ACORD 20 (2009/12)

ACORD 20 (2009/12) rev. 03-23-2011
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 20 (2009/12)
Certificate of Aviation Liability
Insurance
ACORD 20, Certificate of Aviation Liability Insurance, is issued as a
matter of information only, and confers no rights upon the certificate holder. This
certificate does not amend, extend, or alter the coverage afforded by policies.
The above information is included in the opening statement of the form.
If the receiver of the form wants to verify that coverage exists on a policy and has no direct
interest in the policy, use the certificate of insurance. However, if the receiver of the form
does have a verifiable interest in the policy, such as an additional insured, the liability
policy must be amended by endorsement, to provide the appropriate coverage for the
interested party prior to issuing a certificate of insurance (since the certificate confers no
rights upon the holder and does not amend the policy).
TITLE
Purpose of the Certificate of Insurance
The purpose of the Certificate of Insurance has been the topic of frequent discussions
throughout the industry. Attention centers around the true purpose of a certificate and the
rights, if any, it conveys to a certificate holder.
In a 1974 court decision (United States Pipe & Foundry Co. v United States Fidelity &
Guar. Co, 505 F. 2d 88 (5th Cir. 1974), the court ruled that a certificate is not a contract
between the holder and the insurer. It only provides information to an interested third
party that insurance is in force at the time of issuance. The court also stated: The
provision regarding notification in the event of cancellation is a mere promise,
unsupported by any consideration. Although many companies provide notice of
cancellation to certificate holders, they are not obliged to do so, since the holder is not a
party to the contract.
ACORD 20 (2009/12) rev. 03-23-2011
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Section Name
Field Name
Field and/or Section Description
TITLE
The Certificate of Aviation Liability Insurance is used for most casualty situations in which
the insured has requested certification to a third party of issued casualty coverages.
The ACORD Certificate should be issued only in compliance with company instructions.
ACORD recommends that the Certificate NOT be used in the following situations:
* To waive rights
* To provide information to the owner of a leased motor vehicle or the lender about both
liability and physical damage coverages applying to the vehicle (ACORD 23, Automobile
Certificate of Insurance, should be used for this)
* To quote wording from a contract
* To attach to an endorsement
* To quote any wording that amends a policy unless the policy itself has been amended
TITLE
IMPORTANT
Unlike ACORD 23, 24, 25, 27 and 28, certificates and evidence forms, ACORD 20 and 21
do not require filing since they deal exclusively with uncontrolled/unregulated inland
marine insurance. Nevertheless, virtually every state will not allow any change in a
certificate of insurance that would attempt to modify a policy unless the revised certificate
is filed and approved as a policy form. In these states, this form can only be changed to
reflect the terms and conditions of the policy on which it is reporting. Such change(s)
must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date (MM/DD/YYYY)
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Producer
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.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext)
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Producer Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
INSURED
Name & Mailing Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INSURED
Enter text: The named insured's mailing address line one.
INSURED
Enter text: The named insured's mailing address line two.
INSURED
Enter text: The named insured's mailing address city name.
INSURED
Enter code: The named insured's mailing address state or province code.
INSURED
Enter code: The named insured's mailing address postal code.
INSURER(S) AFFORDING
COVERAGE
Company A
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.
INSURER(S) AFFORDING
COVERAGE
Company A %
Enter percentage: The percentage interest the insurer has in the policy.
INSURER(S) AFFORDING
COVERAGE
Company A NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
INSURER(S) AFFORDING
COVERAGE
Company B
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.
INSURER(S) AFFORDING
COVERAGE
Company B %
Enter percentage: The percentage interest the insurer has in the policy.
ACORD 20 (2009/12) rev. 03-23-2011
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Section Name
Field Name
Field and/or Section Description
INSURER(S) AFFORDING
COVERAGE
Company B NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
INSURER(S) AFFORDING
COVERAGE
Company C
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.
INSURER(S) AFFORDING
COVERAGE
Company C %
Enter percentage: The percentage interest the insurer has in the policy.
INSURER(S) AFFORDING
COVERAGE
Company C NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
INSURER(S) AFFORDING
COVERAGE
Company D
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.
INSURER(S) AFFORDING
COVERAGE
Company D %
Enter percentage: The percentage interest the insurer has in the policy.
INSURER(S) AFFORDING
COVERAGE
Company D NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
INSURER(S) AFFORDING
COVERAGE
Company E
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.
