ACORD 404 (2014/12) - Agriculture Liability Section
ACORD 404 (2014/12) - Agriculture Liability Section
ACORD 404, Agriculture Liability Section, is designed to handle the basic underwriting needs for agriculture liability exposures. If the risk is to be
provided with commercial general liability rather than farm liability coverage, use ACORD 125, Commercial Insurance Application, and ACORD
126, Commercial General Liability Section. For umbrella or excess liability coverage, use either ACORD 83, Personal Umbrella Application, or
ACORD 131, Umbrella / Excess Section.
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, it is still
important to complete it. Many companies separate the applications by subline 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
Loc #
Enter number: The producer assigned number of the location.
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
Applicant / First Named
Insured
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
Rnwl
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
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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)
LIABILITY COVERAGE
Bodily Injury and Property
Damage Liability - Each
Occurrence Limit
Enter limit: The each occurrence limit amount for bodily injury and property damage coverage.
LIABILITY COVERAGE
Bodily Injury and Property
Damage Liability - General
Aggregate Limit
Enter limit: The general aggregate limit amount for bodily injury and property damage coverage.
LIABILITY COVERAGE
Personal and Advertising
Injury Liability - Each
Occurrence Limit
Enter limit: The each occurrence limit amount for personal and advertising injury coverage.
LIABILITY COVERAGE
Personal and Advertising
Injury Liability - General
Aggregate Limit
Enter limit: The general aggregate limit amount for personal and advertising injury coverage.
LIABILITY COVERAGE
Medical Payments - Any One
Person
Enter limit: The each person limit amount for medical payments coverage.
LIABILITY COVERAGE
Medical Payments - Each
Occurrence Limit
Enter limit: The each occurrence limit amount for medical payments coverage.
LIABILITY COVERAGE
Property Damage Liability
Fire Damage Limit - Any One
Fire
Enter limit: The any one fire limit amount for fire damage coverage.
LIABILITY COVERAGE
Additional Coverage -
Damage to Property of
Others
Enter limit: The limit amount for damage to property of others coverage.
LIABILITY COVERAGE
Other Coverages One
Enter code: The code for the coverage.
LIABILITY COVERAGE
Enter text: The description of the coverage.
LIABILITY COVERAGE
Other Coverages Limit One
Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE
Other Coverages Two
Enter code: The code for the coverage.
LIABILITY COVERAGE
Enter text: The description of the coverage.
LIABILITY COVERAGE
Other Coverages Limit Two
Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE
Other Coverages Three
Enter code: The code for the coverage.
LIABILITY COVERAGE
Enter text: The description of the coverage.
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LIABILITY COVERAGE
Other Coverages Limit
Three
Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE
Farm Personal Liability Yes
Check the box (if applicable): Indicates farm personal liability coverage is requested.
LIABILITY COVERAGE
Farm Personal Liability No
Check the box (if applicable): Indicates farm personal liability coverage is not requested.
LIABILITY COVERAGE
Farm Commercial Liability
Yes
Check the box (if applicable): Indicates farm commercial liability coverage is requested.
LIABILITY COVERAGE
Farm Commercial Liability
No
Check the box (if applicable): Indicates farm commercial liability coverage is not requested.
LIABILITY COVERAGE
Personal Liability Coverage
Yes
Check the box (if applicable): Indicates personal liability coverage is requested.
LIABILITY COVERAGE
Personal Liability Coverage
No
Check the box (if applicable): Indicates personal liability coverage is not requested.
LIABILITY COVERAGE
Name and Address of
Insured(s) One
Enter text: The additional interest's full name.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address line one.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address line two.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address city name.
LIABILITY COVERAGE
Enter code: The additional interest's mailing address state or province code.
LIABILITY COVERAGE
Enter code: The additional interest's mailing address postal code.
LIABILITY COVERAGE
Name and Address of
Insured(s) Two
Enter text: The additional interest's full name.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address line one.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address line two.
LIABILITY COVERAGE
Enter text: The additional interest's mailing address city name.
LIABILITY COVERAGE
Enter code: The additional interest's mailing address state or province code.
LIABILITY COVERAGE
Enter code: The additional interest's mailing address postal code.
