable): Indicates the type of policy is excess.
Check the box (if applicable): Indicates "coverage trigger" is on an occurrence basis on an
POLICY INFORMATION Occurrence excess or umbrella liability policy.
Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis
POLICY INFORMATION Claims Made on an excess or umbrella liability policy.
POLICY INFORMATION Expiring Pol # Enter identifier: The policy number of the previous coverage.
Enter date: The retroactive date you are requesting for the policy being applied for. This is
the proposed earliest date for which an occurrence could "trigger" coverage under a
POLICY INFORMATION Proposed Retroactive Date Claims Made policy.
Enter date: The current retroactive date should be shown if the Umbrella is over a Claims
POLICY INFORMATION Current Retroactive Date Made primary policy. If the current retroactive date is different from the proposed retroactive date, an explanation must be provided.
Limit of Liability - Each
POLICY INFORMATION Occurrence Enter limit: The excess umbrella liability limit each occurrence limit.
POLICY INFORMATION Limit of Liability Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
POLICY INFORMATION answered by the issuing insurer(s).
POLICY INFORMATION Limit of Liability Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
POLICY INFORMATION answered by the issuing insurer(s).
POLICY INFORMATION Retained Limit Enter deductible: The excess or umbrella liability deductible or retention amount.
Enter Y for a “Yes” response. Input N for “No” response. Indicates that first dollar defense
POLICY INFORMATION First Dollar Defense coverage is requested.
EMPLOYEE BENEFITS
LIABILITY Limit of Insurance (ea Employee) Enter limit: The each employee limit for employee benefits coverage.
EMPLOYEE BENEFITS
LIABILITY Aggregate Limit for EBL Enter limit: The aggregate limit for employee benefits coverage.
EMPLOYEE BENEFITS
LIABILITY Retained Limit for EBL Enter amount: The retention amount for employee benefits coverage.

ACORD 131 (2009/02) rev. 02-27-2009 3 of 23

Section Name Field Name Field and/or Section Description
EMPLOYEE BENEFITS LIABILITY Retroactive Date for EBL Enter date: The retroactive date for employee benefits coverage.
EMPLOYEE BENEFITS LIABILITY Name of Benefit Program Enter text: The full name of the benefit program.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
ACORD 131 (2009/02) rev. 02-27-2009 4 of 23
Section Name Field Name Field and/or Section Description
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.

ACORD 131 (2009/02) rev. 02-27-2009 5 of 23

Section Name Field Name Field and/or Section Description
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
ACORD 131 (2009/02) rev. 02-27-2009 6 of 23
Section Name Field Name Field and/or Section Description
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.
PRIMARY LOCATION AND SUBSIDIARIES Number (#) Enter number: The location number for the premises.
PRIMARY LOCATION AND SUBSIDIARIES Name Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND SUBSIDIARIES Location Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter text: The city of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The state of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND SUBSIDIARIES Description Enter text: The description of the operations of this risk. A restatement of the products classification wording is often not sufficient (e.g., "Metal Goods Manufacturing NOC" could include anything from paper clips to bridge girders).
PRIMARY LOCATION AND SUBSIDIARIES Annual Payroll Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND SUBSIDIARIES Ann. Gross Sales Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND SUBSIDIARIES Foreign Sales Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND SUBSIDIARIES # Empl. Enter number: The number of employees.