INSURER(S) AFFORDING
COVERAGE
Company E %
Enter percentage: The percentage interest the insurer has in the policy.
INSURER(S) AFFORDING
COVERAGE
Company E NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
INSURER(S) AFFORDING
COVERAGE
Company F
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.
INSURER(S) AFFORDING
COVERAGE
Company F %
Enter percentage: The percentage interest the insurer has in the policy.
INSURER(S) AFFORDING
COVERAGE
Company F NAIC #
Enter code: The identification code assigned to the insurer by the NAIC.
AIRPORT & FBO LIABILITY
COVERAGES
Certificate Number
Enter identifier: The producer assigned number for the certificate.
AIRPORT & FBO LIABILITY
COVERAGES
Revision Number
Enter number: The producer assigned revision number for the certificate.
AIRPORT & FBO LIABILITY
COVERAGES
Insurer Letter
Enter code: The company letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the Airport & FBO Liability Policy.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
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. As used here, the
Airport & FBO Liability policy number.
AIRPORT & FBO LIABILITY
COVERAGES
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the Airport & FBO Liability policy effective date.
AIRPORT & FBO LIABILITY
COVERAGES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the Airport & FBO Liability policy expiration date.
AIRPORT & FBO LIABILITY
COVERAGES
Additional Insured? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured for any of the Airport & FBO policy coverages
described in the certificate.
AIRPORT & FBO LIABILITY
COVERAGES
Subrogation Waived?
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the Airport FBO liability section of the policy.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Premises Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Premises Liability BI Ea Per
Enter limit: The bodily injury each person limit amount for premises liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Premises Liability Ea Occ
Enter limit: The each occurrence limit amount for premises liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Premises Liability PD
Enter limit: The property damage limit amount for premises liability coverage.
AIRPORT & FBO LIABILITY Premises Medical Payments
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Premises Medical Payments
COVERAGES
Option Description
Enter text: The description of the option being requested.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY Premises Medical Payments
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Premises Medical Payments
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Premises Medical Payments Ea
COVERAGES
Per
Enter limit: The each person limit amount for premises medical payments coverage.
AIRPORT & FBO LIABILITY Premises Medical Payments Ea
COVERAGES
Occ
Enter limit: The each occurrence limit amount for premises medical payments coverage.
AIRPORT & FBO LIABILITY Products Liability Sale of Fuel &
COVERAGES
Oil
Check the box (if applicable): Indicates the sale of fuel and oil option applies to the
products liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Products Liability Extended
Check the box (if applicable): Indicates the extended option applies to the products liability
coverage.
AIRPORT & FBO LIABILITY Products Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Products Liability Option
COVERAGES
Description
Enter text: The description of the option being requested. Examples: Sale of Used
Aircraft, Sale of New Aircraft, Parts Installed, Parts Not Installed, Food and Beverage,
Pilot Supplies.
AIRPORT & FBO LIABILITY
COVERAGES
Products Liability BI Ea Per
Enter limit: The bodily injury each person limit amount for products liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Products Liability Ea Occ
Enter limit: The each occurrence limit amount for products liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Products Liability Aggr
Enter limit: The aggregate limit amount for products liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Completed Operations Extended
Check the box (if applicable): Indicates the extended option applies to the completed
operations liability coverage.
AIRPORT & FBO LIABILITY Completed Operations Liability
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Completed Operations Liability
COVERAGES
Option Description
Enter text: The description of the option being requested. Examples: Sale of Fuel and Oil,
Parts Not Installed, Sale of New Aircraft, Sale of Used Aircraft, Restaurant Liability, Repair
and Services.
AIRPORT & FBO LIABILITY Completed Operations Liability
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Completed Operations Liability
COVERAGES
Option Description
Enter text: The description of the option being requested. Examples: Sale of Fuel and Oil,
Parts Not Installed, Sale of New Aircraft, Sale of Used Aircraft, Restaurant Liability, Repair
and Services.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY Completed Operations Liability BI
COVERAGES
Ea Per
Enter limit: The bodily injury each person limit amount for completed operations liability
coverage.
AIRPORT & FBO LIABILITY Completed Operations Liability Ea
COVERAGES
Occ
Enter limit: The each occurrence limit amount for completed operations liability coverage.