COVERAGE
Initial Farm Premises Acres:
Enter number: The number of acres of the initial farm premises.
COVERAGE
Initial Farm Premises Acres:
- Basis/Rate
Enter code: The premium basis code for the initial farm premises.
COVERAGE
Enter rate: The rate for the initial farm premises.
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COVERAGE
Initial Farm Premises Acres:
- Premium
Enter amount: The premium amount for the initial farm premises.
COVERAGE
Total Acreage for all
locations, including initial
farm premises
Enter number: The total acreage for all locations, including the initial farm premises.
COVERAGE
Total Acreage for all
locations, including initial
farm premises: - Basis/Rate
Enter code: The premium basis code for all locations, including the initial farm premises.
COVERAGE
Enter rate: The rate for all locations, including the initial farm premises.
COVERAGE
Total Acreage for all
locations, including initial
farm premises: - Premium
Enter amount: The premium amount for all locations, including the initial farm premises.
COVERAGE
Additional Farm Premises
Maintained By Named
Insured - Loc #
Enter identifier: The producer assigned location identifier for the additional farm premises
maintained by the named insured.
COVERAGE
Additional Farm Premises
Maintained By Named
Insured - Basis/Rate
Enter code: The premium basis code for the additional farm premises maintained by the named
insured.
COVERAGE
Enter rate: The rate for the additional farm premises maintained by the named insured.
COVERAGE
Additional Farm Premises
Maintained By Named
Insured - Premium
Enter amount: The premium amount for the additional farm premises maintained by the named
insured.
COVERAGE
Additional Non-Farm
Premises Occupied by
Insured - Seasonal
Check the box (if applicable): Indicates the additional non-farm premises occupied by the
insured is seasonal.
COVERAGE
Additional Non-Farm
Premises Occupied by
Insured - Permanent
Check the box (if applicable): Indicates if the additional non-farm premises occupied by the
insured is permanent.
COVERAGE
Additional Non-Farm
Premises Occupied by
Insured - Loc #
Enter identifier: The producer assigned location identifier for the additional non-farm premises
occupied by the insured.
COVERAGE
Additional Non-Farm
Premises Occupied by
Insured - Basis/Rate
Enter code: The premium basis code for additional non-farm premises occupied by the insured.
COVERAGE
Enter rate: The rate for additional non-farm premises occupied by the insured.
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COVERAGE
Additional Non-Farm
Premises Occupied by
Insured - Premium
Enter amount: The premium amount for additional non-farm premises occupied by the insured.
COVERAGE
Additional Residence
Rented to Others - #
Families
Enter number: The number of families in the additional residence rented to others.
COVERAGE
Additional Residence
Rented to Others - LOC #
Enter identifier: The producer assigned location identifier for the additional residence rented to
others.
COVERAGE
Additional Residence
Rented to Others -
Basis/Rate
Enter code: The premium basis code for the additional residence rented to others.
COVERAGE
Enter rate: The rate for the additional residence rented to others.
COVERAGE
Additional Residence
Rented to Others - Premium
Enter amount: The premium amount for additional residence rented to others.
COVERAGE
Custom Farming Receipts -
Receipts $
Enter amount: The receipts amount for custom farming.
COVERAGE
Custom Farming Receipts -
Basis/Rate
Enter code: The premium basis code for custom farming.
COVERAGE
Enter rate: The rate for custom farming.
COVERAGE
Custom Farming Receipts -
Premium
Enter amount: The premium amount for custom farming.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
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COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
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COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Activity
Enter text: The description of the incidental business activity (i.e., roadside stands, day care,
hunting and fishing, etc.).
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COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Receipts
Enter amount: The receipts amount for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Basis/Rate
Enter code: The premium basis code for the incidental business activity.
COVERAGE
Enter rate: The rate for the incidental business activity.
COVERAGE
Incidental Business
Activities (i.e., Roadside
Stands, Day Care, Hunting
and Fishing) - Premiums
Enter amount: The premium amount for the incidental business activity.
COVERAGE
Limited Farm Pollution
Liability - Limit
Enter limit: The limit amount for limited farm pollution liability.
COVERAGE
Limited Farm Pollution
Liability - Basis/Rate
Enter code: The premium basis code for limited farm pollution liability.
