Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 145 (2013/09)
Accounts Receivable / Valuable
Papers
ACORD 145, Accounts Receivable / Valuable Papers section,
addresses the basic underwriting and rating needs for both Accounts Receivable and
Valuable Paper coverages written under an Inland Marine or Property policy. As much
information as possible should be collected regarding receivables and valuable papers to
evaluate the particular risk. All questions regarding the particular risk must be completed.
ACORD 101, Additional Remarks Schedule, may be attached if more space is required.
Accounts Receivable is on page 1 of the form and Valuable Papers is on page 2.
This form is designed to be used in conjunction with ACORD 125, Commercial Insurance
Application - Applicant Information Section. Refer to ACORD 125 for information on that
form.
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 date on which the form is completed.
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
Applicant / First Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
Reporting (Checkbox)
Check the box (if applicable): Indicates Accounts Receivable insurance is requested on a
reporting basis. Reporting coverage usually requires monthly reports of the applicant's
total Accounts Receivable and is subject to annual premium adjustment.
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
Non-Reporting (Checkbox)
Check the box (if applicable): Indicates Accounts Receivable insurance is requested on a
non-reporting basis.
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Section Name
Field Name
Field and/or Section Description
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
Your Premises - Limit
Enter limit: The limit required for accounts receivable located on your premises, including
branch locations.
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
Not at Your Premises - Limit
Enter limit: The limit required for accounts receivable located off your premises.
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
In Transit - Limit
Enter limit: The limit required for accounts receivable in transit.
POLICY INFORMATION /
ACCOUNTS RECEIVABLE
All Covered Property at all
Locations - Limit
Enter limit: The sum of all accounts receivable covered property at all locations.
PREMISES/BUILDING
INFORMATION
Premises #
Enter number: The location number for the premises. As used here, the premises location
number as stated in the Applicant Information Section (ACORD 125).
PREMISES/BUILDING
INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location. As used here, the premises building number as stated in
the Applicant Information Section (ACORD 125).
PREMISES/BUILDING
INFORMATION
Building Construction
Enter code: The primary construction type of the premises. Common construction
classifications are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES/BUILDING
INFORMATION
Sprinklers-Yes (Checkbox)
Check the box (if applicable): Indicates the building is equipped with a fire sprinkler
system.
PREMISES/BUILDING
INFORMATION
Sprinklers-No (Checkbox)
Check the box (if applicable): Indicates the building is not equipped with a fire sprinkler
system.
PREMISES/BUILDING
INFORMATION
Classification of Business-Retail
(Checkbox)
Check the box (if applicable): Indicates the nature of business is retail.
PREMISES/BUILDING
INFORMATION
Percentage of Retail Business
Enter percentage: The percentage of the total accounts receivable the retail business
represents.
PREMISES/BUILDING
INFORMATION
Classification of Business-
Wholesale (Checkbox)
Check the box (if applicable): Indicates the nature of business is wholesale.
PREMISES/BUILDING
INFORMATION
Percentage of Wholesale Business
Enter percentage: The percentage of the total accounts receivable the wholesale business
represents.
PREMISES/BUILDING
INFORMATION
Classification of Business-
Manufacturing (Checkbox)
Check the box (if applicable): Indicates the nature of business is manufacturing.
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Section Name
Field Name
Field and/or Section Description
PREMISES/BUILDING
INFORMATION
Percentage of Manufacturing
Business
Enter percentage: The percentage of the total accounts receivable the manufacturing
business represents.
PREMISES/BUILDING
INFORMATION
Classification of Business-
Insurance (Checkbox)
Check the box (if applicable): Indicates the nature of business is insurance.
PREMISES/BUILDING
INFORMATION
Percentage of Insurance Business
Enter percentage: The percentage of the total accounts receivable the insurance business
represents.
LOCATION OF
RECORDS/PROTECTION
Address or Location
Enter text: The first address line of the commercial structure. As used here, complete this
section in regard to the location and protection systems for the Accounts Receivable.
