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ACORD 407 (2007/09) 1 of 20
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 05/08/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 407 (2007/09) |
Livestock Mortality Section |
The title of the form. ACORD 407, Livestock Mortality Section, is used as attachment to ACORD 401, Agriculture Application, to apply for insurance coverage on livestock mortality, livestock theft, major medical, surgery, loss of use, and named and optional perils |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION SECTION |
Contact Name |
Enter text: The name of the individual at the producer's establishment that is the primary contact. |
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IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION SECTION |
FAX |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION SECTION |
E-Mail Address |
Enter text: The producer's contact person e-mail address. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION SECTION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
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. |
ACORD 407 (2007/09) 2 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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IDENTIFICATION SECTION |
Underwriter |
Enter text: The company underwriter (or other company staff person) that this form should be directed to. |
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IDENTIFICATION SECTION |
Underwriter Office |
Enter identifier: The company underwriting office that this application should be directed to. |
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IDENTIFICATION SECTION |
Policies or Program Requested |
Enter code: The product code of the insurer for the policy. |
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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. |
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IDENTIFICATION SECTION |
Account No. |
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. |
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APPLICANT INFORMATION |
Applicant Name |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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APPLICANT INFORMATION |
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Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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APPLICANT INFORMATION |
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Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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APPLICANT INFORMATION |
Individual |
Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual". |
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APPLICANT INFORMATION |
Partnership |
Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership". |
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APPLICANT INFORMATION |
Corporation |
Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation". |
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APPLICANT INFORMATION |
Joint Venture |
Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture". |
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APPLICANT INFORMATION |
Other |
Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form. |
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APPLICANT INFORMATION |
Describe other |
Enter text: The description of the legal entity if not listed on the form. |
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APPLICANT INFORMATION |
Years in business |
Enter number: The number of years the insured has been in business. |
ACORD 407 (2007/09) 3 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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APPLICANT INFORMATION |
NAICS |
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity (if known). |
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APPLICANT INFORMATION |
Federal ID# |
Enter identifier: The tax identifier of the named insured. |
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APPLICANT INFORMATION |
Mailing address |
Enter text: The named insured's mailing address line one. |
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APPLICANT INFORMATION |
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Enter text: The named insured's mailing address line two. |
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APPLICANT INFORMATION |
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Enter text: The named insured's mailing address city name. |
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APPLICANT INFORMATION |
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Enter code: The named insured's mailing address state or province code. |
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APPLICANT INFORMATION |
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Enter code: The named insured's mailing address postal code. |
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APPLICANT INFORMATION |
Contact Name |
Enter text: The full name of the contact. |
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APPLICANT INFORMATION |
Phone (A/C, No, Ext) |
Enter number: The named insured's primary phone number. |
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APPLICANT INFORMATION |
E-Mail Address |
Enter text: The named insured's primary e-mail address. |
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ANIMAL INFORMATION |
Animal # One |
Enter identifier: The producer assigned identifier for the animal. |
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ANIMAL INFORMATION |
LOC # One |
Enter number: The producer assigned number of the location. |
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ANIMAL INFORMATION |
Bldg # One |
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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ANIMAL INFORMATION |
Name of Animal One |
Enter text: The full name of the animal. |
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ANIMAL INFORMATION |
Sire One |
Enter text: The name of the animal's sire (father). |
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ANIMAL INFORMATION |
Dam One |
Enter text: The name of the animal's dam (mother). |
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ANIMAL INFORMATION |
Registration # One |