ACORD 131 (2009/02) rev. 02-27-2009 7 of 23

Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Carrier / Policy Number Enter text: The full name of the insurer of the underlying automobile policy.
UNDERLYING INSURANCE Enter identifier: The policy number of the underlying automobile policy.
UNDERLYING INSURANCE Policy Effective Date Enter date: The effective date of the underlying automobile policy.
UNDERLYING INSURANCE Policy Expiration Date Enter date: The expiration date of the underlying automobile policy.
UNDERLYING INSURANCE Limits - CSL Ea Acc Enter limit: The combined single limit on the underlying automobile policy.
UNDERLYING INSURANCE BI Ea Acc Enter limit: The bodily injury each accident limit or combined single limit on the underlying automobile policy.
UNDERLYING INSURANCE BI Ea Per Enter limit: The bodily injury each person limit on the underlying automobile policy.
UNDERLYING INSURANCE PD Ea Acc Enter limit: The property damage each accident limit on the underlying automobile policy.
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The combined single limit premium on the underlying automobile policy.
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The bodily injury premium amount on the underlying automobile policy.
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The property damage premium amount on the underlying automobile policy.
UNDERLYING INSURANCE Rating Mod Enter rate: The combined rating modification and experience modification debit or credit as they apply.
UNDERLYING INSURANCE General Liability - Occur Check the box (if applicable): Indicates the underlying general liability policy is on an occurrence basis.
UNDERLYING INSURANCE Claims Made Check the box (if applicable): Indicates the underlying general liability policy is on a claims made basis.
UNDERLYING INSURANCE Carrier / Policy Number Enter text: The full name of the insurer of the underlying general liability policy.
UNDERLYING INSURANCE Enter identifier: The policy number of the underlying general liability policy.
UNDERLYING INSURANCE Policy Effective Date Enter date: The effective date of the underlying general liability policy.
UNDERLYING INSURANCE Policy Expiration Date Enter date: The expiration date of the underlying general liability policy.
UNDERLYING INSURANCE Each Occurrence Enter limit: The each occurrence limit on the underlying general liability policy.
UNDERLYING INSURANCE General Aggr Enter limit: The general aggregate limit on the underlying general liability policy.
UNDERLYING INSURANCE Prod & Comp Ops Aggregate Enter limit: The products and completed operations limit on the underlying general liability policy.
UNDERLYING INSURANCE Personal & Adv Injury Enter limit: The personal and advertising injury limit on the underlying general liability policy.
UNDERLYING INSURANCE Damage To Rented Premises Enter limit: The fire damage (damage to rented premises) limit on the underlying general liability policy.
UNDERLYING INSURANCE Medical Expense Enter limit: The medical expense limit on the underlying general liability policy.
ACORD 131 (2009/02) rev. 02-27-2009 8 of 23
Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Prem / Ops Enter amount: The premises operations premium amount on the underlying general liability policy.
UNDERLYING INSURANCE Products Enter amount: The products premium on the underlying general liability policy.
UNDERLYING INSURANCE Other Enter amount: The premium associated with other coverages on the underlying general liability policy.
UNDERLYING INSURANCE Rating Mod Enter rate: The combined rating modification and experience modification debit or credit as they apply.
UNDERLYING INSURANCE Employers Liability - Carrier/Policy Number Enter text: The full name of the insurer of the underlying employers liability policy.
UNDERLYING INSURANCE Enter identifier: The policy number of the underlying employers liability policy.
UNDERLYING INSURANCE Policy Effective Date Enter date: The effective date of the underlying employers liability policy.
UNDERLYING INSURANCE Policy Expiration Date Enter date: The expiration date of the underlying employers liability policy.
UNDERLYING INSURANCE Each Accident Enter limit: The limit of the underlying employers liability policy.
UNDERLYING INSURANCE Disease Each Employee Enter limit: The disease each employee limit of the underlying employers liability policy.
UNDERLYING INSURANCE Disease Policy Limit Enter limit: The disease policy limit of the underlying employers liability policy.
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The premium amount on the underlying employers liability policy.
UNDERLYING INSURANCE Rating Mod Enter rate: The combined rating modification and experience modification debit or credit as they apply.
UNDERLYING INSURANCE Blank Space - Type Enter text: The description of the underlying policy type.
UNDERLYING INSURANCE Carrier / Policy Number Enter text: The full name of the insurer of the underlying policy. As used here, contains the carrier name and the policy number.
UNDERLYING INSURANCE Policy Effective Date Enter date: The effective date of the underlying policy.
UNDERLYING INSURANCE Policy Expiration Date Enter date: The expiration date of the underlying policy.
UNDERLYING INSURANCE Limits Enter text: The description of the coverage.
UNDERLYING INSURANCE Enter limit: The combined single or total limit on the underlying policy.
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The premium amount on the underlying policy.
UNDERLYING INSURANCE Rating Mod Enter rate: The combined rating modification and experience modification debit or credit as they apply.
UNDERLYING INSURANCE Type Enter text: The description of the underlying policy type.
UNDERLYING INSURANCE Carrier / Policy Number Enter text: The full name of the insurer of the underlying policy. As used here, contains the carrier name and the policy number.
UNDERLYING INSURANCE Policy Effective Date Enter date: The effective date of the underlying policy.
UNDERLYING INSURANCE Policy Expiration Date Enter date: The expiration date of the underlying policy.
UNDERLYING INSURANCE Limits Enter text: The description of the coverage.
UNDERLYING INSURANCE Enter limit: The combined single or total limit on the underlying policy.