Information on the classification of safes, vaults and alarm systems can be found in the
Crime Section of the ISO Classification and Rating Manual. Indicate the address where
Accounts Receivable are kept. This might also appear in the Applicant Information Section
(ACORD 125). If so, indicate per ACORD 125 and list the location number.
LOCATION OF
RECORDS/PROTECTION
Enter text: The city of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Enter code: The state of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Enter code: The postal code of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Section of Building
Enter text: The section of the building where records of Accounts Receivable are kept;
e.g., warehouse vs. office (separate fire rate) and floor have underwriting importance. If
other than office, explain.
LOCATION OF
RECORDS/PROTECTION
Fire Contents Rate
Enter percentage: The 80 percent coinsurance (Basic Group I Personal Property Rate) for
the section of the building where Accounts Receivable are usually kept.
LOCATION OF
RECORDS/PROTECTION
Safe/Vault/Receptacle
Manufacturer
Enter text: The safe or vault manufacturer's name.
LOCATION OF
RECORDS/PROTECTION
Label-UL (Checkbox)
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories,
Inc. (UL).
LOCATION OF
RECORDS/PROTECTION
Label-SMNA (Checkbox)
Check the box (if applicable): Indicates the rating is based on Safe Manufacturers National
Association (SMNA).
LOCATION OF
RECORDS/PROTECTION
Class
Enter code: The construction classification representing the extent of burglary protection
for this safe or vault. Use the classification from the Burglary label and not the Fire label
located on the safe or vault. For industry definitions of the classifications, refer to the
Commercial Lines Manual.
LOCATION OF
RECORDS/PROTECTION
Door Type-Round (Checkbox)
Check the box (if applicable): Indicates the door is round.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Door Type-Square (Checkbox)
Check the box (if applicable): Indicates the door is square.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Outer
(Checkbox)
Check the box (if applicable): Indicates if there are outer combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Inner
(Checkbox)
Check the box (if applicable): Indicates if there are inner combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Chest
(Checkbox)
Check the box (if applicable): Indicates if there are chest combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Door Thickness
Enter number: The door thickness in inches, excluding bolt work.
LOCATION OF
RECORDS/PROTECTION
Wall Thickness
Enter number: The wall thickness is inches.
LOCATION OF
RECORDS/PROTECTION
Construction
Enter text: The construction of the safe, vault or other receptacle (e.g., 4-inch steel door,
with 12-inch reinforced stone walls).
LOCATION OF
RECORDS/PROTECTION
Duplicate Records-Yes (Checkbox)
Check the box (if applicable): Indicates duplicate accounts receivable records are kept.
LOCATION OF
RECORDS/PROTECTION
Duplicate Records-No (Checkbox)
Check the box (if applicable): Indicates duplicate accounts receivable records are not kept.
LOCATION OF
RECORDS/PROTECTION
% of Records Duplicated
Enter percentage: The percent of all accounts receivable that have duplicate records.
LOCATION OF
RECORDS/PROTECTION
Period Records Kept
Enter number: The number of months all duplicate records are maintained.
LOCATION OF
RECORDS/PROTECTION
Location of Duplicate Records
Address Line 1
Enter text: The first address line of the commercial structure. As used here, the location
where duplicate records are kept.
LOCATION OF
RECORDS/PROTECTION
City
Enter text: The city of the commercial structure. As used here, the location where duplicate
records are kept.
LOCATION OF
RECORDS/PROTECTION
State
Enter code: The state of the commercial structure. As used here, the location where
duplicate records are kept.
LOCATION OF
RECORDS/PROTECTION
Zip Code
Enter code: The postal code of the commercial structure. As used here, the location where
duplicate records are kept.
LOCATION OF
RECORDS/PROTECTION
Location of Duplicate Records
Description
Enter text: The precise storage location or section of the building where the duplicate
records are kept.
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Hold-Up (Checkbox)
Check the box (if applicable): Indicates the alarm type is a hold-up alarm. A manual or
semiautomatic control which can transmit an alarm in the event of a hold-up.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Premises (Checkbox)
Check the box (if applicable): Indicates the alarm type is a premises alarm. A sensing
device installed on premises which transmits an alarm in the event of unauthorized entry.