Enter identifier: The registration number of the animal. |
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ANIMAL INFORMATION |
Sex One |
Enter code: The gender of the animal. |
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ANIMAL INFORMATION |
Birth Date One |
Enter date: The birth date of the animal. |
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ANIMAL INFORMATION |
Breed One |
Enter text: The breed of the animal. |
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ANIMAL INFORMATION |
Use & Function One |
Enter text: The description of the use / function of the animal. |
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ANIMAL INFORMATION |
Acquired From One |
Enter text: The name of the person or organization the animal was acquired from. |
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ANIMAL INFORMATION |
Purchase Price One |
Enter amount: The purchase price of the animal. |
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ANIMAL INFORMATION |
Payment Method - Cash One |
Check the box (if applicable): Indicates the animal was purchased with cash. |
ACORD 407 (2007/09) 4 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ANIMAL INFORMATION |
Payment Method - Check One |
Check the box (if applicable): Indicates the animal was purchased with a check. |
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ANIMAL INFORMATION |
Payment Method - Other One |
Check the box (if applicable): Indicates the animal was purchased with a method other than those listed. |
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ANIMAL INFORMATION |
Describe Payment Method - Other One |
Enter text: The payment method used to purchase the animal. |
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ANIMAL INFORMATION |
Acquisition Method - Auction One |
Check the box (if applicable): Indicates the animal was acquired at an auction. |
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ANIMAL INFORMATION |
Acquisition Method - Private One |
Check the box (if applicable): Indicates the animal was acquired through private means. |
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ANIMAL INFORMATION |
Acquisition Method - Homebred One |
Check the box (if applicable): Indicates the animal was homebred. |
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ANIMAL INFORMATION |
Acquisition Method - Other One |
Check the box (if applicable): Indicates the animal was acquired in a method other than those listed. |
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ANIMAL INFORMATION |
Acquisition Method - Describe other One |
Enter text: The method the animal was acquired. |
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ANIMAL INFORMATION |
Date Acquired One |
Enter date: The date the animal was acquired. |
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ANIMAL INFORMATION |
Accommodations - Stall One |
Check the box (if applicable): Indicates the animal's accommodations is a stall. |
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ANIMAL INFORMATION |
Accommodations - Corral One |
Check the box (if applicable): Indicates the animal's accommodations is a corral. |
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ANIMAL INFORMATION |
Accommodations - Open Pasture One |
Check the box (if applicable): Indicates the animal's accommodations is an open pasture. |
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ANIMAL INFORMATION |
Accommodations - Other |
Check the box (if applicable): Indicates the animal's accommodations is other than those listed. |
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ANIMAL INFORMATION |
Accommodations - Other Description |
Enter text: The description of the animal's accommodations. |
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ANIMAL INFORMATION |
Number of Acres One |
Enter number: The number of acres the animal has access to. |
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ANIMAL INFORMATION |
Animal # Two |
Enter identifier: The producer assigned identifier for the animal. |
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ANIMAL INFORMATION |
LOC # Two |
Enter number: The producer assigned number of the location. |
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ANIMAL INFORMATION |
Bldg # Two |
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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ANIMAL INFORMATION |
Name of Animal Two |
Enter text: The full name of the animal. |
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ANIMAL INFORMATION |
Sire Two |
Enter text: The name of the animal's sire (father). |
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ANIMAL INFORMATION |
Dam Two |
Enter text: The name of the animal's dam (mother). |
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ANIMAL INFORMATION |
Registration # Two |
Enter identifier: The registration number of the animal. |
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ANIMAL INFORMATION |
Sex Two |
Enter code: The gender of the animal. |
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ANIMAL INFORMATION |
Birth Date Two |
Enter date: The birth date of the animal. |
ACORD 407 (2007/09) 5 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ANIMAL INFORMATION |
Breed Two |
Enter text: The breed of the animal. |
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ANIMAL INFORMATION |
Use & Function Two |
Enter text: The description of the use / function of the animal. |
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ANIMAL INFORMATION |
Acquired From Two |
Enter text: The name of the person or organization the animal was acquired from. |
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ANIMAL INFORMATION |
Purchase Price Two |
Enter amount: The purchase price of the animal. |
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ANIMAL INFORMATION |
Payment Method - Cash Two |
Check the box (if applicable): Indicates the animal was purchased with cash. |
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ANIMAL INFORMATION |
Payment Method - Check Two |
Check the box (if applicable): Indicates the animal was purchased with a check. |
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ANIMAL INFORMATION |
Payment Method - Other Two |
Check the box (if applicable): Indicates the animal was purchased with a method other than those listed. |
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ANIMAL INFORMATION |
