ACORD 402 (2014/12) - AGRICULTURE PROPERTY SECTION
ACORD 402 (2014/12) - AGRICULTURE PROPERTY SECTION
ACORD 402, Agriculture Property Section, is designed to handle the basic underwriting and rating needs for Agriculture property exposures.
The Property Section accommodates five separate premises.
This form was designed to be used in conjunction with ACORD 401, Agriculture Application - Applicant Information Section. Much of the
information for the Identification Section should match the data found within the Applicant Information Section of ACORD 401. Even though this
data matches the data on ACORD 401, it is still important to complete it. Many companies separate the applications by sub-line of business for
rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION
Renewal
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
ACORD 402 (2014/12) rev. 04-29-2014
Page 1 of 45
PREMISES INFORMATION
Location #
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Building Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
PREMISES INFORMATION
Subject of Insurance One
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # One
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % One
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
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PREMISES INFORMATION
Cause of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium One
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Two
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Two
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Two
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
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PREMISES INFORMATION
Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Two
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Three
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Three
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Three
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Three
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
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PREMISES INFORMATION
Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Three
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Four
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Four
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Four
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Four
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
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PREMISES INFORMATION
Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Four
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Five
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Five
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Five
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Five
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Five
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
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PREMISES INFORMATION
Cause of Loss Five
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Five
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Five
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Total Value
Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION
Total Premium
Enter amount: The premium for this property.
PREMISES INFORMATION
Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION
Rate Group
Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION
Diag#
Enter identifier: The producer assigned identifier for the diagram of the location. As used here,
show the number used on the diagram on ACORD 405.
PREMISES INFORMATION
Const Type
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES 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.
PREMISES INFORMATION
Heat Type
Enter text: The description of the type of fuel used by the heating unit. As used here, if more
than one type exists, document the secondary types in the remarks section. Use ACORD 101,
Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION
Roof Year
Enter year: The year the roofing improvements took place.
PREMISES INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
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.
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PREMISES INFORMATION
Length
Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Width
Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Height
Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Additional Coverages,
Restrictions, Endorsements
and Rating Information
Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL
INFORMATION
Are any wood or coal fired
stoves used in any
buildings? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any wood or coal fired stoves used?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves on the
premises.
PREMISES GENERAL
INFORMATION
If there are any alarms on
the premises, indicate the
type of alarm and the floors
protected.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any burglar and / or fire alarms?.
PREMISES GENERAL
INFORMATION
Burglary Alarm
Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
Fire Alarm
Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
3. Are there any other
protective devices?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any other protective devices?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation of other protective devices used.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
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ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the other type of additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name
Enter text: The additional interest's full name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
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ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
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.
REMARKS
Remarks
Enter text: The general remarks associated with the farm policy. Use this section to provide any
additional information required for underwriting or rating. Attach additional sheets if more space
is required.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
IDENTIFICATION SECTION
Building Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
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PREMISES INFORMATION
Subject of Insurance One
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # One
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % One
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium One
Enter amount: The premium amount for this subject of insurance.
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PREMISES INFORMATION
Subject of Insurance Two
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Two
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Two
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Two
Enter amount: The premium amount for this subject of insurance.
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PREMISES INFORMATION
Subject of Insurance Three
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Three
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Three
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Three
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Three
Enter amount: The premium amount for this subject of insurance.
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PREMISES INFORMATION
Subject of Insurance Four
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Four
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Four
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Four
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Four
Enter amount: The premium amount for this subject of insurance.
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PREMISES INFORMATION
Subject of Insurance Five
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Five
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Five
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Five
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Five
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Five
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Five
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Five
Enter amount: The premium amount for this subject of insurance.
ACORD 402 (2014/12) rev. 04-29-2014
Page 15 of 45
PREMISES INFORMATION
Total Value
Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION
Total Premium
Enter amount: The premium for this property.
PREMISES INFORMATION
Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION
Rate Group
Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION
Diag#
Enter identifier: The producer assigned identifier for the diagram of the location. As used here,
show the number used on the diagram on ACORD 405.
PREMISES INFORMATION
Const Type
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES 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.
PREMISES INFORMATION
Heat Type
Enter text: The description of the type of fuel used by the heating unit. As used here, if more
than one type exists, document the secondary types in the remarks section. Use ACORD 101,
Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION
Roof Year
Enter year: The year the roofing improvements took place.
PREMISES INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
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.
PREMISES INFORMATION
Length
Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Width
Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Height
Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Additional Coverages,
Restrictions, Endorsements
and Rating Information
Enter text: The remarks associated with a specific location or sublocation.
ACORD 402 (2014/12) rev. 04-29-2014
Page 16 of 45
PREMISES GENERAL
INFORMATION
Are any wood or coal fired
stoves used in any
buildings?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any wood or coal fired stoves used?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves on the
premises.
