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ACORD Form 175 Commercial Policy
Change Request Instructions
 

 
ACORD 175 (2009/01) rev. 04-03-2009 1 of 30
Section Name Field Name Field and/or Section Description
TITLE Commercial Policy Change The title of the form. ACORD 175, Commercial Policy Change Request, is used to submit
ACORD 175 (2009/01) Request requested changes in a commercial insurance policy to the carrier.
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 Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
Enter text: The name of the individual at the producer's establishment that is the primary
IDENTIFICATION SECTION Contact Name contact.
Enter number: The producer's contact person's phone number. If applicable, include the
IDENTIFICATION SECTION Phone No. area code and extension.
IDENTIFICATION SECTION Fax No. Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address Enter text: The producer's contact person e-mail address.
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
IDENTIFICATION SECTION Code firm) by the insurer.
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
IDENTIFICATION SECTION Subcode person) within a producer's office (e.g. agency or brokerage).
Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION Agency Customer ID agency or brokerage).
IDENTIFICATION SECTION Insured's Name Enter text: The named insured(s) as it/they will appear on the policy declarations page.
Insured's Name and Mailing
IDENTIFICATION SECTION Address If Changed Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line one.
ACORD 175 (2009/01) rev. 04-03-2009 2 of 30
Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured's mailing address postal code.
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 Attention Enter text: The name of the individual at the insurance company that is the primary contact.
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 Account Number Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number.
IDENTIFICATION SECTION Effective Date of Change Enter date: The date on which the change should take effect.
IDENTIFICATION SECTION Policy Inception Date Enter date: The date on which the terms and conditions of the policy commenced.
IDENTIFICATION SECTION Policy Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Property Check the box (if applicable): Indicates the type of policy is property.
IDENTIFICATION SECTION Inland Marine Check the box (if applicable): Indicates the type of policy is inland marine.
IDENTIFICATION SECTION Umbrella Check the box (if applicable): Indicates the type of policy is umbrella.
IDENTIFICATION SECTION General Liability Check the box (if applicable): Indicates the type of policy is general liability.

ACORD 175 (2009/01) rev. 04-03-2009 3 of 30

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Auto Check the box (if applicable): Indicates the type of policy is automobile.
IDENTIFICATION SECTION Truckers Check the box (if applicable): Indicates the type of policy is truckers.
IDENTIFICATION SECTION Motor Carriers Check the box (if applicable): Indicates the type of policy is motor carriers.
IDENTIFICATION SECTION Business Owners Check the box (if applicable): Indicates the type of policy is business owners.
IDENTIFICATION SECTION Workers Comp Check the box (if applicable): Indicates the type of policy is workers compensation.
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
IDENTIFICATION SECTION Other Policy Type One listed.
IDENTIFICATION SECTION Other Policy Type Description One Enter text: The description of the type of policy issued to the insured.
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
IDENTIFICATION SECTION Other Policy Type Two listed.
IDENTIFICATION SECTION Other Policy Type Description Two Enter text: The description of the type of policy issued to the insured.
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
IDENTIFICATION SECTION Other Policy Type Three listed.
Other Policy Type Description
IDENTIFICATION SECTION Three Enter text: The description of the type of policy issued to the insured.
Enter text: The remarks associated with a policy change. Attach ACORD 101, Additional
SHORT DESCRIPTION OF Short Description of Changes / Remarks Schedule, if more space is required. As used here, enter a short description of
CHANGES / REMARKS Remarks the changes.
PREMISES INFORMATION
SECTION Add Check the box (if applicable): Indicates if the type of change being requested is an add.
PREMISES INFORMATION Check the box (if applicable): Indicates if the type of change being requested is a change
SECTION Change to an existing piece of data.
PREMISES INFORMATION
SECTION Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
PREMISES INFORMATION
SECTION LOC # Enter number: The location number for the premises.
PREMISES INFORMATION Enter number: The building number for the premises. Used when more than one building
SECTION BLD # exists at an individual location.

ACORD 175 (2009/01) rev. 04-03-2009 4 of 30

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION SECTION Street, City, County, State Enter text: The first address line of the commercial structure.
PREMISES INFORMATION SECTION Enter text: The city of the commercial structure.
PREMISES INFORMATION SECTION Enter text: The county of the commercial structure.
PREMISES INFORMATION SECTION Enter code: The state of the commercial structure.
PREMISES INFORMATION SECTION Enter code: The postal code of the commercial structure.
PREMISES INFORMATION SECTION City Limits Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION SECTION City Limits Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION SECTION Interest Check the box (if applicable): Indicates the named insured's interest in the building is as its owner.
PREMISES INFORMATION SECTION Interest Check the box (if applicable): Indicates the named insured's interest is the building is as its tenant.
PREMISES INFORMATION SECTION Yr Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PREMISES INFORMATION SECTION Part Occupied Enter percentage: The percentage of the building the named insured occupies.
PREMISES INFORMATION SECTION Add Check the box (if applicable): Indicates if the type of change being requested is an add.
PREMISES INFORMATION SECTION Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
PREMISES INFORMATION SECTION Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS LOC # Enter number: The location number for the premises.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BLD # Enter number: The building number for the premises. Used when more than one building exists at an individual location.