Describe Payment Method - Other Two |
Enter text: The payment method used to purchase the animal. |
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ANIMAL INFORMATION |
Acquisition Method - Auction Two |
Check the box (if applicable): Indicates the animal was acquired at an auction. |
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ANIMAL INFORMATION |
Acquisition Method - Private Two |
Check the box (if applicable): Indicates the animal was acquired through private means. |
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ANIMAL INFORMATION |
Acquisition Method - Homebred Two |
Check the box (if applicable): Indicates the animal was homebred. |
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ANIMAL INFORMATION |
Acquisition Method - Other Two |
Check the box (if applicable): Indicates the animal was acquired in a method other than those listed. |
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ANIMAL INFORMATION |
Acquisition Method - Describe other Two |
Enter text: The method the animal was acquired. |
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ANIMAL INFORMATION |
Date Acquired Two |
Enter date: The date the animal was acquired. |
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ANIMAL INFORMATION |
Accommodations - Stall Two |
Check the box (if applicable): Indicates the animal's accommodations is a stall. |
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ANIMAL INFORMATION |
Accommodations - Corral Two |
Check the box (if applicable): Indicates the animal's accommodations is a corral. |
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ANIMAL INFORMATION |
Accommodations - Open Pasture Two |
Check the box (if applicable): Indicates the animal's accommodations is an open pasture. |
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ANIMAL INFORMATION |
Accommodations - Other |
Check the box (if applicable): Indicates the animal's accommodations is other than those listed. |
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ANIMAL INFORMATION |
Accommodations - Other Description |
Enter text: The description of the animal's accommodations. |
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ANIMAL INFORMATION |
Number of Acres Two |
Enter number: The number of acres the animal has access to. |
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ANIMAL INFORMATION |
Animal # Three |
Enter identifier: The producer assigned identifier for the animal. |
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ANIMAL INFORMATION |
LOC # Three |
Enter number: The producer assigned number of the location. |
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ANIMAL INFORMATION |
Bldg # Three |
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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ANIMAL INFORMATION |
Name of Animal Three |
Enter text: The full name of the animal. |
ACORD 407 (2007/09) 6 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ANIMAL INFORMATION |
Sire Three |
Enter text: The name of the animal's sire (father). |
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ANIMAL INFORMATION |
Dam Three |
Enter text: The name of the animal's dam (mother). |
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ANIMAL INFORMATION |
Registration # Three |
Enter identifier: The registration number of the animal. |
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ANIMAL INFORMATION |
Sex Three |
Enter code: The gender of the animal. |
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ANIMAL INFORMATION |
Birth Date Three |
Enter date: The birth date of the animal. |
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ANIMAL INFORMATION |
Breed Three |
Enter text: The breed of the animal. |
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ANIMAL INFORMATION |
Use & Function Three |
Enter text: The description of the use / function of the animal. |
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ANIMAL INFORMATION |
Acquired From Three |
Enter text: The name of the person or organization the animal was acquired from. |
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ANIMAL INFORMATION |
Purchase Price Three |
Enter amount: The purchase price of the animal. |
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ANIMAL INFORMATION |
Payment Method - Cash Three |
Check the box (if applicable): Indicates the animal was purchased with cash. |
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ANIMAL INFORMATION |
Payment Method - Check Three |
Check the box (if applicable): Indicates the animal was purchased with a check. |
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ANIMAL INFORMATION |
Payment Method - Other Three |
Check the box (if applicable): Indicates the animal was purchased with a method other than those listed. |
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ANIMAL INFORMATION |
Describe Payment Method - Other Three |
Enter text: The payment method used to purchase the animal. |
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ANIMAL INFORMATION |
Acquisition Method - Auction Three |
Check the box (if applicable): Indicates the animal was acquired at an auction. |
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ANIMAL INFORMATION |
Acquisition Method - Private Three |
Check the box (if applicable): Indicates the animal was acquired through private means. |
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ANIMAL INFORMATION |
Acquisition Method - Homebred Three |
Check the box (if applicable): Indicates the animal was homebred. |
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ANIMAL INFORMATION |
Acquisition Method - Other Three |
Check the box (if applicable): Indicates the animal was acquired in a method other than those listed. |
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ANIMAL INFORMATION |
Acquisition Method - Describe other Three |
Enter text: The method the animal was acquired. |
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ANIMAL INFORMATION |
Date Acquired Three |
Enter date: The date the animal was acquired. |
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ANIMAL INFORMATION |
Accommodations - Stall Three |
Check the box (if applicable): Indicates the animal's accommodations is a stall. |
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ANIMAL INFORMATION |
Accommodations - Corral Three |