AIRPORT & FBO LIABILITY Completed Operations Liability
COVERAGES
Aggr
Enter limit: The aggregate limit amount for completed operations liability coverage.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability
COVERAGES
Including Taxi
Check the box (if applicable): Indicates the including taxi option applies to the coverage.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability In
COVERAGES
Flight
Check the box (if applicable): Indicates the in flight option applies to the coverage.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability
COVERAGES
Option Description
Enter text: The description of the option being requested. Example: Ground Only.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability Ea
COVERAGES
Aircraft
Enter limit: The each aircraft limit amount for hangarkeepers legal liability coverage.
AIRPORT & FBO LIABILITY Hangarkeepers Legal Liability Ea
COVERAGES
Occ
Enter limit: The each occurrence limit amount for hangarkeepers legal liability coverage.
AIRPORT & FBO LIABILITY Fire Legal Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Fire Legal Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Fire Legal Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Fire Legal Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Fire Legal Liability Any One Fire
Enter limit: The any one fire limit amount for fire legal liability coverage.
AIRPORT & FBO LIABILITY Personal Injury Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Personal Injury Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Personal Injury Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY Personal Injury Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
Personal Injury Liability Ea Occ
Enter limit: The each occurrence limit amount for personal injury liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Personal Injury Liability Aggr
Enter limit: The aggregate limit amount for personal injury liability coverage.
AIRPORT & FBO LIABILITY Advertising Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates there is an option on advertising liability coverage.
AIRPORT & FBO LIABILITY Advertising Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY Advertising Liability Option
COVERAGES
Checkbox
Check the box (if applicable): Indicates there is an option on advertising liability coverage.
AIRPORT & FBO LIABILITY Advertising Liability Option
COVERAGES
Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Advertising Liability Ea Occ
Enter limit: The each occurrence limit amount for advertising liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Advertising Liability Aggr
Enter limit: The aggregate limit amount for advertising liability coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Contractual Liability Included
Check the box (if applicable): Indicates contractual liability coverage is included in the
policy.
AIRPORT & FBO LIABILITY
COVERAGES
Contractual Liability Excluded
Check the box (if applicable): Indicates contractual liability coverage is excluded from the
policy.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Code
Enter code: The code for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Option Description
Enter text: The description of the option being requested.
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
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Section Name
Field Name
Field and/or Section Description
AIRPORT & FBO LIABILITY
COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AIRPORT & FBO LIABILITY
COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
DESCRIPTION OF
OPERATIONS / REMARKS
(Attach ACORD 101,
Additional Remarks
Schedule if more space is
required)
Description of Operations
Enter text: The Certificate Of Aviation Liability Insurance general remarks including the
description of operations. ACORD 101, Additional Remarks Section, may be attached if
more space is required.
CERTIFICATE HOLDER
Certificate Holder Name & Address
Enter text: The certificate holder's full name.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address line one.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address line two.
CERTIFICATE HOLDER
Enter text: The certificate holder's mailing address city name.
CERTIFICATE HOLDER
Enter code: The certificate holder's mailing address state or province code.
CERTIFICATE HOLDER
Enter code: The certificate holder's mailing address postal code.
CANCELLATION
Authorized Representative
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.
As used here, the authorized representative by all companies to issue Certificates.
IDENTIFICATION SECTION Producer Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
PRIVATE HANGAR
LIABILITY COVERAGES
Insurer Letter
Enter code: The company letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the Private Hangar Liability Policy.
PRIVATE HANGAR
LIABILITY COVERAGES
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. As used here, the
Private Hangar Liability policy number.
PRIVATE HANGAR
LIABILITY COVERAGES
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the Private Hangar Liability policy effective date.
PRIVATE HANGAR
LIABILITY COVERAGES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the Private Hangar Liability policy expiration date.
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Section Name
Field Name
Field and/or Section Description
PRIVATE HANGAR
LIABILITY COVERAGES
Additional Insured? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured for any of the Private Hangar Liability policy
coverages described in the certificate.
PRIVATE HANGAR
LIABILITY COVERAGES
Subrogation Waived?