ACORD 131 (2009/02) rev. 02-27-2009 9 of 23

Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Annual Renewal Premium Enter amount: The premium amount on the underlying policy.
Enter rate: The combined rating modification and experience modification debit or credit
UNDERLYING INSURANCE Rating Mod as they apply.
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
UNDERLYING INSURANCE 1. Are defense costs - Within
(continued) Aggregate Limits? Check the box (if applicable): Indicates defense costs are within aggregate limits.
UNDERLYING INSURANCE
(continued) A Separate Limit? Check the box (if applicable): Indicates defense costs a separate limit?
UNDERLYING INSURANCE
(continued) Unlimited? Check the box (if applicable): Indicates defense costs are unlimited.
UNDERLYING INSURANCE (continued) 2. Indicate the edition date of the ISO form or similar filing for the underlying coverage Enter date: The edition date of the underlying general liability coverage form. Policy coverage may vary depending on the edition date of the policy paper. The underlying general liability coverage forms issued by Insurances Services Office (ISO) vary if they are based on the rules of "86" or the rules of "88".
3. Has any product, work,
accident, or location been
UNDERLYING INSURANCE (continued) excluded, uninsured or self insured from any previous coverage? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Has any product, work, accident, or location been excluded, uninsured or self insured from any previous coverage?".
UNDERLYING INSURANCE Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
4. For Claims Made, indicate the
retroactive date of current
UNDERLYING INSURANCE underlying Enter date: The retroactive date if the policy was issued on a Claims Made basis and there
(continued) policy was a retroactive date.
5. For Claims Made, indicate entry date into uninterrupted Claims Enter date: The retroactive date shown on the applicant's first Claims Made policy. If this is the first such policy, the date will be the same as the proposed retroactive date shown
UNDERLYING INSURANCE Made on the preceding field. If this is a renewal, it is the effective date of the first policy issued in
(continued) coverage the sequence of uninterrupted Claims Made policies.
6. For Claims Made, was "tail"
coverage purchased for any Enter Y for a “Yes” response. Input N for “No” response. The response to the question,
UNDERLYING INSURANCE previous primary or excess "For Claims made, was "tail" coverage purchased for any previous primary or excess
(continued) policy? policy?".
ACORD 131 (2009/02) rev. 02-27-2009 10 of 23
Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Enter date: The effective date of the tail coverage. The proposed retroactive date for the
(continued) Effective Date policy being applied for should not be earlier than the effective date of the tail coverage.
UNDERLYING INSURANCE Enter text: An explanation of a response to a general information or underwriting question.
(continued) Remarks Normally, "Yes" responses require an explanation.
UNDERLYING INSURANCE Coverage/Exposure - Any Auto - Check the box (if applicable): Indicates the underlying policy coverage any automobile
(continued) Coverage (symbol 1).
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying general liability policy is a claims
(continued) CGL - Claims Made - Coverage made policy.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying general liability policy is an
(continued) CGL - Occurrence - Coverage occurrence policy.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes aircraft liability
(continued) Aircraft Liability - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for aircraft liability
(continued) Aircraft Liability - Exposure coverage.
UNDERLYING INSURANCE Aircraft Passenger Liability - Check the box (if applicable): Indicates the underlying policy includes aircraft passenger
(continued) Coverage liability coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE Aircraft Passenger Liability - underlying insurance section of the form causing an exposure to exists for aircraft
(continued) Exposure passenger liability coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes additional interests
(continued) Additional Interests - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for additional
(continued) Additional Interests - Exposure interests coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes care, custody and
(continued) Care, Custody, Control - Coverage control coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for care, custody
(continued) Care, Custody, Control - Exposure and control coverage.
UNDERLYING INSURANCE Employee Benefit Liability - Check the box (if applicable): Indicates the underlying policy includes employee benefits
(continued) Coverage liability coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE Employee Benefit Liability - underlying insurance section of the form causing an exposure to exists for employee
(continued) Exposure benefits liability coverage.