Check the box (if applicable): Indicates the animal's accommodations is a corral. |
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ANIMAL INFORMATION |
Accommodations - Open Pasture Three |
Check the box (if applicable): Indicates the animal's accommodations is an open pasture. |
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ANIMAL INFORMATION |
Accommodations - Other |
Check the box (if applicable): Indicates the animal's accommodations is other than those listed. |
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ANIMAL INFORMATION |
Accommodations - Other Description |
Enter text: The description of the animal's accommodations. |
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ANIMAL INFORMATION |
Number of Acres Three |
Enter number: The number of acres the animal has access to. |
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ANIMAL INFORMATION |
Animal # Four |
Enter identifier: The producer assigned identifier for the animal. |
ACORD 407 (2007/09) 7 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ANIMAL INFORMATION |
LOC # Four |
Enter number: The producer assigned number of the location. |
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ANIMAL INFORMATION |
Bldg # Four |
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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ANIMAL INFORMATION |
Name of Animal Four |
Enter text: The full name of the animal. |
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ANIMAL INFORMATION |
Sire Four |
Enter text: The name of the animal's sire (father). |
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ANIMAL INFORMATION |
Dam Four |
Enter text: The name of the animal's dam (mother). |
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ANIMAL INFORMATION |
Registration # Four |
Enter identifier: The registration number of the animal. |
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ANIMAL INFORMATION |
Sex Four |
Enter code: The gender of the animal. |
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ANIMAL INFORMATION |
Birth Date Four |
Enter date: The birth date of the animal. |
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ANIMAL INFORMATION |
Breed Four |
Enter text: The breed of the animal. |
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ANIMAL INFORMATION |
Use & Function Four |
Enter text: The description of the use / function of the animal. |
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ANIMAL INFORMATION |
Acquired From Four |
Enter text: The name of the person or organization the animal was acquired from. |
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ANIMAL INFORMATION |
Purchase Price Four |
Enter amount: The purchase price of the animal. |
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ANIMAL INFORMATION |
Payment Method - Cash Four |
Check the box (if applicable): Indicates the animal was purchased with cash. |
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ANIMAL INFORMATION |
Payment Method - Check Four |
Check the box (if applicable): Indicates the animal was purchased with a check. |
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ANIMAL INFORMATION |
Payment Method - Other Four |
Check the box (if applicable): Indicates the animal was purchased with a method other than those listed. |
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ANIMAL INFORMATION |
Describe Payment Method - Other Four |
Enter text: The payment method used to purchase the animal. |
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ANIMAL INFORMATION |
Acquisition Method - Auction Four |
Check the box (if applicable): Indicates the animal was acquired at an auction. |
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ANIMAL INFORMATION |
Acquisition Method - Private Four |
Check the box (if applicable): Indicates the animal was acquired through private means. |
|
ANIMAL INFORMATION |
Acquisition Method - Homebred Four |
Check the box (if applicable): Indicates the animal was homebred. |
|
ANIMAL INFORMATION |
Acquisition Method - Other Four |
Check the box (if applicable): Indicates the animal was acquired in a method other than those listed. |
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ANIMAL INFORMATION |
Acquisition Method - Describe other Four |
Enter text: The method the animal was acquired. |
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ANIMAL INFORMATION |
Date Acquired Four |
Enter date: The date the animal was acquired. |
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ANIMAL INFORMATION |
Accommodations - Stall Four |
Check the box (if applicable): Indicates the animal's accommodations is a stall. |
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ANIMAL INFORMATION |
Accommodations - Corral Four |
Check the box (if applicable): Indicates the animal's accommodations is a corral. |
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ANIMAL INFORMATION |
Accommodations - Open Pasture Four |
Check the box (if applicable): Indicates the animal's accommodations is an open pasture. |
ACORD 407 (2007/09) 8 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ANIMAL INFORMATION |
Accommodations - Other |
Check the box (if applicable): Indicates the animal's accommodations is other than those listed. |
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ANIMAL INFORMATION |
Accommodations - Other Description |
Enter text: The description of the animal's accommodations. |
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ANIMAL INFORMATION |
Number of Acres Four |
Enter number: The number of acres the animal has access to. |
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COVERAGES/LIMITS |
Animal # One |
Enter identifier: The producer assigned identifier for the animal. |
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COVERAGES/LIMITS |
Mortality One |
Enter limit: The limit amount for mortality coverage. |
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COVERAGES/LIMITS |
Options - Full Mortality One |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the full mortality option has been selected. |
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ADDITIONAL COVERAGES |
Options - Theft One |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the theft option has been selected. |
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ADDITIONAL COVERAGES |