ACORD 175 (2009/01) rev. 04-03-2009 5 of 30

Section Name Field Name Field and/or Section Description
NATURE OF
BUSINESS/DESCRIPTION Description of Operation by
OF OPERATIONS Premises Enter text: The description of the nature/type of business.
AUTO-VEHICLE
DESCRIPTION/LIMITS Policy Limit(s) Changed Check the box (if applicable): Indicates if there is a change to the policy limits.
AUTO-VEHICLE
DESCRIPTION/LIMITS Add Check the box (if applicable): Indicates if the type of change being requested is an add.
AUTO-VEHICLE Check the box (if applicable): Indicates if the type of change being requested is a change
DESCRIPTION/LIMITS Change to an existing piece of data.
AUTO-VEHICLE
DESCRIPTION/LIMITS Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
AUTO-VEHICLE
DESCRIPTION/LIMITS VEH # One Enter number: The producer assigned vehicle number.
AUTO-VEHICLE
DESCRIPTION/LIMITS Year One Enter year: The model year of the vehicle.
AUTO-VEHICLE
DESCRIPTION/LIMITS Make One Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
AUTO-VEHICLE
DESCRIPTION/LIMITS Model One Enter text: The manufacturer's model name for the vehicle.
AUTO-VEHICLE
DESCRIPTION/LIMITS Body Type One Enter code: The body type of the vehicle.
AUTO-VEHICLE Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
DESCRIPTION/LIMITS V.I.N One manufacturer.
AUTO-VEHICLE Check the box (if applicable): Indicates the predominant type of the vehicle is private
DESCRIPTION/LIMITS PP (private passenger) One passenger.
AUTO-VEHICLE Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
DESCRIPTION/LIMITS SPEC (special) One classic, antique automobile).
AUTO-VEHICLE
DESCRIPTION/LIMITS COML (commercial) One Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
AUTO-VEHICLE
DESCRIPTION/LIMITS SYM\AGE One Enter code: The symbol required for physical damage coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Cost New One Enter amount: The original cost of the vehicle.
AUTO-VEHICLE
DESCRIPTION/LIMITS Street (Required in KY) One Enter text: The vehicle's physical address line one.
ACORD 175 (2009/01) rev. 04-03-2009 6 of 30
Section Name Field Name Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION/LIMITS City One Enter text: The vehicle's physical address city name.
AUTO-VEHICLE
DESCRIPTION/LIMITS County One Enter text: The vehicle's physical address county name.
AUTO-VEHICLE
DESCRIPTION/LIMITS State One Enter code: The vehicle's physical address state or province code.
AUTO-VEHICLE
DESCRIPTION/LIMITS Zip One Enter code: The vehicle's physical address postal code.
AUTO-VEHICLE
DESCRIPTION/LIMITS LIC State One Enter code: The state or province in which the vehicle is registered.
AUTO-VEHICLE
DESCRIPTION/LIMITS TERR One Enter code: The rating territory code where the vehicle is principally garaged.
AUTO-VEHICLE Enter number: The actual weight of the vehicle or the combined weight of tractor and
DESCRIPTION/LIMITS GVW / GCW One trailer in pounds.
AUTO-VEHICLE Enter code: The rate class of the vehicle. If two rate classes are required, this element
DESCRIPTION/LIMITS Class One should be used to enter the liability code.
AUTO-VEHICLE Enter code: The secondary Special Industry Class code which applies to commercial
DESCRIPTION/LIMITS SIC One vehicles as determined by industry rating manuals.
Enter rate: The primary liability rating factor contains the number which is used, along with
AUTO-VEHICLE the secondary rating factor, in determining the liability premium. The primary rating factor
DESCRIPTION/LIMITS Factor One which is always positive is based on the primary class.
AUTO-VEHICLE Enter number: The seating capacity of the vehicle. Required for rating public passenger
DESCRIPTION/LIMITS Seat CP One vehicles.
AUTO-VEHICLE
DESCRIPTION/LIMITS Radius One Enter number: The radius in whole numbers within which this vehicle is operated.
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation
AUTO-VEHICLE in which the vehicle is operated. The source of this code is the Insurance Services Office
DESCRIPTION/LIMITS Farthest Terminal One Zone code list.
AUTO-VEHICLE Drive to Work or School under 15 Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
DESCRIPTION/LIMITS miles one way One work or school, and is driven to work or school under 15 miles one way.
AUTO-VEHICLE Drive to Work or School 15 miles Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
DESCRIPTION/LIMITS or over one way One work or school, and is driven to work or school 15 miles or over one way.
AUTO-VEHICLE
DESCRIPTION/LIMITS Pleasure One Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
AUTO-VEHICLE
DESCRIPTION/LIMITS Farm One Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
ACORD 175 (2009/01) rev. 04-03-2009 7 of 30
Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS Commercial One Check the box (if applicable): Indicates the primary use for the vehicle is for commercial purposes.
AUTO-VEHICLE DESCRIPTION/LIMITS Retail One Check the box (if applicable): Indicates the primary use for the vehicle is for the retail industry.
AUTO-VEHICLE DESCRIPTION/LIMITS Service One Check the box (if applicable): Indicates the primary use for the vehicle is for the service industry.
AUTO-VEHICLE DESCRIPTION/LIMITS Liab One Check the box (if applicable): Indicates the vehicle has liability coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS No-fault One Check the box (if applicable): Indicates the vehicle has no-fault coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Add'l No-fault One Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Med Pay One Check the box (if applicable): Indicates the vehicle has medical payments coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Unins Motor One Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Undrins Motor One Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Towing & Labor One Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Spec C of L One Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS F One Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS FT One Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS FTW One Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS LSP One Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS COMP/OTC One Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Coll One Check the box (if applicable): Indicates the vehicle has collision coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Rent Reimb One Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation expense coverage.