PREMISES GENERAL
INFORMATION
If there are any alarms on
the premises, indicate the
type of alarm and the floors
protected.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any burglar and / or fire alarms?.
PREMISES GENERAL
INFORMATION
Burglary Alarm
Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
Fire Alarm
Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
3. Are there any other
protective devices?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any other protective devices?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation of other protective devices used.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the other type of additional interest.
ACORD 402 (2014/12) rev. 04-29-2014
Page 17 of 45
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name
Enter text: The additional interest's full name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ACORD 402 (2014/12) rev. 04-29-2014
Page 18 of 45
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
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.
PREMISES INFORMATION
Location #
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Building Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
PREMISES INFORMATION
Subject of Insurance One
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # One
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % One
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 19 of 45
PREMISES INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium One
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Two
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Two
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Two
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 20 of 45
PREMISES INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Two
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Three
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Three
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Three
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 21 of 45
PREMISES INFORMATION
Valuation Three
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Three
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Four
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Four
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Four
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 22 of 45
PREMISES INFORMATION
Valuation Four
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Four
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Five
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Five
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Five
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Five
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 23 of 45
PREMISES INFORMATION
Valuation Five
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Five
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Five
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Five
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Total Value
Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION
Total Premium
Enter amount: The premium for this property.
PREMISES INFORMATION
Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION
Rate Group
Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION
Diag#
Enter identifier: The producer assigned identifier for the diagram of the location. As used here,
show the number used on the diagram on ACORD 405.
PREMISES INFORMATION
Const Type
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES 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.
PREMISES INFORMATION
Heat Type
Enter text: The description of the type of fuel used by the heating unit. As used here, if more
than one type exists, document the secondary types in the remarks section. Use ACORD 101,
Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION
Roof Year
Enter year: The year the roofing improvements took place.
ACORD 402 (2014/12) rev. 04-29-2014
Page 24 of 45
PREMISES INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
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.
PREMISES INFORMATION
Length
Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Width
Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Height
Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Additional Coverages,
Restrictions, Endorsements
and Rating Information
Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL
INFORMATION
Are any wood or coal fired
stoves used in any
buildings?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any wood or coal fired stoves used?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves on the
premises.
PREMISES GENERAL
INFORMATION
If there are any alarms on
the premises, indicate the
type of alarm and the floors
protected.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any burglar and / or fire alarms?.
PREMISES GENERAL
INFORMATION
Burglary Alarm
Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
Fire Alarm
Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
ACORD 402 (2014/12) rev. 04-29-2014
Page 25 of 45
PREMISES GENERAL
INFORMATION
3. Are there any other
protective devices?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any other protective devices?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation of other protective devices used.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the other type of additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name
Enter text: The additional interest's full name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address city name.
ACORD 402 (2014/12) rev. 04-29-2014
Page 26 of 45
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
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.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
PREMISES INFORMATION
Location #
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Building Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ACORD 402 (2014/12) rev. 04-29-2014
Page 27 of 45
PREMISES INFORMATION
Subject of Insurance One
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # One
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % One
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium One
Enter amount: The premium amount for this subject of insurance.
ACORD 402 (2014/12) rev. 04-29-2014
Page 28 of 45
PREMISES INFORMATION
Subject of Insurance Two
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Two
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Two
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Two
Enter amount: The premium amount for this subject of insurance.
ACORD 402 (2014/12) rev. 04-29-2014
Page 29 of 45
PREMISES INFORMATION
Subject of Insurance Three
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Three
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Three
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Three
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Three
Enter amount: The premium amount for this subject of insurance.
ACORD 402 (2014/12) rev. 04-29-2014
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PREMISES INFORMATION
Subject of Insurance Four
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Four
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Four
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Four
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Four
Enter amount: The premium amount for this subject of insurance.
ACORD 402 (2014/12) rev. 04-29-2014
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PREMISES INFORMATION
Subject of Insurance Five
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Five
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Five
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Five
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
PREMISES INFORMATION
Valuation Five
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Five
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Five
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Five
Enter amount: The premium amount for this subject of insurance.
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Page 32 of 45
PREMISES INFORMATION
Total Value
Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION
Total Premium
Enter amount: The premium for this property.
PREMISES INFORMATION
Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION
Rate Group
Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION
Diag#
Enter identifier: The producer assigned identifier for the diagram of the location. As used here,
show the number used on the diagram on ACORD 405.
PREMISES INFORMATION
Const Type
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES 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.
PREMISES INFORMATION
Heat Type
Enter text: The description of the type of fuel used by the heating unit. As used here, if more
than one type exists, document the secondary types in the remarks section. Use ACORD 101,
Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION
Roof Year
Enter year: The year the roofing improvements took place.
PREMISES INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
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.