Options - Named Perils One |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the named perils option has been selected. |
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ADDITIONAL COVERAGES |
Options - Optional Perils One |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the option perils option has been selected. |
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ADDITIONAL COVERAGES |
Major Medical One |
Enter limit: The limit amount for major medical coverage. |
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ADDITIONAL COVERAGES |
Surgery One |
Enter limit: The limit amount for surgery coverage. |
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ADDITIONAL COVERAGES |
Loss of Use One |
Enter limit: The limit amount for loss of use coverage. |
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ADDITIONAL COVERAGES |
Premium One |
Enter amount: The premium amount for the animal. |
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COVERAGES/LIMITS |
Animal # Two |
Enter identifier: The producer assigned identifier for the animal. |
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COVERAGES/LIMITS |
Mortality Two |
Enter limit: The limit amount for mortality coverage. |
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COVERAGES/LIMITS |
Options - Full Mortality Two |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the full mortality option has been selected. |
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ADDITIONAL COVERAGES |
Options - Theft Two |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the theft option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Named Perils Two |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the named perils option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Optional Perils Two |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the option perils option has been selected. |
|
ADDITIONAL COVERAGES |
Major Medical Two |
Enter limit: The limit amount for major medical coverage. |
ACORD 407 (2007/09) 9 of 20
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Section Name |
Field Name |
Field and/or Section Description |
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ADDITIONAL COVERAGES |
Surgery Two |
Enter limit: The limit amount for surgery coverage. |
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ADDITIONAL COVERAGES |
Loss of Use Two |
Enter limit: The limit amount for loss of use coverage. |
|
ADDITIONAL COVERAGES |
Premium Two |
Enter amount: The premium amount for the animal. |
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COVERAGES/LIMITS |
Animal # Three |
Enter identifier: The producer assigned identifier for the animal. |
|
COVERAGES/LIMITS |
Mortality Three |
Enter limit: The limit amount for mortality coverage. |
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COVERAGES/LIMITS |
Options - Full Mortality Three |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the full mortality option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Theft Three |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the theft option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Named Perils Three |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the named perils option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Optional Perils Three |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the option perils option has been selected. |
|
ADDITIONAL COVERAGES |
Major Medical Three |
Enter limit: The limit amount for major medical coverage. |
|
ADDITIONAL COVERAGES |
Surgery Three |
Enter limit: The limit amount for surgery coverage. |
|
ADDITIONAL COVERAGES |
Loss of Use Three |
Enter limit: The limit amount for loss of use coverage. |
|
ADDITIONAL COVERAGES |
Premium Three |
Enter amount: The premium amount for the animal. |
|
COVERAGES/LIMITS |
Animal # Four |
Enter identifier: The producer assigned identifier for the animal. |
|
COVERAGES/LIMITS |
Mortality Four |
Enter limit: The limit amount for mortality coverage. |
|
COVERAGES/LIMITS |
Options - Full Mortality Four |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the full mortality option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Theft Four |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the theft option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Named Perils Four |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the named perils option has been selected. |
|
ADDITIONAL COVERAGES |
Options - Optional Perils Four |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the option perils option has been selected. |
|
ADDITIONAL COVERAGES |
Major Medical Four |
Enter limit: The limit amount for major medical coverage. |
ACORD 407 (2007/09) 10 of 20
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Section Name |
Field Name |
Field and/or Section Description |
|
ADDITIONAL COVERAGES |
Surgery Four |
Enter limit: The limit amount for surgery coverage. |
|
ADDITIONAL COVERAGES |
Loss of Use Four |
Enter limit: The limit amount for loss of use coverage. |
|
ADDITIONAL COVERAGES |
Premium Four |
Enter amount: The premium amount for the animal. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
GENERAL INFORMATION |
Animal # One |
Enter identifier: The producer assigned identifier for the animal. |
|
GENERAL INFORMATION |
Coverage Code One |
Enter code: The code for the coverage. |
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GENERAL INFORMATION |
Coverage Description One |
Enter text: The description of the coverage being requested. |
|
GENERAL INFORMATION |
Limit 1 One |
Enter limit: The limit amount for the coverage. |
|
GENERAL INFORMATION |
Deductible One |
Enter deductible: The deductible amount for the coverage. |
|
GENERAL INFORMATION |
Additional Options 1 One |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 2 One |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Additional Options 3 One |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 4 One |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Premium One |
Enter amount: The premium amount for the coverage. |
|
GENERAL INFORMATION |
Animal # Two |
Enter identifier: The producer assigned identifier for the animal. |
|
GENERAL INFORMATION |
Coverage Code Two |
Enter code: The code for the coverage. |
|
GENERAL INFORMATION |
Coverage Description Two |