The Premises Extent must be completed for Premises Alarms.
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Safe (Checkbox)
Check the box (if applicable): Indicates the alarm type is a safe/vault alarm. A system that
protects the safe or vault and is connected to an outside central station, gong or siren. The
Extent of Protection for safe/vault must be completed.
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Local Gong
(Checkbox)
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Central Station
(Checkbox)
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Police Connect
(Checkbox)
Check the box (if applicable): Indicates if alarms (hold-up and burglar) are transmitted to
police headquarters rather than to a private control station
LOCATION OF
RECORDS/PROTECTION
Alarm Description-With Keys
(Checkbox)
Check the box (if applicable): Indicates the alarm company, located off the insured's
premises, has keys to the applicant's property.
LOCATION OF
RECORDS/PROTECTION
Grade
Enter code: The alarm grade as described in the Insurance Services Office crime rating
manual (e.g., AA, A, B, C) which indicates the time required to respond to a signal from the
alarm system.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection for Safe/Vault-
Partial (Checkbox)
Check the box (if applicable): Indicates the extent of protection for the safe/vault is partial
and covers around the door only.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection for Safe/Vault-
Complete (Checkbox)
Check the box (if applicable): Indicates the extent of protection for the safe/vault is
complete and covers the sides, top walls, floor and ceiling.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection for Premises-1
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 1 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection for Premises-2
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 2 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection for Premises-3
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 3 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Alarm Installed & Serviced By
Enter text: The name of the alarm company that installed and services the alarm. Alarm
companies often install, maintain, and service the system in addition to providing Central
Station facilities.
LOCATION OF
RECORDS/PROTECTION
# Guards
Enter number: The number of guards within the premises or at its door during regular
business hours.
LOCATION OF
RECORDS/PROTECTION
# Watchpersons
Enter number: The number of watchpersons on the premises during non-office hours.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Watchpersons-RPT/Cent. St
(Checkbox)
Check the box (if applicable): Indicates the watchpersons report to a central station on an
hourly basis.
LOCATION OF
RECORDS/PROTECTION
Watchpersons-Clock Hrly
(Checkbox)
Check the box (if applicable): Indicates the watchpersons register hourly with an approved
watchperson's clock (Detex Time Clock, etc.).
LOCATION OF
RECORDS/PROTECTION
Watchpersons-Don't Signal
(Checkbox)
Check the box (if applicable): Indicates the watchpersons do not do any type of reporting
or registering.
LOCATION OF
RECORDS/PROTECTION
Certificate Number
Enter identifier: The Underwriters Laboratories or other testing organization Certificate
Number, if applicable. Attach a copy of the certificate to the application.
LOCATION OF
RECORDS/PROTECTION
Expiration Date
Enter date: The expiration date of the certificate.
LOCATION OF
RECORDS/PROTECTION
Accessible Openings & Protection
Enter text: The information regarding access to the premises. Indicate number of doors
and if they are protected. Indicate what type of locks are used, and if there is a gate or
bars.
LOCATION OF
RECORDS/PROTECTION
Other Protection
Enter text: The description of other protective measures or devices (e.g., if windows have
steel grates and are connected to an alarm). Indicate if the building has skylights and if
windows are visible from the street.
HISTORY OF
RECEIVABLES
Mo./Yr One
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Account Receivable One
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Two
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Two
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Three
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Three
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Four
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Four
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Five
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Account Receivable Five
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
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Section Name
Field Name
Field and/or Section Description
HISTORY OF
RECEIVABLES
Mo./Yr Six
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Six
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Seven
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Seven
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Eight
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Eight
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Nine
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Account Receivable Nine
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Ten
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Ten
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Eleven
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Eleven
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Mo./Yr Twelve
Enter text: The date (MM/YYYY) for which the accounts receivable history is being
presented.