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the Private Hangar Liability section of the policy.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability
Including Taxi
Check the box (if applicable): Indicates the including taxi option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability In
Flight
Check the box (if applicable): Indicates the in flight option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability
Option Description
Enter text: The description of the option being requested. Example: Ground Only.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability Ea
Aircraft
Enter limit: The each aircraft limit amount for hangarkeepers legal liability coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Hangarkeepers Legal Liability Ea
Occ
Enter limit: The each occurrence limit amount for hangarkeepers legal liability coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Coverage Code
Enter code: The code for the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
PRIVATE HANGAR
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
PRIVATE HANGAR
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
PRIVATE HANGAR
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
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Section Name
Field Name
Field and/or Section Description
PRIVATE HANGAR
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
PRIVATE HANGAR
LIABILITY COVERAGES
Coverage Code
Enter code: The code for the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
PRIVATE HANGAR
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
PRIVATE HANGAR
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
PRIVATE HANGAR
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
PRIVATE HANGAR
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AVIATION PRODUCTS
LIABILITY COVERAGES
Insurer Letter
Enter code: The company letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the Products Liability policy.
AVIATION PRODUCTS
LIABILITY COVERAGES
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. As used here, the
Aviation Products Liability policy number.
AVIATION PRODUCTS
LIABILITY COVERAGES
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence. As used here, the Aviation Products Liability policy effective date.
AVIATION PRODUCTS
LIABILITY COVERAGES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. As used
here, the Aviation Products Liability policy expiration date.
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Section Name
Field Name
Field and/or Section Description
AVIATION PRODUCTS
LIABILITY COVERAGES
Additional Insured? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured for any of the Products Liability policy coverages
described in the certificate.
AVIATION PRODUCTS
LIABILITY COVERAGES
Subrogation Waived?
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the Products Liability section of the policy.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Incl Comp Ops
Check the box (if applicable): Indicates completed operations are included in the products
liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Excl Comp Ops
Check the box (if applicable): Indicates completed operations are excluded from the
products liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Incl Spacecraft
Check the box (if applicable): Indicates spacecraft are included in the products liability
coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Excl Spacecraft
Check the box (if applicable): Indicates spacecraft are excluded from the products liability
coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Ea Occ
Enter limit: The each occurrence limit for products liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Products Liability Aggr
Enter limit: The aggregate limit for products liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Grounding Liability Ea Occ
Enter limit: The each occurrence limit amount for grounding liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Grounding Liability Aggr
Enter limit: The aggregate limit amount for grounding liability coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Foreign Military Aircraft Products
Included
Check the box (if applicable): Indicates foreign military aircraft products coverage is
included in the policy.
AVIATION PRODUCTS
LIABILITY COVERAGES
Coverage Code
Enter code: The code for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
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Section Name
Field Name
Field and/or Section Description
AVIATION PRODUCTS
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AVIATION PRODUCTS
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AVIATION PRODUCTS
LIABILITY COVERAGES
Coverage Code
Enter code: The code for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Option Description
Enter text: The description of the option being requested.
AVIATION PRODUCTS
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AVIATION PRODUCTS
LIABILITY COVERAGES
Limit
Enter limit: The limit amount for the coverage.
AVIATION PRODUCTS
LIABILITY COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Line of Business
Enter text: The description of the line of business classification.
OTHER COVERAGES
Insurer Letter
Enter code: The company letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the policy.
OTHER COVERAGES
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.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
OTHER COVERAGES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
OTHER COVERAGES
Additional Insured? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured for any of the policy coverages described in this
section of the certificate.
OTHER COVERAGES
Subrogation Waived?
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the Aviation Liability section of the policy.
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Line of Business
Enter text: The description of the line of business classification.
OTHER COVERAGES
Insurer Letter
Enter code: The company letter of the insurer, as identified in the Insurer(s) Affording
Coverage form section, associated with the policy.
OTHER COVERAGES
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.
OTHER COVERAGES
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
OTHER COVERAGES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
OTHER COVERAGES
Additional Insured? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the certificate holder
has been named as an additional insured for any of the policy coverages described in this
section of the certificate.
OTHER COVERAGES
Subrogation Waived?
Enter Y for a Yes response. Input N for No response. Indicates subrogation has been
waived on the Aviation Liability section of the policy.
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
ACORD 20 (2009/12) rev. 03-23-2011
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Coverage Code
Enter code: The code for the coverage.
OTHER COVERAGES
Coverage Description
Enter text: The description of other coverage (not the limit) on the policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s)
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
ACORD 20 (2009/12) rev. 03-23-2011
24 of 24
Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Option Checkbox
Check the box (if applicable): Indicates a coverage option applies to the coverage.
OTHER COVERAGES
Option Description
Enter text: The description of the option being requested.
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
OTHER COVERAGES
Limit
Enter limit: The limit amount for the coverage.
OTHER COVERAGES
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).