ACORD 131 (2009/02) rev. 02-27-2009 11 of 23

Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Foreign Liability / Travel - Check the box (if applicable): Indicates the underlying policy includes foreign liability/travel
(continued) Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE Foreign Liability / Travel - underlying insurance section of the form causing an exposure to exists for foreign
(continued) Exposure liability/travel coverage.
UNDERLYING INSURANCE Garage Keepers Liability - Check the box (if applicable): Indicates the underlying policy includes garage keepers
(continued) Coverage liability coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE Garage Keepers Liability - underlying insurance section of the form causing an exposure to exists for garage keepers
(continued) Exposure liability coverage.
UNDERLYING INSURANCE Incidental Medical Malpractice - Check the box (if applicable): Indicates the underlying policy includes incidental medical
(continued) Coverage malpractice coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE Incidental Medical Malpractice - underlying insurance section of the form causing an exposure to exists for incidental
(continued) Exposure medical malpractice coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes liquor liability
(continued) Liquor Liability - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for liquor liability
(continued) Liquor Liability - Exposure coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes pollution liability
(continued) Pollution Liability - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for pollution liability
(continued) Pollution Liability - Exposure coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes professional liability
(continued) Professional Liability - Coverage (errors and omissions) coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for professional
(continued) Professional Liability - Exposure liability (errors and omissions) coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes vendors liability
(continued) Vendor Liability - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for vendors liability
(continued) Vendor Liability - Exposure coverage.
ACORD 131 (2009/02) rev. 02-27-2009 12 of 23
Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes watercraft liability
(continued) Watercraft Liability - Coverage coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for watercraft
(continued) Watercraft Liability - Exposure liability coverage.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes a coverage not
(continued) Other - Coverage listed.
UNDERLYING INSURANCE
(continued) Other - Description Enter text: The description of the coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for the coverage
(continued) Other - Exposure described.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes a coverage not
(continued) Other - Coverage listed.
UNDERLYING INSURANCE
(continued) Other - Description Enter text: The description of the coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for the coverage
(continued) Other - Exposure described.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes a coverage not
(continued) Other - Coverage listed.
UNDERLYING INSURANCE
(continued) Other - Description Enter text: The description of the coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for the coverage
(continued) Other - Exposure described.
UNDERLYING INSURANCE Check the box (if applicable): Indicates the underlying policy includes a coverage not
(continued) Other - Coverage listed.
UNDERLYING INSURANCE
(continued) Other - Description Enter text: The description of the coverage.
Check the box (if applicable): Indicates the limits are less than those shown on the
UNDERLYING INSURANCE underlying insurance section of the form causing an exposure to exists for the coverage
(continued) Other - Exposure described.
UNDERLYING INSURANCE (continued) Underlying Insurance Coverage Information Enter text: The description of underlying insurance coverage information including all restrictions (e.g. laser endorsements, discrimination, subrogation waivers) or extensions of coverage.
ACORD 131 (2009/02) rev. 02-27-2009 13 of 23
Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE (continued) Previous Experience Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.