ACORD 175 (2009/01) rev. 04-03-2009 8 of 30

Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS FG One Check the box (if applicable): Indicates the vehicle has full glass coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Other Coverage One Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
AUTO-VEHICLE DESCRIPTION/LIMITS Other Coverage Description One Check the box (if applicable): The description of the other type of coverage on the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS ACV One Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the actual cash value.
AUTO-VEHICLE DESCRIPTION/LIMITS AA One Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the agree amount.
AUTO-VEHICLE DESCRIPTION/LIMITS ST AMT One Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the stated amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Applicable Limit One Enter amount: The agreed or stated amount used in determining the value of the vehicle at the time of loss.
AUTO-VEHICLE DESCRIPTION/LIMITS COMP/OTC One Check the box (if applicable): Indicates the deductible is for comprehensive or other than collision coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Spec C of L One Check the box (if applicable): Indicates the deductible is for specified causes of loss. The Specified Cause of Loss Codes are: SCL Specified Cause of Loss F Fire F&T Fire and Theft F,T&W Fire, Theft and Wind LSP Limited Specified Perils SP Specified Perils
AUTO-VEHICLE DESCRIPTION/LIMITS Applicable Limit One Enter amount: The comprehensive or specified cause of loss deductible amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Collision Deductible One Enter deductible: The collision deductible amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Net Veh CR/CR One Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under remarks a description of each debit or credit used in the calculation of the net rating factor.
AUTO-VEHICLE DESCRIPTION/LIMITS Total Premium One Enter amount: The total amount for the vehicle.

ACORD 175 (2009/01) rev. 04-03-2009 9 of 30

Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS Liability One Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
AUTO-VEHICLE DESCRIPTION/LIMITS No-fault One Enter limit: The personal injury protection (PIP) limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Add'l No-fault One Enter limit: The additional personal injury protection (APIP) limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Medical Payments One Enter limit: The medical payments per person limit.
AUTO-VEHICLE DESCRIPTION/LIMITS Uninsured Motorists One Enter limit: The uninsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Underinsured Motorists One Enter limit: The underinsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Policy Limit(s) Changed Check the box (if applicable): Indicates if there is a change to the policy limits.
AUTO-VEHICLE DESCRIPTION/LIMITS Add Check the box (if applicable): Indicates if the type of change being requested is an add.
AUTO-VEHICLE DESCRIPTION/LIMITS Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
AUTO-VEHICLE DESCRIPTION/LIMITS Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
AUTO-VEHICLE DESCRIPTION/LIMITS VEH # Two Enter number: The producer assigned vehicle number.
AUTO-VEHICLE DESCRIPTION/LIMITS Year Two Enter year: The model year of the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS Make Two Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
AUTO-VEHICLE DESCRIPTION/LIMITS Model Two Enter text: The manufacturer's model name for the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS Body Type Two Enter code: The body type of the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS V.I.N Two Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
AUTO-VEHICLE DESCRIPTION/LIMITS PP (private passenger) Two Check the box (if applicable): Indicates the predominant type of the vehicle is private passenger.