HISTORY OF
RECEIVABLES
Accounts Receivable Twelve
Enter amount: The amount of receivables outstanding as of the last fiscal day of the month
of the prior year immediately preceding the date of this application.
HISTORY OF
RECEIVABLES
Deferred Payment Percentage
Enter percentage: The percentage of accounts receivable under a deferred payment plan.
HISTORY OF
RECEIVABLES
Uncollected Accounts - Year One
Enter year: The year for which uncollectible receivables are being recorded. This
information should be entered for the prior three years.
HISTORY OF
RECEIVABLES
Uncollected Accounts - ($) One
Enter amount: The amount of uncollectible receivables.
HISTORY OF
RECEIVABLES
Uncollected Accounts - Year Two
Enter year: The year for which uncollectible receivables are being recorded. This
information should be entered for the prior three years.
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Section Name
Field Name
Field and/or Section Description
HISTORY OF
RECEIVABLES
Uncollected Accounts - ($) Two
Enter amount: The amount of uncollectible receivables.
HISTORY OF
RECEIVABLES
Uncollected Accounts - Year Three
Enter year: The year for which uncollectible receivables are being recorded. This
information should be entered for the prior three years.
HISTORY OF
RECEIVABLES
Uncollected Accounts - ($) Three
Enter amount: The amount of uncollectible receivables.
GENERAL INFORMATION
1. Is Cycle Billing accounting
system used? Yes (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Is cycle billing
accounting system used?.
GENERAL INFORMATION
1. Is Cycle Billing accounting
system used? No (Checkbox)
Check the box (if applicable): Indicates a No response to the question, Is cycle billing
accounting system used?.
GENERAL INFORMATION
2. Are billed and unbilled records
kept separate? Yes (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Are billed and
unbilled records kept separate?.
GENERAL INFORMATION
2. Are billed and unbilled records
kept separate? No (Checkbox)
Check the box (if applicable): Indicates a No response to the question, Are billed and
unbilled records kept separate?.
GENERAL INFORMATION
3. Has there been flooding at any
location? Yes (Checkbox)
Check the box (if applicable): Indicates a Yes response to the question, Has there been
flooding at any location?.
GENERAL INFORMATION
3. Has there been flooding at any
location? No (Checkbox)
Check the box (if applicable): Indicates a No response to the question, Has there been
flooding at any location?.
GENERAL INFORMATION
Remarks
Enter text: The general remarks associated with the commercial inland marine line of
business. Use this section to provide any additional information required for underwriting
or rating.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
POLICY INFORMATION
Your Premises - Limit
Enter limit: The limit required for valuable papers located on your premises, including
branch locations.
POLICY INFORMATION
Not at Your Premises - Limit
Enter limit: The limit required for valuable papers located off your premises.
POLICY INFORMATION
Blanket (Checkbox)
Check the box (if applicable): Indicates the coverage is to be written on a blanket basis. If
blanket coverage is requested enter the blanket limit amount.
POLICY INFORMATION
Amount ($)
Enter limit: The blanket limit amount.
POLICY INFORMATION
Specified Amount (Checkbox)
Check the box (if applicable): Indicates coverage is to be written on a specified amount
basis. If coverage is to be written on a specified amount basis, an agreed amount per item
should be entered in the Papers section along with a description of the specified paper.
POLICY INFORMATION
Occurrence Deductible
Enter deductible: The per occurrence deductible amount.
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Section Name
Field Name
Field and/or Section Description
POLICY INFORMATION
Can Papers Be Replaced? Yes
(Checkbox)
Check the box (if applicable): Indicates papers can be replaced.
POLICY INFORMATION
Can Papers Be Replaced? No
(Checkbox)
Check the box (if applicable): Indicates papers can not be replaced.
LOCATION
Premises #
Enter number: The location number for the premises.
LOCATION
Building #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
LOCATION
Building Construction
Enter code: The primary construction type of the premises. Common construction
classifications are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
LOCATION
Sprinklers-Yes (Checkbox)
Check the box (if applicable): Indicates the building is equipped with a fire sprinkler
system.