ACORD 131 (2009/02) rev. 02-27-2009 14 of 23

Section Name Field Name Field and/or Section Description
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) Enter date: The date the claim was filed.
UNDERLYING INSURANCE (continued) Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
UNDERLYING INSURANCE (continued) Enter text: A brief description of the loss.
UNDERLYING INSURANCE (continued) Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE (continued) Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE (continued) No Such Claims 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. As used here, also indicates there were no claims exceeding $10,000.
CARE, CUSTODY, CONTROL Loc Enter number: The producer assigned number for the location if applicable to the ACORD 125.
CARE, CUSTODY, CONTROL Real Property/Personal Property Check the box (if applicable): Indicates the property in the care, custody and control of the insured is real property.
CARE, CUSTODY, CONTROL Personal Property Check the box (if applicable): Indicates the property in the care, custody and control of the insured is personal property.
CARE, CUSTODY, CONTROL Value Enter amount: The value of the entire building, not just the portion occupied, for real property or the value of the personal property.

ACORD 131 (2009/02) rev. 02-27-2009 15 of 23

Section Name Field Name Field and/or Section Description
CARE, CUSTODY,
CONTROL A, B, C, D Check the box (if applicable): Indicates the insured is held harmless in the lease.
CARE, CUSTODY,
CONTROL B Check the box (if applicable): Indicates the insured has a waiver of subrogation.
CARE, CUSTODY,
CONTROL C Check the box (if applicable): Indicates the insured is a named insured on the fire policy.
CARE, CUSTODY, Enter text: The description of the insured's liability for the described premises when other
CONTROL D than those listed.
CARE, CUSTODY,
CONTROL Sq Ft of Bldg Occ Enter number: The total square footage of the premises occupied by the applicant.
CARE, CUSTODY, Occupancy / Description of Enter text: The description of the building occupancy or of the property held by the insured
CONTROL Personal Property in his care, custody and control.
VEHICLES # Owned Enter number: The number of owned
VEHICLES # Non-owned Enter number: The number of non-owned private passenger vehicles.
VEHICLES # Leased Enter number: The number of leased private passenger vehicles.
VEHICLES Property Hauled Enter text: The description of property hauled in private passenger vehicles.
Enter number: The number of private passenger vehicles that fall within the category of
local radius/distance in accordance with a company's rating rules. The Insurance Services
VEHICLES Local Office maintains the definition of "local"..
Enter number: The number of private passenger vehicles that fall within the category of
intermediate radius/distance in accordance with a company's rating rules. The Insurance
VEHICLES Intermediate Services Office maintains the definition of "intermediate".
Enter number: The number of private passenger vehicles that fall within the category of
long distance radius/distance in accordance with a company's rating rules. The Insurance
VEHICLES Long Distance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned light weight trucks.
VEHICLES # Non-owned Enter number: The number of non-owned light weight trucks.
VEHICLES # Leased Enter number: The number of leased light weight trucks.
VEHICLES Property Hauled Enter text: The description of property hauled in light weight trucks.
Enter number: The number of light weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services
VEHICLES Local Office maintains the definition of "intermediate".
Enter number: The number of light weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services
VEHICLES Intermediate Office maintains the definition of "intermediate".
ACORD 131 (2009/02) rev. 02-27-2009 16 of 23
Section Name Field Name Field and/or Section Description
VEHICLES Long Distance Enter number: The number of light weight trucks that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned medium weight trucks.
VEHICLES # Non-owned Enter number: The number of non-owned medium weight trucks.
VEHICLES # Leased Enter number: The number of leased medium weight trucks.
VEHICLES Property Hauled Enter text: The description of property hauled in medium weight trucks.
VEHICLES Local Enter number: The number of medium weight trucks that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Intermediate Enter number: The number of medium weight trucks that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of medium weight trucks that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned heavy weight trucks.
VEHICLES # Non-owned Enter number: The number of non-owned heavy weight trucks.
VEHICLES # Leased Enter number: The number of leased heavy weight trucks.
VEHICLES Property Hauled Enter text: The description of property hauled in heavy weight trucks.
VEHICLES Local Enter number: The number of heavy weight trucks that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Intermediate Enter number: The number of heavy weight trucks that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of heavy weight trucks that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned extra heavy weight trucks.
VEHICLES # Non-owned Enter number: The number of non-owned extra heavy weight trucks.
VEHICLES # Leased Enter number: The number of leased extra heavy weight trucks.
VEHICLES Property Hauled Enter text: The description of property hauled in extra heavy weight trucks.
VEHICLES Local Enter number: The number of extra heavy weight trucks that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
ACORD 131 (2009/02) rev. 02-27-2009 17 of 23
Section Name Field Name Field and/or Section Description
