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ACORD 187 (3/98) 1 of 6
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 05/29/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 187 (3/98) |
Professional Liability Supplement |
The title of the form. ACORD 187, Professional Liability Supplement, is used to apply for professional liability coverage for any of the following classes: * Barbers and Beauticians * Funeral Directors * Optical and Hearing Aid Establishments * Printers * Veterinarians This form is intended to be used as a supplement to the following forms: * ACORD 126, Commercial General Liability Section * ACORD 160, Business Owners Application * ACORD 165, Small Commercial Account Package App |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Producer |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION SECTION |
Phone (A/C, No, Ext.) |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION SECTION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
ACORD 187 (3/98) 2 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
First Named Insured |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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IDENTIFICATION SECTION |
Years In Business |
Enter number: The number of years the insured has been in business. |
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IDENTIFICATION SECTION |
Nature Of Business |
Enter text: The description of the nature/type of business. |
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IDENTIFICATION SECTION |
# of Employees - Full Time |
Enter number: The number of full time employees. |
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IDENTIFICATION SECTION |
# of Employees - Part Time |
Enter number: The number of part time employees. |
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IDENTIFICATION SECTION |
Annual Sales/Receipts |
Enter amount: The total annual gross sales or receipts. |
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GENERAL INFORMATION |
Are all employees licensed as required by law? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are all employees licensed as required by law?". |
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GENERAL INFORMATION |
Are all employees licensed as required by law? No |
Check the box (if applicable): Indicates a "No" response to the question, "Are all employees licensed as required by law?". |
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GENERAL INFORMATION |
Is applicant a member of a local or national organization? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Is applicant a member of a local or national organization?". |
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GENERAL INFORMATION |
If yes, provide name |
Enter text: The name of the local or national organization the applicant is a member of. |
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GENERAL INFORMATION |
Is applicant a member of a local or national organization? No |
Check the box (if applicable): Indicates a "No" response to the question, "Is applicant a member of a local or national organization?". |
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GENERAL INFORMATION |
Do any employees work for others in addition to the applicant? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Do any employees work for others in addition to the applicant?". |
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GENERAL INFORMATION |
Do any employees work for others in addition to the applicant? No |
Check the box (if applicable): Indicates a "No" response to the question, "Do any employees work for others in addition to the applicant?". |
ACORD 187 (3/98) 3 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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If funeral prepayment plans are |
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offered, are funds properly |
Check the box (if applicable): Indicates a "Yes" response to the question, "If funeral |
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FUNERAL DIRECTORS |
audited, managed and distributed |
prepayment plans are offered, are funds properly audited, managed and distributed by full- |
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INFORMATION |
by full-time director? Yes |
time director?". |
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FUNERAL DIRECTORS INFORMATION |
If funeral prepayment plans are offered, are funds properly audited, managed and distributed by full-time director? No |
Check the box (if applicable): Indicates a "No" response to the question, "If funeral prepayment plans are offered, are funds properly audited, managed and distributed by full-time director?". |
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FUNERAL DIRECTORS |
Does applicant specialize in |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant |
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INFORMATION |
cremation services? Yes |
specialize in cremation services?". |
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FUNERAL DIRECTORS |
Does applicant specialize in |
Check the box (if applicable): Indicates a "No" response to the question, "Does applicant |
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INFORMATION |
cremation services? No |
specialize in cremation services?". |
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Are all prescriptions checked |
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OPTICAL AND HEARING |
against the original order when the |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are all |
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AID ESTABLISHMENTS |
merchandise is delivered? Yes |
prescriptions checked against the original order when the merchandise is delivered?". |
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Are all prescriptions checked |
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OPTICAL AND HEARING |
against the original order when the |
Check the box (if applicable): Indicates a "No" response to the question, "Are all |
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AID ESTABLISHMENTS |
merchandise is delivered? No |
prescriptions checked against the original order when the merchandise is delivered?". |
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OPTICAL AND HEARING AID ESTABLISHMENTS |
Are records of all tests performed, prescriptions filled and customer's acceptance of merchandise kept on computer or in a fire-resistant cabinet? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are records of all tests performed, prescriptions filled and customer's acceptance of merchandise kept on computer or in a fire-resistant cabinet?". |
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Are records of all tests performed, |
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prescriptions filled and customer's |
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acceptance of merchandise kept |
Check the box (if applicable): Indicates a "No" response to the question, "Are records of |
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OPTICAL AND HEARING |
on computer or in a fire-resistant |
all tests performed, prescriptions filled and customer's acceptance of merchandise kept |
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AID ESTABLISHMENTS |
cabinet? No |
on computer or in a fire-resistant cabinet?". |
ACORD 187 (3/98) 4 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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Are hearing aids or optical goods |
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manufactured or delivered only as |
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OPTICAL AND HEARING |
a result of a prescription from a physician, audiologist or |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are hearing aids or optical goods manufactured or delivered only as a result of a prescription from a |
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AID ESTABLISHMENTS |
optometrist? Yes |
physician, audiologist or optometrist?". |