ACORD 175 (2009/01) rev. 04-03-2009 10 of 30

Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS SPEC (special) Two Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g. classic, antique automobile).
AUTO-VEHICLE DESCRIPTION/LIMITS COML (commercial) Two Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
AUTO-VEHICLE DESCRIPTION/LIMITS SYM\AGE Two Enter code: The symbol required for physical damage coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Cost New Two Enter amount: The original cost of the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS Street (Required in KY) Two Enter text: The vehicle's physical address line one.
AUTO-VEHICLE DESCRIPTION/LIMITS City Two Enter text: The vehicle's physical address city name.
AUTO-VEHICLE DESCRIPTION/LIMITS County Two Enter text: The vehicle's physical address county name.
AUTO-VEHICLE DESCRIPTION/LIMITS State Two Enter code: The vehicle's physical address state or province code.
AUTO-VEHICLE DESCRIPTION/LIMITS Zip Two Enter code: The vehicle's physical address postal code.
AUTO-VEHICLE DESCRIPTION/LIMITS LIC State Two Enter code: The state or province in which the vehicle is registered.
AUTO-VEHICLE DESCRIPTION/LIMITS TERR Two Enter code: The rating territory code where the vehicle is principally garaged.
AUTO-VEHICLE DESCRIPTION/LIMITS GVW / GCW Two Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds.
AUTO-VEHICLE DESCRIPTION/LIMITS Class Two Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
AUTO-VEHICLE DESCRIPTION/LIMITS SIC Two Enter code: The secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals.
AUTO-VEHICLE DESCRIPTION/LIMITS Factor Two Enter rate: The primary liability rating factor contains the number which is used, along with the secondary rating factor, in determining the liability premium. The primary rating factor which is always positive is based on the primary class.
AUTO-VEHICLE DESCRIPTION/LIMITS Seat CP Two Enter number: The seating capacity of the vehicle. Required for rating public passenger vehicles.
AUTO-VEHICLE DESCRIPTION/LIMITS Radius Two Enter number: The radius in whole numbers within which this vehicle is operated.
ACORD 175 (2009/01) rev. 04-03-2009 11 of 30
Section Name Field Name Field and/or Section Description
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation
AUTO-VEHICLE in which the vehicle is operated. The source of this code is the Insurance Services Office
DESCRIPTION/LIMITS Farthest Terminal Two Zone code list.
AUTO-VEHICLE Drive to Work or School under 15 Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
DESCRIPTION/LIMITS miles one way Two work or school, and is driven to work or school under 15 miles one way.
Drive to Work or School 15 miles
AUTO-VEHICLE or over one way Two Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
DESCRIPTION/LIMITS work or school, and is driven to work or school 15 miles or over one way.
AUTO-VEHICLE
DESCRIPTION/LIMITS Pleasure Two Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
AUTO-VEHICLE
DESCRIPTION/LIMITS Farm Two Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
AUTO-VEHICLE DESCRIPTION/LIMITS Commercial Two Check the box (if applicable): Indicates the primary use for the vehicle is for commercial purposes.
AUTO-VEHICLE Check the box (if applicable): Indicates the primary use for the vehicle is for the retail
DESCRIPTION/LIMITS Retail Two industry.
AUTO-VEHICLE Check the box (if applicable): Indicates the primary use for the vehicle is for the service
DESCRIPTION/LIMITS Service Two industry.
AUTO-VEHICLE
DESCRIPTION/LIMITS Liab Two Check the box (if applicable): Indicates the vehicle has liability coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS No-fault Two Check the box (if applicable): Indicates the vehicle has no-fault coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Add'l No-fault Two Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Med Pay Two Check the box (if applicable): Indicates the vehicle has medical payments coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Unins Motor Two Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Undrins Motor Two Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Towing & Labor Two Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS Spec C of L Two Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
AUTO-VEHICLE
DESCRIPTION/LIMITS F Two Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS FT Two Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS FTW Two Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS LSP Two Check the box (if applicable): Indicates limited specified perils is a specified cause of loss on this vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS COMP/OTC Two Check the box (if applicable): Indicates the vehicle has comprehensive or other than collision coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Coll Two Check the box (if applicable): Indicates the vehicle has collision coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Rent Reimb Two Check the box (if applicable): Indicates the vehicle has rental reimbursement or transportation expense coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS FG Two Check the box (if applicable): Indicates the vehicle has full glass coverage.
AUTO-VEHICLE DESCRIPTION/LIMITS Other Coverage Two Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically listed.
AUTO-VEHICLE DESCRIPTION/LIMITS Other Coverage Description Two Check the box (if applicable): The description of the other type of coverage on the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS ACV Two Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the actual cash value.
AUTO-VEHICLE DESCRIPTION/LIMITS AA Two Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the agree amount.
AUTO-VEHICLE DESCRIPTION/LIMITS ST AMT Two Check the box (if applicable): Indicates the valuation method used in determining the value of the vehicle at the time of loss is the stated amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Applicable Limit Two Enter amount: The agreed or stated amount used in determining the value of the vehicle at the time of loss.
AUTO-VEHICLE DESCRIPTION/LIMITS COMP/OTC Two Check the box (if applicable): Indicates the deductible is for comprehensive or other than collision coverage.

ACORD 175 (2009/01) rev. 04-03-2009 12 of 30 ACORD 175 (2009/01) rev. 04-03-2009 14 of 30 ACORD 175 (2009/01) rev. 04-03-2009 25 of 30 ACORD 175 (2009/01) rev. 04-03-2009 26 of 30 ACORD 175 (2009/01) rev. 04-03-2009 27 of 30 ACORD 175 (2009/01) rev. 04-03-2009 30 of 30

ACORD 175 (2009/01) rev. 04-03-2009 13 of 30

Section Name Field Name Field and/or Section Description
AUTO-VEHICLE DESCRIPTION/LIMITS Spec C of L Two Check the box (if applicable): Indicates the deductible is for specified causes of loss. The Specified Cause of Loss Codes are: SCL Specified Cause of Loss F Fire F&T Fire and Theft F,T&W Fire, Theft and Wind LSP Limited Specified Perils SP Specified Perils
AUTO-VEHICLE DESCRIPTION/LIMITS Applicable Limit Two Enter amount: The comprehensive or specified cause of loss deductible amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Collision Deductible Two Enter deductible: The collision deductible amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Net Veh CR/CR Two Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under remarks a description of each debit or credit used in the calculation of the net rating factor.
AUTO-VEHICLE DESCRIPTION/LIMITS Total Premium Two Enter amount: The total amount for the vehicle.
AUTO-VEHICLE DESCRIPTION/LIMITS Liability Two Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
AUTO-VEHICLE DESCRIPTION/LIMITS No-fault Two Enter limit: The personal injury protection (PIP) limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Add'l No-fault Two Enter limit: The additional personal injury protection (APIP) limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Medical Payments Two Enter limit: The medical payments per person limit.
AUTO-VEHICLE DESCRIPTION/LIMITS Uninsured Motorists Two Enter limit: The uninsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE DESCRIPTION/LIMITS Underinsured Motorists Two Enter limit: The underinsured motorists combined single limit per accident limit amount.
DRIVER INFORMATION Add Check the box (if applicable): Indicates if the type of change being requested is an add.
DRIVER INFORMATION Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
Section Name Field Name Field and/or Section Description
DRIVER INFORMATION Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
DRIVER INFORMATION Driver # One Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Name One Enter text: The driver's first name (given name). As used here, if the company requires an address enter it in remarks.
DRIVER INFORMATION Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION Enter text: The driver's last name (surname).
DRIVER INFORMATION Sex One Enter code: The gender of the driver.
DRIVER INFORMATION Mar Stat One Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
DRIVER INFORMATION Date of Birth One Enter date: The birth date of the driver.
DRIVER INFORMATION Yrs Exp One Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION Year LIC One Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION Drivers License Number/Social Security Number One Enter identifier: The driver's license number. As used here, if the driver's license number is not available, enter the social security number.
DRIVER INFORMATION State LIC One Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date Hire One Enter date: The date the driver was hired.
DRIVER INFORMATION Broaden No-Fault One Enter Y for a “Yes” response. Input N for “No” response. Indicates that broadened no fault coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION DOC One Enter Y for a “Yes” response. Input N for “No” response. Indicates the driver is covered by Drive Other Car coverage.
DRIVER INFORMATION Use Veh # One Enter number: The producer assigned vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use One Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).