VEHICLES Intermediate Enter number: The number of extra heavy weight trucks. that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of extra heavy weight trucks that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned heavy weight truck tractors.
VEHICLES # Non-owned Enter number: The number of non-owned heavy weight truck tractors.
VEHICLES # Leased Enter number: The number of leased heavy weight truck tractors.
VEHICLES Property Hauled Enter text: The description of property hauled in heavy weight truck tractors.
VEHICLES Local Enter number: The number of heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Intermediate Enter number: The number of heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of heavy weight truck tractors that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned extra heavy weight truck tractors.
VEHICLES # Non-owned Enter number: The number of non-owned extra heavy weight truck tractors.
VEHICLES # Leased Enter number: The number of leased extra heavy weight truck tractors.
VEHICLES Property Hauled Enter text: The description of property hauled in extra heavy weight truck tractors.
VEHICLES Local Enter number: The number of extra heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Intermediate Enter number: The number of extra heavy weight truck tractors that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of extra heavy weight truck tractors that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
VEHICLES # Owned Enter number: The number of owned buses.
VEHICLES # Non-owned Enter number: The number of non-owned buses.
VEHICLES # Leased Enter number: The number of leased buses.
VEHICLES Property Hauled Enter text: The description of property hauled in buses.
ACORD 131 (2009/02) rev. 02-27-2009 18 of 23
Section Name Field Name Field and/or Section Description
VEHICLES Local Enter number: The number of buses that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Intermediate Enter number: The number of buses that fall within the category of local radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "intermediate".
VEHICLES Long Distance Enter number: The number of buses that fall within the category of long distance radius/distance in accordance with a company's rating rules. The Insurance Services Office maintains the definition of "long distance".
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
ADDITIONAL EXPOSURES 1. Media used, annual costs Enter code: The type of advertising media used (e.g. Print, Television, Radio, etc.)
ADDITIONAL EXPOSURES Annual Cost Enter amount: The annual cost of the advertising media used.
ADDITIONAL EXPOSURES 2. Services of advertising agency used? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are services of an Advertising Agency used?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 3. Any coverage provided under agency's policy? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any coverage provided under agency's policy?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 4. Does applicant own, lease or operate aircraft? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant own/lease/operate aircraft?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 5. Are explosives, caustics, flammables or other dangerous cargo hauled? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are explosives, caustics, flammables or other dangerous cargo hauled?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 6. Are passengers carried for a fee? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are passengers carried for a fee?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 7. Any units not insured by underlying policies? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any units not insured by underlying policies?".
ACORD 131 (2009/02) rev. 02-27-2009 19 of 23
Section Name Field Name Field and/or Section Description
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 8. Are any vehicles leased or rented to others? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are any vehicles leased or rented to others?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 9. Is Hired and Non-Owned coverage provided? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is hired and non-owned coverage provided?"
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 10. Is bridge, dam or marine work performed? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is bridge, dam or marine work performed?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 11. Describe typical jobs performed Enter text: The description of work performed by the insured. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
ADDITIONAL EXPOSURES 12. Describe agreement Enter text: The description of the contractual agreement(s) pertaining to the work performed. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
ADDITIONAL EXPOSURES 13. Does applicant own, rent, or otherwise use cranes? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant own, rent or otherwise use cranes?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 14. Do subcontractors carry coverages or limits less than applicant? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do subcontractors carry coverages or limits less than applicant?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 15. Is applicant self-insured in any state? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is applicant self-insured in any state?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 16. Regulation: - Jones Act Check the box (if applicable): Indicates the employee/self-insured is subject to the Jones Act.
ADDITIONAL EXPOSURES FELA Check the box (if applicable): Indicates the employee/self-insured is subject to the Federal Employers Liability Act.