Enter text: The description of the coverage being requested. |
|
GENERAL INFORMATION |
Limit 1 Two |
Enter limit: The limit amount for the coverage. |
|
GENERAL INFORMATION |
Deductible Two |
Enter deductible: The deductible amount for the coverage. |
|
GENERAL INFORMATION |
Additional Options 1 Two |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 2 Two |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Additional Options 3 Two |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 4 Two |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Premium Two |
Enter amount: The premium amount for the coverage. |
|
GENERAL INFORMATION |
Animal # Three |
Enter identifier: The producer assigned identifier for the animal. |
|
GENERAL INFORMATION |
Coverage Code Three |
Enter code: The code for the coverage. |
|
GENERAL INFORMATION |
Coverage Description Three |
Enter text: The description of the coverage being requested. |
|
GENERAL INFORMATION |
Limit 1 Three |
Enter limit: The limit amount for the coverage. |
|
GENERAL INFORMATION |
Deductible Three |
Enter deductible: The deductible amount for the coverage. |
|
GENERAL INFORMATION |
Additional Options 1 Three |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 2 Three |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Additional Options 3 Three |
Enter code: The code for an option applicable to the coverage. |
ACORD 407 (2007/09) 11 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
Additional Options 4 Three |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Premium Three |
Enter amount: The premium amount for the coverage. |
|
GENERAL INFORMATION |
Animal # Four |
Enter identifier: The producer assigned identifier for the animal. |
|
GENERAL INFORMATION |
Coverage Code Four |
Enter code: The code for the coverage. |
|
GENERAL INFORMATION |
Coverage Description Four |
Enter text: The description of the coverage being requested. |
|
GENERAL INFORMATION |
Limit 1 Four |
Enter limit: The limit amount for the coverage. |
|
GENERAL INFORMATION |
Deductible Four |
Enter deductible: The deductible amount for the coverage. |
|
GENERAL INFORMATION |
Additional Options 1 Four |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 2 Four |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Additional Options 3 Four |
Enter code: The code for an option applicable to the coverage. |
|
GENERAL INFORMATION |
Additional Options 4 Four |
Enter text: The description of the option being requested. |
|
GENERAL INFORMATION |
Premium Four |
Enter amount: The premium amount for the coverage. |
|
GENERAL INFORMATION |
1. Does the amount of insurance applied for, on any specific animal, exceed the purchase price of that animal? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does the amount of insurance applied for, on any specific animal, exceed the purchase price of that animal?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
2. Does anyone other than you have an insurable interest in any animals listed? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Does anyone other than you have an insurable interest in any animals listed?". |
|
GENERAL INFORMATION |
Name One |
Enter text: The additional interest's full name. |
|
GENERAL INFORMATION |
Address One |
Enter text: The additional interest's mailing address line one. |
|
GENERAL INFORMATION |
|
Enter text: The additional interest's mailing address city name. |
|
GENERAL INFORMATION |
|
Enter code: The additional interest's mailing address state or province code. |
|
GENERAL INFORMATION |
|
Enter code: The additional interest's mailing address postal code. |
|
GENERAL INFORMATION |
Percent One |
Enter percentage: The percentage of ownership the additional interest has in the item. |
|
GENERAL INFORMATION |
Name Two |
Enter text: The additional interest's full name. |
|
GENERAL INFORMATION |
Address Two |
Enter text: The additional interest's mailing address line one. |
|
GENERAL INFORMATION |
|
Enter text: The additional interest's mailing address city name. |
|
GENERAL INFORMATION |
|
Enter code: The additional interest's mailing address state or province code. |
|
GENERAL INFORMATION |
|
Enter code: The additional interest's mailing address postal code. |
|
GENERAL INFORMATION |
Percent Two |
Enter percentage: The percentage of ownership the additional interest has in the item. |
ACORD 407 (2007/09) 12 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
3. Is any animal leased to others? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is any animal leased to others?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
4. Has any animal had any insurance not listed in the prior insurance section? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any animal had any insurance not listed in the prior insurance section?". |
|
GENERAL INFORMATION |
Company One |
Enter text: The name of the previous insurer. |
|
GENERAL INFORMATION |
Policy Number One |
Enter identifier: The policy number of the previous coverage. |
|
GENERAL INFORMATION |
Expiration Date One |
Enter date: The expiration date of the previous coverage. |
|
GENERAL INFORMATION |
Company Two |
Enter text: The name of the previous insurer. |
|
GENERAL INFORMATION |
Policy Number Two |
Enter identifier: The policy number of the previous coverage. |
|
GENERAL INFORMATION |
Expiration Date Two |
Enter date: The expiration date of the previous coverage. |
|
GENERAL INFORMATION |
5. Is there any other insurance on any animal included in this application? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is there any other insurance on any animal included in this application?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
6. Has any animal suffered any accident, disease or sickness, had colic/bloat or indigestion, or experienced birthing difficulties? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any animal suffered any accident, disease or sickness, had colic/bloat or indigestion, or experienced birthing difficulties?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
7. Are there any animals not wormed on a regular basis? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are there any animals that are not wormed on a regular schedule?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
8. Have all animals received all appropriate inoculations within the last year? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have all animals received all appropriate inoculations within the last year?". |