COVERAGE
Enter rate: The rate for limited farm pollution liability.
COVERAGE
Limited Farm Pollution
Liability - Premium
Enter amount: The premium amount for limited farm pollution liability.
COVERAGE
Contingent Liability for Crop
Dusting by Independent
Aircraft - Cost
Enter amount: The cost for contingent liability for crop dusting by independent aircraft.
COVERAGE
Contingent Liability for Crop
Dusting by Independent
Aircraft - Limit
Enter limit: The limit amount for contingent liability for crop dusting by independent aircraft.
COVERAGE
Contingent Liability for Crop
Dusting by Independent
Aircraft - Basis/Rate
Enter code: The premium basis code for contingent liability for crop dusting by independent
aircraft.
COVERAGE
Enter rate: The rate for contingent liability for crop dusting by independent aircraft.
COVERAGE
Contingent Liability for Crop
Dusting by Independent
Aircraft - Premium
Enter amount: The premium amount for contingent liability for crop dusting by independent
aircraft.
COVERAGE
Animal Collision - Limit Per
Head
Enter limit: The per head limit for animal collision coverage.
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COVERAGE
Animal Collision - # of Head
Enter number: The head count for animal collision coverage.
COVERAGE
Animal Collision -
Basis/Rate
Enter code: The premium basis code for animal collision coverage.
COVERAGE
Enter rate: The rate for animal collision coverage.
COVERAGE
Animal Collision - Premium
Enter amount: The premium amount for animal collision coverage.
COVERAGE
Employers Liability - # of
Person Months
Enter number: The number of persons per month for employers liability coverage.
COVERAGE
Employers Liability - # Full
Time Employees
Enter number: The number of full time employees for employers liability coverage.
COVERAGE
Employers Liability - # Part
Time Employees
Enter number: The number of part time employees for employers liability coverage.
COVERAGE
Employers Liability - Total
Payroll
Enter amount: The total payroll amount for employers liability coverage.
COVERAGE
Employers Liability -
Basis/Rate
Enter code: The premium basis code for employers liability coverage.
COVERAGE
Enter rate: The rate for employers liability coverage.
COVERAGE
Employers Liability -
Premium
Enter amount: The premium amount for employers liability coverage.
COVERAGE
Other Coverage
Enter code: The code for the coverage.
COVERAGE
Enter text: The description of the coverage.
COVERAGE
Other Coverages -
Basis/Rate
Enter code: The premium basis code for the coverage.
COVERAGE
Enter rate: The rate for the coverage.
COVERAGE
Other Coverages - Premium
Enter amount: The premium amount for the coverage.
COVERAGE
Other Coverage
Enter code: The code for the coverage.
COVERAGE
Enter text: The description of the coverage.
COVERAGE
Other Coverages -
Basis/Rate
Enter code: The premium basis code for the coverage.
COVERAGE
Enter rate: The rate for the coverage.
COVERAGE
Other Coverages - Premium
Enter amount: The premium amount for the coverage.
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COVERAGE
Other Coverage
Enter code: The code for the coverage.
COVERAGE
Enter text: The description of the coverage.
COVERAGE
Other Coverages -
Basis/Rate
Enter code: The premium basis code for the coverage.
COVERAGE
Enter rate: The rate for the coverage.
COVERAGE
Other Coverages - Premium
Enter amount: The premium amount for the coverage.
COVERAGE
Total Premium
Enter amount: The premium amount for the farm liability line of business.
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.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Additional Interest One
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Loss Payee One
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Mortgagee One
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Lienholder One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Employee as Lessor One
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Other Interest One
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Describe Other Interest One
Enter text: The description of the other type of additional interest.
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ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Name and Address One
Enter text: The additional interest's full name.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address line one.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address city name.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Reference / Loan # One
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Certificate Required One
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Interest In Item Number -
Location One
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Building One
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Vehicle One
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Boat One
Enter number: The producer assigned number of the boat which has an additional interest.
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ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Scheduled Item Number
One
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Other One
Enter text: The description of the item which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Item Description One
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.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Additional Interest Two
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Loss Payee Two
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Mortgagee Two
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Lienholder Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Employee as Lessor Two
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Other Interest Two
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Describe Other Interest Two
Enter text: The description of the other type of additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Name and Address Two
Enter text: The additional interest's full name.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address line one.