ACORD 131 (2009/02) rev. 02-27-2009 20 of 23

Section Name Field Name Field and/or Section Description
ADDITIONAL EXPOSURES Stop Gap Check the box (if applicable): Indicates the employee/self-insured is subject to Stop Gap.
ADDITIONAL EXPOSURES Other Check the box (if applicable): Indicates the employee/self-insured is subject to regulations not listed.
ADDITIONAL EXPOSURES Other Description Enter text: The description of the regulations the employee/self-insured is subject to.
ADDITIONAL EXPOSURES 17. Hospital or first aid facility maintained? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Hospital or first aid facility maintained?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 18. Coverage provided for doctors/nurses? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Coverage provided for doctors/nurses?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 19. Indicate # of doctors, nurses, beds. Enter number: The number of doctors.
ADDITIONAL EXPOSURES Nurses Enter number: The number of nurses.
ADDITIONAL EXPOSURES Beds Enter number: The number of beds/bunks.
ADDITIONAL EXPOSURES Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
ADDITIONAL EXPOSURES EPA # Enter identifier: The number assigned to the insured by the Environmental Protection Agency.
ADDITIONAL EXPOSURES 20. Do current or past products, or their components, contain hazardous materials that may require special disposal methods? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do current or past products, or their components, contain hazardous materials that may require special disposal methods?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 21. Indicate the coverages carried: GL with Standard ISO Pollution Exclusion Check the box (if applicable): Indicates the insured carries a general liability policy with standard Insurance Services Office pollution exclusion coverage.
ADDITIONAL EXPOSURES GL with Standard Sudden & Accidental Only Check the box (if applicable): Indicates the insured carries a general liability policy with standard sudden and accidental only coverage.
ADDITIONAL EXPOSURES GL with Pollution Coverage Endorsement Check the box (if applicable): Indicates the insured carries a general liability policy with a pollution coverage endorsement.
ACORD 131 (2009/02) rev. 02-27-2009 21 of 23
Section Name Field Name Field and/or Section Description
ADDITIONAL EXPOSURES Separate Pollution Coverage Check the box (if applicable): Indicates the insured carries separate pollution coverage.
ADDITIONAL EXPOSURES 22. Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Are missiles, engines, guidance systems, frames or any other product used/installed in aircraft?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 23. Any foreign operations, foreign products distributed in the USA or US products sold / distributed in foreign countries? (If "YES", Attach ACORD 815) Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries?".
ADDITIONAL EXPOSURES 24. Product liability loss in past three (3) years? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any product liability loss in past specified number of years?".
ADDITIONAL EXPOSURES Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
ADDITIONAL EXPOSURES 25. Gross sales from each of the last three (3) years. Enter amount: The gross sales or receipts amount.
ADDITIONAL EXPOSURES Gross Sales Enter amount: The gross sales or receipts amount.
ADDITIONAL EXPOSURES Gross Sales Enter amount: The gross sales or receipts amount.
ADDITIONAL EXPOSURES 26. Describe independent contractors Enter text: The description of independent contractors. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
ADDITIONAL EXPOSURES 27. Does applicant own or lease watercraft? Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does applicant own or lease watercraft?".
ADDITIONAL EXPOSURES Loc # Enter number: The location number for the premises.
ADDITIONAL EXPOSURES # Owned Enter number: The number of watercraft owned. As used here, the number of watercraft owned of the same type.