ACORD 175 (2009/01) rev. 04-03-2009 15 of 30

Section Name Field Name Field and/or Section Description
WORKERS' COMPENSATION RATING INFORMATION Type of Change One Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I - Informational Only No Change. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). Use "I" to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter "A" in the type of change for Collision. Enter "I" in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
WORKERS'
COMPENSATION RATING
INFORMATION State One Enter text: The name of the state to which the rating information is applicable.
WORKERS'
COMPENSATION RATING
INFORMATION LOC One Enter number: The producer assigned number of the location.
WORKERS' COMPENSATION RATING INFORMATION Class Code One Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used.
WORKERS'
COMPENSATION RATING
INFORMATION Descr Code One Enter code: The company description code for this type of risk (if applicable).
WORKERS' COMPENSATION RATING INFORMATION Categories, Duties, Classifications One Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
WORKERS' COMPENSATION RATING INFORMATION # of Employees One Enter number: The number of full time employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate.
WORKERS' COMPENSATION RATING INFORMATION # of Employees One Enter number: The number of part time employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate
ACORD 175 (2009/01) rev. 04-03-2009 16 of 30
Section Name Field Name Field and/or Section Description
WORKERS' COMPENSATION RATING INFORMATION Estimated Annual Remuneration One Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
WORKERS' COMPENSATION RATING INFORMATION Type of Change Two Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I - Informational Only No Change. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). Use "I" to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter "A" in the type of change for Collision. Enter "I" in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
WORKERS'
COMPENSATION RATING
INFORMATION State Two Enter text: The name of the state to which the rating information is applicable.
WORKERS'
COMPENSATION RATING
INFORMATION LOC Two Enter number: The producer assigned number of the location.
WORKERS' COMPENSATION RATING INFORMATION Class Code Two Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained from the National Counsel on Compensation Insurance (NCCI) Workers Compensation and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages may be used.
WORKERS'
COMPENSATION RATING
INFORMATION Descr Code Two Enter code: The company description code for this type of risk (if applicable).
WORKERS' COMPENSATION RATING INFORMATION Categories, Duties, Classifications Two Enter text: The descriptions of activities and operations. One class code may include several descriptions. It is extremely important to enter the specific classification description or, at least, a brief statement regarding the duties of the employees. Enter as much information as necessary to avoid misclassifying the operations.
WORKERS' COMPENSATION RATING INFORMATION # of Employees Two Enter number: The number of full time employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate.

ACORD 175 (2009/01) rev. 04-03-2009 17 of 30

Section Name Field Name Field and/or Section Description
WORKERS' COMPENSATION RATING INFORMATION # of Employees Two Enter number: The number of part time employees to whom the classification applies. The average number is sufficient when the total number fluctuates during the year. Underwriters use this number to determine if the payroll estimates appear adequate
WORKERS' COMPENSATION RATING INFORMATION Estimated Annual Remuneration Two Enter amount: The estimated total annual remuneration/payroll for the class. Remuneration/Payroll means money or substitutes for money, such as the value of meals or lodging if provided. Accurate payroll estimates help avoid additional premium requirements being discovered during an audit. Do not include overtime premium.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Premises # Enter number: The location number for the premises.
PROPERTY / INLAND
MARINE - PREMISES Enter number: The building number for the premises. Used when more than one building
INFORMATION Building # exists at an individual location.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Add Check the box (if applicable): Indicates if the type of change being requested is an add.
PROPERTY / INLAND
MARINE - PREMISES Check the box (if applicable): Indicates if the type of change being requested is a change
INFORMATION Change to an existing piece of data.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Subject of Insurance One Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY / INLAND
MARINE - PREMISES Enter limit: The maximum amount of coverage provided for this subject of insurance or
INFORMATION Amount One premium-bearing option.
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
PROPERTY / INLAND subject of insurance being insured. If the amount of insurance falls below this percentage,
MARINE - PREMISES the insured must share in the amount of the loss. This field should be completed even
INFORMATION Coins % One when writing agreed amount coverage.