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ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address line two.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter text: The additional interest's mailing address city name.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Enter code: The additional interest's mailing address postal code.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Reference / Loan # Two
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Certificate Required Two
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Interest In Item Number -
Location Two
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Building Two
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Vehicle Two
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Boat Two
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Scheduled Item Number
Two
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Other Two
Enter text: The description of the item which has an additional interest.
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ADDITIONAL
INTEREST/CERTIFICATE
RECIPIENT
Item Description Two
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.
GENERAL INFORMATION
1. Does applicant build,
repair or design machinery,
equipment or systems for
anyone at a charge or
rent/lease equipment to
others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant build, repair or design machinery, equipment or systems for anyone at a Charge
or Fee?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant builds, repairs or designs machinery,
equip mentor systems for anyone at a charge.
GENERAL INFORMATION
2. Does applicant rent or
lease equipment to others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant rent or lease equipment to others?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant rents or leases equipment to others.
GENERAL INFORMATION
3. Does any machinery or
equipment owned or
operated by the applicant no
conform to applicable safety
regulations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does machinery or equipment owned or operated by the applicant not conform to applicable
safety regulations?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any machinery or equipment owned or operated by the
applicant does not conform to applicable safety regulations.
GENERAL INFORMATION
4. Does applicant mix,
process, slaughter, butcher
or otherwise prepare for any
end consumer his or any
other grower's product?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant mix, process, slaughter, butcher or otherwise prepare for any end consumer
his or any other grower's product?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant mixes, processes, slaughters, butchers or
otherwise prepares for any end consumer his or any other growers product?
GENERAL INFORMATION
5. Does applicant handle
any product, such as seed,
fertilizer, sprays, etc. for
resale?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant handle any product, such as seed, fertilizer, sprays, etc. for resale?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant handles any products, such as seed,
fertilizer, sprays, etc. for resale.
ACORD 404 (2014/12) rev. 04-29-2014
Page 14 of 19
GENERAL INFORMATION
6. Are any contract or
service operations
performed for others such
as snow removal, tiling,
excavating or ditching?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any contract or service operations performed for others such as snow removal, tilling,
excavating, or ditching?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any contract or service operations are performed for
others such as snow removal, tiling (e.g. field/ drain tile), excavating or ditching.
GENERAL INFORMATION
7. Is there any unusual
hazard such as (but not
limited to) open dump pits,
silage pits, sump holes,
ponds, lakes or reservoirs?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any unusual hazards such as (but not limited to) dump pits, silage pits, gravel pits, rock
quarries, sump holes, ponds, lakes or reservoirs?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there are any unusual hazards such as (but not limited
to) open dump pits, manure pits, sump holes, ponds, lakes or reservoirs.
GENERAL INFORMATION
8. Is there an airstrip on the
premises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there an airstrip on the premises?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is an airstrip on the premises.
GENERAL INFORMATION
9. Are any hold harmless
or indemnifying
agreements in effect?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any Hold Harmless or Indemnifying agreements in effect?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there are any hold harmless or indemnifying
agreements in effect.
GENERAL INFORMATION
10. Is there a swimming
pool on premises?
Enter code: Indicates the response to the question, Is there a swimming pool on the
premises?.
GENERAL INFORMATION
If Yes, is it in ground?
Enter Y for a Yes response. Input N for No response. Indicates if the swimming pool is in the
ground.
GENERAL INFORMATION
Is it fenced?
Enter Y for a Yes response. Input N for No response. Indicates if the swimming pool is
surrounded by a fence that is an approved height.
GENERAL INFORMATION
Is there a diving board?
Enter Y for a Yes response. Input N for No response. Indicates if the swimming pool has a
diving board.
GENERAL INFORMATION
Is there a slide?
Enter Y for a Yes response. Input N for No response. Indicates if the swimming pool has a
slide.
GENERAL INFORMATION
Depth:
Enter number: The maximum depth of the swimming pool in feet.
GENERAL INFORMATION
11. Is there any watercraft
exposure?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any watercraft exposure?.