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Are hearing aids or optical goods |
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manufactured or delivered only as |
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OPTICAL AND HEARING |
a result of a prescription from a physician, audiologist or |
Check the box (if applicable): Indicates a "No" response to the question, "Are hearing aids or optical goods manufactured or delivered only as a result of a prescription from a |
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AID ESTABLISHMENTS |
optometrist? No |
physician, audiologist or optometrist?". |
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OPTICAL AND HEARING |
Does applicant employ |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant |
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AID ESTABLISHMENTS |
optometrists or opticians? Yes |
employ optometrists or opticians?". |
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OPTICAL AND HEARING |
Does applicant employ |
Check the box (if applicable): Indicates a "No" response to the question, "Does applicant |
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AID ESTABLISHMENTS |
optometrists or opticians? No |
employ optometrists or opticians?". |
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Are lottery, gaming or raffle tickets |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are lottery, |
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PRINTERS |
printed? Yes |
gaming or raffle tickets printed?". |
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Are lottery, gaming or raffle tickets |
Check the box (if applicable): Indicates a "No" response to the question, "Are lottery, |
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PRINTERS |
printed? No |
gaming or raffle tickets printed?". |
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Are food or drug labels printed? |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are food or |
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PRINTERS |
Yes |
drug labels printed?". |
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Are food or drug labels printed? |
Check the box (if applicable): Indicates a "No" response to the question, "Are food or drug |
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PRINTERS |
No |
labels printed?". |
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Are transportation, admission or |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are |
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PRINTERS |
special event tickets printed? Yes |
transportation, admission or special event tickets printed?". |
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Are transportation, admission or |
Check the box (if applicable): Indicates a "No" response to the question, "Are |
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PRINTERS |
special event tickets printed? No |
transportation, admission or special event tickets printed?". |
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Are money orders, securities, or |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are money |
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PRINTERS |
travelers checks printed? Yes |
orders, securities, or travelers checks printed?". |
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Are money orders, securities, or |
Check the box (if applicable): Indicates a "No" response to the question, "Are money |
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PRINTERS |
travelers checks printed? No |
orders, securities, or travelers checks printed?". |
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Does the applicant have a written |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does the |
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PRINTERS |
quality control program? Yes |
applicant have a written quality control program?". |
ACORD 187 (3/98) 5 of 6
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Section Name |
Field Name |
Field and/or Section Description |
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PRINTERS |
Does the applicant have a written quality control program? No |
Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant have a written quality control program?". |
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PRINTERS |
Are customers required to proofread before printing takes place? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are customers required to proof-read before printing takes place?". |
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PRINTERS |
Are customers required to proofread before printing takes place? No |
Check the box (if applicable): Indicates a "No" response to the question, "Are customers required to proof-read before printing takes place?". |
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PRINTERS |
Is the applicant a contract printer for publishers? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant a contract printer for publishers?". |
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PRINTERS |
Is the applicant a contract printer for publishers? No |
Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant a contract printer for publishers?". |
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PRINTERS |
Does the applicant write documents? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Does the applicant write documents?". |
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PRINTERS |
Does the applicant write documents? No |
Check the box (if applicable): Indicates a "No" response to the question, "Does the applicant write documents?". |
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PRINTERS |
How are solvents and/or other pollutants disposed of? |
Enter text: The description of how solvents and/or other pollutants are disposed. |
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VETERINARIANS |
Are any services provided to animals used or bred for professional racing, show or delivery services? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are any services provided to animals used or bred for professional racing, show or delivery services?". |
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VETERINARIANS |
Are any services provided to animals used or bred for professional racing, show or delivery services? No |
Check the box (if applicable): Indicates a "No" response to the question, "Are any services provided to animals used or bred for professional racing, show or delivery services?". |
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VETERINARIANS |
Are any services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other show enterprises? Yes |
Check the box (if applicable): Indicates a "Yes" response to the question, "Are any services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other show enterprises?". |
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Section Name |
Field Name |
Field and/or Section Description |
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VETERINARIANS |
Are any services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other show enterprises? No |
Check the box (if applicable): Indicates a "No" response to the question, "Are any services provided to animals belonging to zoos, circuses, carnivals, rodeos, theatrical or other show enterprises?". |
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VETERINARIANS |
# of Owners: |
Enter number: The number of owners. |
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VETERINARIANS |
# of Employed Vets: |
Enter number: The number of employed veterinarians. |
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REMARKS |
Remarks |
Enter text: The general remarks associated with professional liability. Use the remarks area to document anything else that would help the underwriter evaluate your application. Attach the ACORD 101, Additional Remarks Schedule, if more space is required. |
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EDITION |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 187 (3/98) 6 of 6
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