ADDITIONAL EXPOSURES Length Enter number: The length of the watercraft expressed in feet.
ADDITIONAL EXPOSURES Horsepower Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks.
ADDITIONAL EXPOSURES Loc # Enter number: The location number for the premises.
ADDITIONAL EXPOSURES # Owned Enter number: The number of watercraft owned. As used here, the number of watercraft owned of the same type.
ACORD 131 (2009/02) rev. 02-27-2009 22 of 23
Section Name Field Name Field and/or Section Description
ADDITIONAL EXPOSURES Length Enter number: The length of the watercraft expressed in feet.
ADDITIONAL EXPOSURES Horsepower Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks.
ADDITIONAL EXPOSURES Loc # Enter number: The location number for the premises.
ADDITIONAL EXPOSURES # Stories Enter number: The number of stories, counting the ground floor as one, which this building has.
ADDITIONAL EXPOSURES # Units Enter number: The number of separate living units in the structure.
ADDITIONAL EXPOSURES # Swimming Pools Enter number: The number of swimming pools on the premises.
ADDITIONAL EXPOSURES # Diving Boards Enter number: The number of diving boards on the premises.
ADDITIONAL EXPOSURES Loc # Enter number: The location number for the premises.
ADDITIONAL EXPOSURES # Stories Enter number: The number of stories, counting the ground floor as one, which this building has.
ADDITIONAL EXPOSURES # Units Enter number: The number of separate living units in the structure.
ADDITIONAL EXPOSURES # Swimming Pools Enter number: The number of swimming pools on the premises.
ADDITIONAL EXPOSURES # Diving Boards Enter number: The number of diving boards on the premises.
REMARKS Remarks Enter text: The remarks associated with the commercial umbrella line of business. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
REMARKS Remarks Enter text: The remarks associated with the commercial umbrella line of business. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
SIGNATURE Uninsured Motorists (UM) Coverage Enter limit: The limit for commercial umbrella / excess uninsured motorists coverage (if applicable in your states).
SIGNATURE Underinsured Motorists (UIM) Coverage Enter limit: The limit for commercial umbrella / excess underinsured motorists coverage (if applicable in your state).
SIGNATURE Applicable Only in Louisiana - I Select UM Limits Initial here: The named insured's initials. As used here, applicable in Louisiana.
SIGNATURE I Reject UM Coverage Initial here: The named insured's initials. As used here, applicable in Louisiana.
SIGNATURE Applicable Only in New Hampshire - I Select UM Limits Initial here: The named insured's initials. As used here, applicable in New Hampshire.
SIGNATURE I Reject UM Coverage Initial here: The named insured's initials. As used here, applicable in New Hampshire.
SIGNATURE Applicable Only in Wisconsin (UM) - Is Available Check the box (if applicable): Indicates that uninsured motorists coverage is available. As used here, applicable in Wisconsin.
Section Name Field Name Field and/or Section Description
SIGNATURE Applicable Only in Wisconsin (UM) - Is Not Available Check the box (if applicable): Indicates that uninsured motorists coverage is not available. As used here, applicable in Wisconsin.
SIGNATURE Applicable Only in Wisconsin (UIM) - Is Available Check the box (if applicable): Indicates that underinsured motorists coverage is available. As used here, applicable in Wisconsin.
SIGNATURE Applicable Only in Wisconsin (UIM) - Is Not Available Check the box (if applicable): Indicates that underinsured motorists coverage is not available. As used here, applicable in Wisconsin.
SIGNATURE 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 Producer's Name (Please Print) Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE State Producer License No Enter identifier: The State License Number of the producer. As used here, this is required in Florida.
SIGNATURE Applicant's Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
SIGNATURE 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).

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