ACORD 175 (2009/01) rev. 04-03-2009 18 of 30

Section Name Field Name Field and/or Section Description
Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are:
ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value
PROPERTY / INLAND MARINE - PREMISES INFORMATION Valuation One RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
PROPERTY / INLAND * Broad
MARINE - PREMISES * Special excluding theft
INFORMATION Causes of Loss One * Earthquake
PROPERTY / INLAND Enter percentage: The inflation guard percentage gives an automatic increase in the
MARINE - PREMISES amount of coverage based on a percentage over time. List both the percentage amount
INFORMATION Inflation Guards % One and the period of time during which it applies (e.g., 4% per year).
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY / INLAND
MARINE - PREMISES Forms and Conditions to Apply Enter text: The form numbers and special conditions that apply to this subject of
INFORMATION One insurance. Also indicate here if coverage is blanket or average rated.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Subject of Insurance Two Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY / INLAND
MARINE - PREMISES Enter limit: The maximum amount of coverage provided for this subject of insurance or
INFORMATION Amount Two premium-bearing option.
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
PROPERTY / INLAND subject of insurance being insured. If the amount of insurance falls below this percentage,
MARINE - PREMISES the insured must share in the amount of the loss. This field should be completed even
INFORMATION Coins % Two when writing agreed amount coverage.
ACORD 175 (2009/01) rev. 04-03-2009 19 of 30
Section Name Field Name Field and/or Section Description
Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are:
ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value
PROPERTY / INLAND MARINE - PREMISES INFORMATION Valuation Two RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
PROPERTY / INLAND * Broad
MARINE - PREMISES * Special excluding theft
INFORMATION Causes of Loss * Earthquake
PROPERTY / INLAND Enter percentage: The inflation guard percentage gives an automatic increase in the
MARINE - PREMISES amount of coverage based on a percentage over time. List both the percentage amount
INFORMATION Inflation Guards % Two and the period of time during which it applies (e.g., 4% per year).
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY / INLAND
MARINE - PREMISES Forms and Conditions to Apply Enter text: The form numbers and special conditions that apply to this subject of
INFORMATION Two insurance. Also indicate here if coverage is blanket or average rated.
PROPERTY / INLAND Additional Coverages, Options,
MARINE - PREMISES Endorsements, and Rating
INFORMATION Information Enter text: The remarks associated with a specific location or sublocation.
Enter code: The primary construction type of the premises. Common construction classifications are:
* Frame
* Joisted Masonry * Non-Combustible
PROPERTY / INLAND MARINE - PREMISES * Masonry Non-Combustible * Modified Fire Resistive
INFORMATION Construction Type * Fire Resistive
PROPERTY / INLAND
MARINE - PREMISES Enter number: The distance in feet from the nearest hydrant that supports the protection
INFORMATION Distance to Hydrant class used.
ACORD 175 (2009/01) rev. 04-03-2009 20 of 30
Section Name Field Name Field and/or Section Description
PROPERTY / INLAND MARINE - PREMISES INFORMATION Distance to Fire Stat Enter number: The distance in miles from the nearest fire station that supports the protection class used.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Fire District / Code Number Enter text: The property's fire district name.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Enter code: The property's fire district code number which can be found in the individual states manual pages.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Prot CL Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY / INLAND MARINE - PREMISES INFORMATION # Stories Enter number: The number of stories for this building not including any basement.
PROPERTY / INLAND MARINE - PREMISES INFORMATION # Basements Enter number: The number of basements for this building.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Yr Built Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Total Area Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Wiring Check the box (if applicable): Indicates if any wiring improvements have been made since the original construction.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Year Enter year: The year the wiring improvements took place.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Roofing Check the box (if applicable): Indicates if any roofing improvements have been made since the original construction.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Year Enter year: The year the roofing improvements took place.