|
EQUINE INFORMATION |
Inoculation One |
Enter text: The description of the inoculation given to the animals. |
|
EQUINE INFORMATION |
Date One |
Enter date: The date the inoculation was given to the animals. |
|
EQUINE INFORMATION |
Inoculation Two |
Enter text: The description of the inoculation given to the animals. |
|
EQUINE INFORMATION |
Date Two |
Enter date: The date the inoculation was given to the animals. |
ACORD 407 (2007/09) 13 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
EQUINE INFORMATION |
Inoculation Three |
Enter text: The description of the inoculation given to the animals. |
|
EQUINE INFORMATION |
Date Three |
Enter date: The date the inoculation was given to the animals. |
|
EQUINE INFORMATION |
Inoculation Four |
Enter text: The description of the inoculation given to the animals. |
|
EQUINE INFORMATION |
Date Four |
Enter date: The date the inoculation was given to the animals. |
|
EQUINE INFORMATION |
9. Do you have a veterinarian or veterinary group that you use consistently? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you have a veterinarian group or veterinary group that you use consistently?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
10. Has any animal been examined or treated by a veterinarian for other than routine care? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any animal been examined or treated by a veterinarian for other than routine care?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
11. Is there now any contagious or infectious disease on any premises, or has there been during the last twelve (12) months? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is there now any contagious or infectious disease on any premises, or has there been during the last twelve (12) months?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
12. Have you lost any animals to death in the last three years? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you lost any animals to death in the last three years?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
13. Is any animal on medication or supplements? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is any animal on regular medication or supplements?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
14. Are any animals not observed or cared for on a daily basis? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Are any animals not observed and cared for on a daily basis?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
ACORD 407 (2007/09) 14 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
EQUINE INFORMATION |
1. Is any horse not healthy or sound for its intended use? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is any horse not healthy or sound the use intended?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
2. For all quarter horses, appaloosas or paint horses, does any horse have an ancestor known to carry HYPP? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "For all quarter horses, appaloosas or paint horses, does any horse have an ancestor known to carry HYPP?". |
|
EQUINE INFORMATION |
Name of Horse One |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
HYPP One |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the animal has an ancestor known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Status One |
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Name of Horse Two |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
HYPP Two |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the animal has an ancestor known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Status Two |
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Name of Horse Three |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
HYPP Three |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the animal has an ancestor known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Status Three |
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Name of Horse Four |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
HYPP Four |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the animal has an ancestor known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
Status Four |
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis (HYPP). |
|
EQUINE INFORMATION |
3. Provide full particulars of any past or present conformation problems; defects or ailments; illness or disease; lameness, injury or physical disability. |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. As used here, provide full particulars of any past or present conformation problems, defects or ailments, illness or disease, lameness, injury or physical disability, including but not limited to: OCD, neurological disorders, navicular disease and / or degenerative joint disease. |
ACORD 407 (2007/09) 15 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
EQUINE INFORMATION |
4. Has any horse been nerved or received any surgical treatment for lameness? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any horse been nerved or received any surgical treatment for lameness?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
5. Has any horse undergone diagnostic ultrasounds, x-rays or bone scans? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any horse undergone diagnostic ultrasounds, X-rays or bone scans?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
6. Has any horse received any joint injections, any type of medication, long or short term, or any preventative treatments in the last twelve (12) months? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any horse received any joint injections, any type of medication, long or short term, or any preventative treatments in the last twelve (12) months?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
7. Has any horse been treated for hoof problems, founder/laminitis, or rotation of the coffin bone? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any horse been treated for hoof problems, founder/laminitis, or rotation of the coffin bone?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
EQUINE INFORMATION |
8. Is any mare in foal? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is any mare in foal?". |
|
EQUINE INFORMATION |
Animal # One |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