ACORD 404 (2014/12) rev. 04-29-2014
Page 15 of 19
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is a watercraft exposure.
GENERAL INFORMATION
12. Is there any snowmobile
exposure?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any snowmobile exposure?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is a snowmobile exposure on the premises.
GENERAL INFORMATION
13. Is there any ATV or dirt
bike exposure?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any ATV or dirt bike exposure?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is an ATV or dirt bike exposure on the premises.
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).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
14. Is there a trampoline on
the premises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a trampoline on the premises?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is a trampoline on the premises.
GENERAL INFORMATION
15. Does applicant serve on
any boards for
remuneration?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant serve on any boards for remuneration?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant serves on any boards for remuneration.
GENERAL INFORMATION
16. Are any premises used
by others for hunting,
fishing or other recreational
activities?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any premises used by others for hunting, fishing or other recreational activities?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any premises is used by others for hunting, fishing or
other recreation activities.
GENERAL INFORMATION
17. Does applicant have any
potentially dangerous
animals or exotic pets?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant have any potentially dangerous animals or exotic pets?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has any potentially dangerous animals or
exotic pets.
ACORD 404 (2014/12) rev. 04-29-2014
Page 16 of 19
LIVESTOCK/DAIRY
INFORMATION
18. Are any livestock
present on premises or are
any livestock anticipated
during the year?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any livestock present on premises or are any livestock anticipated during the year?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether any livestock are present on the premises or are
anticipated during the year.
LIVESTOCK/DAIRY
INFORMATION
19. Are livestock kept in
areas that are not
adequately fenced and
maintained in a good state
of repair? Check the
applicable box to indicate if
the premises is in an open
range area or a closed range
area.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If livestock is kept, are all areas adequately fenced and are fences in a good state of repair?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether livestock are kept in areas not adequately fenced and
maintained in a good state of repair.
LIVESTOCK/DAIRY
INFORMATION
Premises is in Open Range
Area
Check the box (if applicable): Indicates the premises is in an open range area.
LIVESTOCK/DAIRY
INFORMATION
Premises is in Closed
Range Area
Check the box (if applicable): Indicates the premises is in a closed range area.
LIVESTOCK/DAIRY
INFORMATION
20. Are livestock near any
public road or highway?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are livestock near any public road or highway?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether any livestock are near any public road or highway.
LIVESTOCK/DAIRY
INFORMATION
21. Does insured own,
board, race, breed or rent
horses?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does insured own, board, race, breed or rent horses?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether the insured owns, boards, races, breeds or rents
horses.
LIVESTOCK/DAIRY
INFORMATION
22. Any non-owned horses
on any insured premises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any non-owned horses on any insured premises?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether there are any non-owned horses on any insured
premises.
ACORD 404 (2014/12) rev. 04-29-2014
Page 17 of 19
LIVESTOCK/DAIRY
INFORMATION
23. If cattle are present on
premises, do you now or
have you in the past
supplemented cattle feed
with bone meal, protein
supplements or animal
by-products?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If cattle are present on premises, do you now or have you in the past supplemented cattle feed
with bone meal, protein supplements or animal by-products?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has ever, now or in the past,
supplemented cattle feed with bone meal, protein supplements or animal by-products if cattle
are present on the premises.
LIVESTOCK/DAIRY
INFORMATION
24. Number of animals
milked:
Enter number: The number of animals milked.
LIVESTOCK/DAIRY
INFORMATION
25. Is there any processing
of milk?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If dairy farm, is there any processing of milk?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether there is any processing of milk on the premises.
LIVESTOCK/DAIRY
INFORMATION
26. Are there any retail
sales of milk products to
public?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
If dairy farm, is there any retail sales of milk products to public?.
LIVESTOCK/DAIRY
INFORMATION
Remarks
Enter text: An explanation as to whether there are any retail sales of milk products to the public.
LIVESTOCK/DAIRY
INFORMATION
Receipts
Enter amount: The total amount of receipts gained from the sale of milk products.
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 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).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
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.
ACORD 404 (2014/12) rev. 04-29-2014
Page 18 of 19
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (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 404 (2014/12) rev. 04-29-2014
Page 19 of 19