ACORD 175 (2009/01) rev. 04-03-2009 21 of 30

Section Name Field Name Field and/or Section Description
PROPERTY / INLAND MARINE - PREMISES INFORMATION Plumbing Check the box (if applicable): Indicates if any plumbing improvements have been made since the original construction.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Year Enter year: The year the plumbing improvements took place.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Heating Check the box (if applicable): Indicates if any heating improvements have been made since the original construction.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Year Enter year: The year the heating improvements took place.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Other Improvements Check the box (if applicable): Indicates if any other improvements have been made since the original construction.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Year Enter text: The description of other improvements that have been made to the structure.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Bldg Code Grade Enter code: The industry code used to collect the building code effectiveness grade code. The source of this code list is public protection classification or individual insurer rating manuals.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Inspected? Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicate if the structure has been inspected specific to its Building Code effectiveness grade.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Roof Type Enter code: The material used to construct the roof. Examples: * Composition (fiberglass, asphalt, etc.) * Metal * Poured * Slate * Tile * Wood Shake/Shingle
PROPERTY / INLAND MARINE - PREMISES INFORMATION Tax Code Enter code: The city, county or state tax code, if applicable.
ACORD 175 (2009/01) rev. 04-03-2009 22 of 30
Section Name Field Name Field and/or Section Description
PROPERTY / INLAND MARINE - PREMISES INFORMATION Other Occupancies Enter text: The description of any other occupancies located in the building not operated by the insured and not listed in the Description of Operations section on the ACORD 125. If no other occupancy, enter None.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Right Exposure & Distance Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the right of the insured premises.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Enter number: The distance to the adjacent exposure on the right of the insured premises in linear feet.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Left Exposure & Distance Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the left of the insured premises.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Enter number: The distance to the adjacent exposure on the left of the insured premises in linear feet.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Rear Exposure & Distance Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the rear of the insured premises.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Enter number: The distance to the adjacent exposure on the rear of the insured premises in linear feet.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Burglar Alarm Type Enter text: The description of any burglar alarm protecting the building or contents. Descriptive terms such as safe, premises, perimeter, or ultrasonic may be suitable.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Certificate # Enter identifier: The Underwriters Laboratories or other testing organization Certificate Number, if applicable. Attach a copy of the certificate to the application.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Expiration Date Enter date: The expiration date of the certificate.
PROPERTY / INLAND MARINE - PREMISES INFORMATION Extent Enter code: The designated extent of protection as described in the Insurance Services Office crime rating manual.
PROPERTY / INLAND MARINE - PREMISES INFORMATION 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.
ACORD 175 (2009/01) rev. 04-03-2009 23 of 30
Section Name Field Name Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Central Station Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
PROPERTY / INLAND
MARINE - PREMISES Check the box (if applicable): Indicates the alarm company, located off the insured's
INFORMATION With Keys premises, has keys to the applicant's property.
PROPERTY / INLAND Enter text: The name of the alarm company that installed and services the alarm. Alarm
MARINE - PREMISES Burglar Alarm Installed and companies often install, maintain, and service the system in addition to providing Central
INFORMATION Serviced By Station facilities.
PROPERTY / INLAND
MARINE - PREMISES Enter number: The number of guards and or watchmen employed or contracted for by the
INFORMATION # Guards/Watchmen insured.
PROPERTY / INLAND Check the box (if applicable): Indicates the guard/watchman is required to make hourly
MARINE - PREMISES rounds using a special time recording device or in connection with the central station
INFORMATION Clock Hourly service. If other than hourly, indicate the time interval in the Other box.
PROPERTY / INLAND
MARINE - PREMISES Check the box (if applicable): Indicates the guard/watchman is required to make some
INFORMATION Other than Hourly other type of rounds.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Other than Hourly Enter text: The description of the rounds the guards/watchmen are required to make.
PROPERTY / INLAND
MARINE - PREMISES Enter text: The description of the type of fire protection for the premises (e.g. sprinklers,
INFORMATION Premises Fire Protection standpipes, Chemical Systems).
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION Fire Alarm Manufacturer Enter text: The name of the manufacturer of the alarm, and if it is UL listed.
PROPERTY / INLAND
MARINE - PREMISES Check the box (if applicable): Indicates the fire alarm rings at an alarm company, police
INFORMATION Central Station department or fire department.
PROPERTY / INLAND
MARINE - PREMISES Check the box (if applicable): Indicates the fire alarm rings on an audible gong located
INFORMATION Local Gong outside of the building.
Enter percentage: The coinsurance percent at which the rate is published. Also, the
INLAND MARINE- amount of property value insured (as a percent). It can also represent the least amount of
SCHEDULED EQUIPMENT % Coinsurance insurance the insured must carry on the property protected by the policy.
ACORD 175 (2009/01) rev. 04-03-2009 24 of 30
Section Name Field Name Field and/or Section Description
INLAND MARINE-SCHEDULED EQUIPMENT Add Check the box (if applicable): Indicates if the type of change being requested is an add.
INLAND MARINE-SCHEDULED EQUIPMENT Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
INLAND MARINE-SCHEDULED EQUIPMENT Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
INLAND MARINE-SCHEDULED EQUIPMENT Number (#) One Enter identifier: The producer assigned identifier for the item.
INLAND MARINE-SCHEDULED EQUIPMENT Model Year One Enter year: The model year of the item.
INLAND MARINE-SCHEDULED EQUIPMENT Description One Enter text: The description of the item.
INLAND MARINE-SCHEDULED EQUIPMENT ID #/Serial # One Enter identifier: The identification number, serial number, or any other identifying symbol of the item.
INLAND MARINE-SCHEDULED EQUIPMENT Date Purchased One Enter date: The date the item was purchased, (MM/DD/YYYY).
INLAND MARINE-SCHEDULED EQUIPMENT New/Used One Enter code: A code indicating if the item was purchased new or used.
INLAND MARINE-SCHEDULED EQUIPMENT Amount of Insurance One Enter limit: The amount of insurance representing the liability limit for the particular described equipment. The limit should reflect the required coinsurance percentage and the requested basis of valuation (ACV or Replacement Cost).
INLAND MARINE-SCHEDULED EQUIPMENT Number (#) Two Enter identifier: The producer assigned identifier for the item.
INLAND MARINE-SCHEDULED EQUIPMENT Model Year Two Enter year: The model year of the item.
INLAND MARINE-SCHEDULED EQUIPMENT Description Two Enter text: The description of the item.
INLAND MARINE-SCHEDULED EQUIPMENT ID #/Serial # Two Enter identifier: The identification number, serial number, or any other identifying symbol of the item.
INLAND MARINE-SCHEDULED EQUIPMENT Date Purchased Two Enter date: The date the item was purchased, (MM/DD/YYYY).
INLAND MARINE-SCHEDULED EQUIPMENT New/Used Two Enter code: A code indicating if the item was purchased new or used.
INLAND MARINE-SCHEDULED EQUIPMENT Amount of Insurance Two Enter limit: The amount of insurance representing the liability limit for the particular described equipment. The limit should reflect the required coinsurance percentage and the requested basis of valuation (ACV or Replacement Cost).
Section Name Field Name Field and/or Section Description
GENERAL LIABILITY - Check the box (if applicable): Indicates if the type of change being requested is a change
LIMITS Change to an existing piece of data.
Enter limit: The general liability, general aggregate limit amount. Any questions about