PREMISES INFORMATION
Length
Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Width
Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Height
Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Additional Coverages,
Restrictions, Endorsements
and Rating Information
Enter text: The remarks associated with a specific location or sublocation.
ACORD 402 (2014/12) rev. 04-29-2014
Page 33 of 45
PREMISES GENERAL
INFORMATION
Are any wood or coal fired
stoves used in any
buildings?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any wood or coal fired stoves used?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves on the
premises.
PREMISES GENERAL
INFORMATION
If there are any alarms on
the premises, indicate the
type of alarm and the floors
protected.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any burglar and / or fire alarms?.
PREMISES GENERAL
INFORMATION
Burglary Alarm
Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
Fire Alarm
Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
3. Are there any other
protective devices?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any other protective devices?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation of other protective devices used.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the other type of additional interest.
ACORD 402 (2014/12) rev. 04-29-2014
Page 34 of 45
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name
Enter text: The additional interest's full name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ACORD 402 (2014/12) rev. 04-29-2014
Page 35 of 45
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
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.
PREMISES INFORMATION
Location #
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Building Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
PREMISES INFORMATION
Subject of Insurance One
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # One
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % One
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 36 of 45
PREMISES INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium One
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Two
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Two
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Two
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 37 of 45
PREMISES INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Two
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Three
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Three
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Three
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 38 of 45
PREMISES INFORMATION
Valuation Three
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Three
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Four
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Four
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Four
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 39 of 45
PREMISES INFORMATION
Valuation Four
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Four
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Subject of Insurance Five
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
PREMISES INFORMATION
Blkt # Five
Enter number: The identifying number for the blanket under which this subject of insurance is
rated. Leave blank if the subject of insurance is not included under a blanket.
PREMISES INFORMATION
Limit of Insurance Five
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PREMISES INFORMATION
Coins % Five
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
ACORD 402 (2014/12) rev. 04-29-2014
Page 40 of 45
PREMISES INFORMATION
Valuation Five
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
PREMISES INFORMATION
Cause of Loss Five
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PREMISES INFORMATION
Deductible Five
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Premium Five
Enter amount: The premium amount for this subject of insurance.
PREMISES INFORMATION
Total Value
Enter limit: The total limit amount for the location / building.
PREMISES INFORMATION
Total Premium
Enter amount: The premium for this property.
PREMISES INFORMATION
Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PREMISES INFORMATION
Rate Group
Enter code: The rating group that carrier has established based on the underwriting of the risk.
PREMISES INFORMATION
Diag#
Enter identifier: The producer assigned identifier for the diagram of the location. As used here,
show the number used on the diagram on ACORD 405.
PREMISES INFORMATION
Const Type
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
PREMISES 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.
PREMISES INFORMATION
Heat Type
Enter text: The description of the type of fuel used by the heating unit. As used here, if more
than one type exists, document the secondary types in the remarks section. Use ACORD 101,
Additional Remarks Schedule if more space is needed.
PREMISES INFORMATION
Roof Year
Enter year: The year the roofing improvements took place.
ACORD 402 (2014/12) rev. 04-29-2014
Page 41 of 45
PREMISES INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
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.
PREMISES INFORMATION
Length
Enter number: The length of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Width
Enter number: The width of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Height
Enter number: The height of the structure. In the USA this is measured in feet.
PREMISES INFORMATION
Additional Coverages,
Restrictions, Endorsements
and Rating Information
Enter text: The remarks associated with a specific location or sublocation.
PREMISES GENERAL
INFORMATION
Are any wood or coal fired
stoves used in any
buildings?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any wood or coal fired stoves used?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves on the
premises.
PREMISES GENERAL
INFORMATION
If there are any alarms on
the premises, indicate the
type of alarm and the floors
protected.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any burglar and / or fire alarms?.
PREMISES GENERAL
INFORMATION
Burglary Alarm
Check the box (if applicable): Indicates the alarm type is a burglar alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES GENERAL
INFORMATION
Fire Alarm
Check the box (if applicable): Indicates the alarm type is a fire alarm.
PREMISES GENERAL
INFORMATION
Type of Alarm, indicate
floors protected by the
alarm
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
ACORD 402 (2014/12) rev. 04-29-2014
Page 42 of 45
PREMISES GENERAL
INFORMATION
3. Are there any other
protective devices?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any other protective devices?.
PREMISES GENERAL
INFORMATION
Remarks
Enter text: An explanation of other protective devices used.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Loss payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other checkbox
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Other Field
Enter text: The description of the other type of additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Certificate Checkbox
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Name
Enter text: The additional interest's full name.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter text: The additional interest's mailing address city name.
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ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Interest in Item Number -
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTERESTS/CERTIFICATE
RECIPIENTS
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.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
ACORD 402 (2014/12) rev. 04-29-2014
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SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
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.
ACORD 402 (2014/12) rev. 04-29-2014
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