LOCATION
Sprinklers-No (Checkbox)
Check the box (if applicable): Indicates the building is not equipped with a fire sprinkler
system.
LOCATION OF
RECORDS/PROTECTION
Address or Location
Enter text: The first address line of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Enter text: The city of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Enter code: The state of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Enter code: The postal code of the commercial structure.
LOCATION OF
RECORDS/PROTECTION
Section of Building
Enter text: The section of the building where records of Accounts Receivable are kept;
e.g., warehouse vs. office (separate fire rate) and floor have underwriting importance. If
other than office, explain.
LOCATION OF
RECORDS/PROTECTION
Fire Contents Rate
Enter percentage: The 80 percent coinsurance (Basic Group I Personal Property Rate) for
the section of the building where Accounts Receivable are usually kept.
LOCATION OF
RECORDS/PROTECTION
Receptacles in which property is
kept at all times
Enter text: The type of receptacle in which the valuable papers are stored.
LOCATION OF
RECORDS/PROTECTION
Safe/Vault/Receptacle
Manufacturer
Enter text: The safe or vault manufacturer's name.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Label-UL (Checkbox)
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories,
Inc. (UL).
LOCATION OF
RECORDS/PROTECTION
Label-SMNA (Checkbox)
Check the box (if applicable): Indicates the rating is based on Safe Manufacturers National
Association (SMNA).
LOCATION OF
RECORDS/PROTECTION
Class
Enter code: The construction classification representing the extent of burglary protection
for this safe or vault. Use the classification from the Burglary label and not the Fire label
located on the safe or vault. For industry definitions of the classifications, refer to the
Commercial Lines Manual.
LOCATION OF
RECORDS/PROTECTION
Door Type-Round (Checkbox)
Check the box (if applicable): Indicates the door is round.
LOCATION OF
RECORDS/PROTECTION
Door Type-Square (Checkbox)
Check the box (if applicable): Indicates the door is square.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Outer
(Checkbox)
Check the box (if applicable): Indicates if there are outer combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Inner
(Checkbox)
Check the box (if applicable): Indicates if there are inner combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Combination Locks-Chest
(Checkbox)
Check the box (if applicable): Indicates if there are chest combination locks on the safe or
vault.
LOCATION OF
RECORDS/PROTECTION
Thickness of Door
Enter number: The door thickness in inches, excluding bolt work.
LOCATION OF
RECORDS/PROTECTION
Thickness of Wall
Enter number: The wall thickness is inches.
LOCATION OF
RECORDS/PROTECTION
Construction
Enter text: The construction of the safe, vault or other receptacle (e.g., 4-inch steel door,
with 12-inch reinforced stone walls).
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Hold Up (Checkbox)
Check the box (if applicable): Indicates the alarm type is a hold-up alarm. A manual or
semiautomatic control which can transmit an alarm in the event of a hold-up.
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Premises (Checkbox)
Check the box (if applicable): Indicates the alarm type is a premises alarm. A sensing
device installed on premises which transmits an alarm in the event of unauthorized entry.
The Premises Extent must be completed for Premises Alarms.
LOCATION OF
RECORDS/PROTECTION
Alarm Type-Safe (Checkbox)
Check the box (if applicable): Indicates the alarm type is a safe/vault alarm. A system that
protects the safe or vault and is connected to an outside central station, gong or siren. The
Extent of Protection for safe/vault must be completed.
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Local Gong
(Checkbox)
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Central Station
(Checkbox)
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Alarm Description-Police Connect
(Checkbox)
Check the box (if applicable): Indicates if alarms (hold-up and burglar) are transmitted to
police headquarters rather than to a private control station
LOCATION OF
RECORDS/PROTECTION
Alarm Description-With Keys
(Checkbox)
Check the box (if applicable): Indicates the alarm company, located off the insured's
premises, has keys to the applicant's property.