GENERAL LIABILITY - appropriate limits or applicable policy coverage(s) should be answered by the issuing
LIMITS General Aggregate insurer(s).
Enter limit: The general liability, products and completed operations aggregate limit
GENERAL LIABILITY - Products & Completed Operations amount. Any questions about appropriate limits or applicable policy coverage(s) should be
LIMITS Aggregate answered by the issuing insurer(s).
Enter limit: The general liability, personal and advertising injury limit amount. Any
GENERAL LIABILITY - questions about appropriate limits or applicable policy coverage(s) should be answered by
LIMITS Personal & Advertising Injury the issuing insurer(s).
Enter limit: The general liability, each occurrence limit amount. Any questions about
GENERAL LIABILITY - appropriate limits or applicable policy coverage(s) should be answered by the issuing
LIMITS Each Occurrence insurer(s).
Enter limit: The general liability, damage to rented premises each occurrence limit amount.
GENERAL LIABILITY - Any questions about appropriate limits or applicable policy coverage(s) should be
LIMITS Damage to Rented Premises answered by the issuing insurer(s).
Enter limit: The general liability, medical expense each person limit amount. Any questions
GENERAL LIABILITY - about appropriate limits or applicable policy coverage(s) should be answered by the
LIMITS Medical Expense issuing insurer(s).
GENERAL LIABILITY -
LIMITS Employee Benefits Enter limit: The general liability employee benefits limit amount.
Enter text: The description of other coverage (not the limit). Any questions about
GENERAL LIABILITY - appropriate limits or applicable policy coverage(s) should be answered by the issuing
LIMITS Other insurer(s).
Enter limit: The general liability, other coverage limit amount. Any questions about
GENERAL LIABILITY - appropriate limits or applicable policy coverage(s) should be answered by the issuing
LIMITS Other Benefits insurer(s).
Section Name Field Name Field and/or Section Description
GENERAL LIABILITY -SCHEDULE OF HAZARDS Type of Change One Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I - Informational Only No Change. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). Use "I" to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter "A" in the type of change for Collision. Enter "I" in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -SCHEDULE OF HAZARDS Location # One Enter number: The producer assigned identifier for the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Haz # One Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Classification One Enter text: The classification the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Class Code One Enter code: The general liability class code that corresponds to the classification description shown in the previous field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Premium Basis One Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Exposure One Enter amount: The amount of the exposure used for this class code in calculating the premium. The contents of this data element depends on the rating basis used. The full amount of exposure is contained.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Terr One Enter code: The rating territory code based on location from the appropriate state exception page.
Section Name Field Name Field and/or Section Description
GENERAL LIABILITY -SCHEDULE OF HAZARDS Type of Change Two Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I - Informational Only No Change. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). Use "I" to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter "A" in the type of change for Collision. Enter "I" in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -SCHEDULE OF HAZARDS Location # Two Enter number: The producer assigned identifier for the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Haz # Two Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Classification Two Enter text: The classification the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Class Code Two Enter code: The general liability class code that corresponds to the classification description shown in the previous field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Premium Basis Two Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Exposure Two Enter amount: The amount of the exposure used for this class code in calculating the premium. The contents of this data element depends on the rating basis used. The full amount of exposure is contained.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Terr Two Enter code: The rating territory code based on location from the appropriate state exception page.
ACORD 175 (2009/01) rev. 04-03-2009 28 of 30
Section Name Field Name Field and/or Section Description
GENERAL LIABILITY -SCHEDULE OF HAZARDS Type of Change Three Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I - Informational Only No Change. Various combinations of changes are permitted in one submission. Use "A" to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use "D" to delete an item (e.g., delete a vehicle, delete a driver). Use "C" to change an item in the policy (e.g., change a deductible, change coverage limits). Use "I" to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter "A" in the type of change for Collision. Enter "I" in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -SCHEDULE OF HAZARDS Location # Three Enter number: The producer assigned identifier for the location number of the risk's location as it appears on the Applicant Information Section of ACORD 125. All classifications should be grouped by location number.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Haz # Three Enter number: A unique (within location) number distinguishing this unit-at-risk from the others.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Classification Three Enter text: The classification the applicant's liability exposures by location, using the ISO Classification Table or other industry organization rules. Enter the appropriate class description from the table in this field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Class Code Three Enter code: The general liability class code that corresponds to the classification description shown in the previous field.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Premium Basis Three Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Exposure Three Enter amount: The amount of the exposure used for this class code in calculating the premium. The contents of this data element depends on the rating basis used. The full amount of exposure is contained.
GENERAL LIABILITY -SCHEDULE OF HAZARDS Terr Three Enter code: The rating territory code based on location from the appropriate state exception page.
UMBRELLA CHANGES Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
UMBRELLA CHANGES Limit of Liability Enter limit: The excess umbrella liability limit each occurrence limit.
UMBRELLA CHANGES Retained Limit Enter deductible: The excess or umbrella liability deductible or retention amount.
UMBRELLA CHANGES Other 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 answered by the issuing insurer(s).
ADDITIONAL INTEREST Add Check the box (if applicable): Indicates if the type of change being requested is an add.

ACORD 175 (2009/01) rev. 04-03-2009 29 of 30

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
ADDITIONAL INTEREST Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST Employee as Lessor Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST Lienholder Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST Loss Payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST Other Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTEREST Other Description Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST Owner Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST Registrant Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST Name and Address Enter text: The additional interest's full name.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST Enter code: The additional interest's country code.
ADDITIONAL INTEREST Rank Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTEREST Evidence: Certificate Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST Location Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST Building Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST Vehicle Enter number: The producer assigned number of the vehicle which has an additional interest.
Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST Boat Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST Airport Enter identifier: The Federal Aviation Administration's designator for the airport (e.g. ORD -O'Hare International Airport).
ADDITIONAL INTEREST Item Class Enter text: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.).
ADDITIONAL INTEREST Item Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTEREST Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
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 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 information is required in Florida.
SIGNATURE Insured'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).