LOCATION OF
RECORDS/PROTECTION
Grade
Enter code: The alarm grade as described in the Insurance Services Office crime rating
manual (e.g., AA, A, B, C) which indicates the time required to respond to a signal from the
alarm system.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection-Safe/Vault-
Partial (Checkbox)
Check the box (if applicable): Indicates the extent of protection for the safe/vault is partial
and covers around the door only.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection-Safe/Vault-
Complete (Checkbox)
Check the box (if applicable): Indicates the extent of protection for the safe/vault is
complete and covers the sides, top walls, floor and ceiling.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection-Premises-1
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 1 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection-Premises-2
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 2 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Extent of Protection-Premises-3
(Checkbox)
Check the box (if applicable): Indicates the extent of protection for the premises is
premises 3 as defined in the ISO Classification and Rating Manual.
LOCATION OF
RECORDS/PROTECTION
Alarm Installed & Serviced By
Enter text: The name of the alarm company that installed and services the alarm. Alarm
companies often install, maintain, and service the system in addition to providing Central
Station facilities.
LOCATION OF
RECORDS/PROTECTION
# Guards
Enter number: The number of guards within the premises or at its door during regular
business hours.
LOCATION OF
RECORDS/PROTECTION
# Watchpersons
Enter number: The number of watchpersons on the premises during non-office hours.
LOCATION OF
RECORDS/PROTECTION
Watchpersons-Rpt/Cent. St
(Checkbox)
Check the box (if applicable): Indicates the watchpersons report to a central station on an
hourly basis.
LOCATION OF
RECORDS/PROTECTION
Watchpersons-Clock Hrly
(Checkbox)
Check the box (if applicable): Indicates the watchpersons register hourly with an approved
watchperson's clock (Detex Time Clock, etc.).
LOCATION OF
RECORDS/PROTECTION
Watchpersons-Don't Signal
(Checkbox)
Check the box (if applicable): Indicates the watchpersons do not do any type of reporting
or registering.
LOCATION OF
RECORDS/PROTECTION
Certificate Number
Enter identifier: The Underwriters Laboratories or other testing organization Certificate
Number, if applicable. Attach a copy of the certificate to the application.
LOCATION OF
RECORDS/PROTECTION
Expiration Date
Enter date: The expiration date of the certificate.
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Section Name
Field Name
Field and/or Section Description
LOCATION OF
RECORDS/PROTECTION
Accessible Openings & Protection
Enter text: The information regarding access to the premises. Indicate number of doors
and if they are protected. Indicate what type of locks are used, and if there is a gate or
bars.
LOCATION OF
RECORDS/PROTECTION
Other Protection
Enter text: The description of other protective measures or devices (e.g., if windows have
steel grates and are connected to an alarm). Indicate if the building has skylights and if
windows are visible from the street.
PAPERS
# One
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers One
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount One
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Two
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Two
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Two
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Three
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Three
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Three
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Four
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Four
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Four
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Five
Enter identifier: The identifier assigned by the producer/agent to the item.
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Section Name
Field Name
Field and/or Section Description
PAPERS
Description of Papers Five
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Five
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Six
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Six
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Six
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Seven
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Seven
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Seven
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Eight
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Eight
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Eight
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
# Nine
Enter identifier: The identifier assigned by the producer/agent to the item.
PAPERS
Description of Papers Nine
Enter text: The description of valuable papers to be insured including manuscripts,
documents, rare printings, etc. Older items require appraisals; architects' or engineers'
plans should be described; deeds and contracts should be categorized. Valuable papers
do not include money and securities.
PAPERS
Specified Amount Nine
Enter limit: The agreed limit amount used when coverage is written on a specified amount
basis.
PAPERS
See Attached List (Checkbox)
Check the box (if applicable): Indicates a schedule of valuable papers is attached.
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Section Name
Field Name
Field and/or Section Description
REMARKS
Remarks
Enter text: The general remarks associated with the commercial inland marine line of
business. Use this section to provide any additional information required for underwriting
or rating.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
SIGNATURE
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
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
(Required in FL)
Enter identifier: The State License Number of the producer.
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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