Name of Covering Stallion One |
Enter text: The name of the animal to which the insured animal is being mated (Covering Stallion). |
|
EQUINE INFORMATION |
Stud Fee Paid One |
Enter amount: The fee paid for the stud. |
|
EQUINE INFORMATION |
Animal # Two |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
Name of Covering Stallion Two |
Enter text: The name of the animal to which the insured animal is being mated (Covering Stallion). |
|
EQUINE INFORMATION |
Stud Fee Paid Two |
Enter amount: The fee paid for the stud. |
|
EQUINE INFORMATION |
Animal # Three |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
Name of Covering Stallion Three |
Enter text: The name of the animal to which the insured animal is being mated (Covering Stallion). |
ACORD 407 (2007/09) 16 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
EQUINE INFORMATION |
Stud Fee Paid Three |
Enter amount: The fee paid for the stud. |
|
EQUINE INFORMATION |
Animal # Four |
Enter text: The full name of the animal. |
|
EQUINE INFORMATION |
Name of Covering Stallion Four |
Enter text: The name of the animal to which the insured animal is being mated (Covering Stallion). |
|
EQUINE INFORMATION |
Stud Fee Paid Four |
Enter amount: The fee paid for the stud. |
|
EQUINE INFORMATION |
9. Has any animal been used as a hunter, jumper or eventer, or for racing? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has any animal been used as a hunter, jumper or eventer, or for racing?". |
|
EQUINE INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
ADDITIONAL INTEREST |
Additional Interest One |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Loss Payee One |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee One |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Lienholder One |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Employee as Lessor One |
Check the box (if applicable): Indicates the additional interest type is an employee as lessor. |
|
ADDITIONAL INTEREST |
Other Interest One |
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form. |
|
ADDITIONAL INTEREST |
Describe Other Interest One |
Enter text: The description of the type of interest in the item. |
|
ADDITIONAL INTEREST |
Rank One |
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item. |
|
ADDITIONAL INTEREST |
Name and Address One |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
Reference # One |
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
|
ADDITIONAL INTEREST |
Certificate Required One |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Location One |
Enter number: The producer assigned number of the location which has an additional interest. |
|
ADDITIONAL INTEREST |
Building One |
Enter number: The producer assigned number of the building which has an additional interest. |
ACORD 407 (2007/09) 17 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
ADDITIONAL INTEREST |
Vehicle One |
Enter number: The producer assigned number of the vehicle which has an additional interest. |
|
ADDITIONAL INTEREST |
Boat One |
Enter number: The producer assigned number of the boat which has an additional interest. |
|
ADDITIONAL INTEREST |
Scheduled Item Number One |
Enter number: The producer assigned number of the scheduled item which has an additional interest. |
|
ADDITIONAL INTEREST |
Other Field One |
Enter text: The description of the item which has an additional interest. |
|
ADDITIONAL INTEREST |
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 |
Additional Interest Two |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Loss Payee Two |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee Two |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Lienholder Two |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Employee as Lessor Two |
Check the box (if applicable): Indicates the additional interest type is an employee as lessor. |
|
ADDITIONAL INTEREST |
Other Interest Two |
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form. |
|
ADDITIONAL INTEREST |
Describe Other Interest Two |
Enter text: The description of the type of interest in the item. |
|
ADDITIONAL INTEREST |
Rank Two |
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item. |
|
ADDITIONAL INTEREST |
Name and Address Two |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
Reference # Two |
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
|
ADDITIONAL INTEREST |
Certificate Required Two |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Location Two |
Enter number: The producer assigned number of the location which has an additional interest. |
|
ADDITIONAL INTEREST |
Building Two |
Enter number: The producer assigned number of the building which has an additional interest. |
ACORD 407 (2007/09) 18 of 20
|
Section Name |
Field Name |
Field and/or Section Description |
|
ADDITIONAL INTEREST |
Vehicle Two |
Enter number: The producer assigned number of the vehicle which has an additional interest. |
|
ADDITIONAL INTEREST |
Boat Two |
Enter number: The producer assigned number of the boat which has an additional interest. |
|
ADDITIONAL INTEREST |
Scheduled Item Number Two |
Enter number: The producer assigned number of the scheduled item which has an additional interest. |
|
ADDITIONAL INTEREST |
Other Field Two |
Enter text: The description of the item which has an additional interest. |
|
ADDITIONAL INTEREST |
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. |
|
ADDITIONAL INTEREST |
Additional Interest Three |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Loss Payee Three |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee Three |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Lienholder Three |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Employee as Lessor Three |
Check the box (if applicable): Indicates the additional interest type is an employee as lessor. |
|
ADDITIONAL INTEREST |
Other Interest Three |
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form. |
|
ADDITIONAL INTEREST |
Describe Other Interest Three |
Enter text: The description of the type of interest in the item. |
|
ADDITIONAL INTEREST |
Rank Three |
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item. |
|
ADDITIONAL INTEREST |
Name and Address Three |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
Reference # Three |
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
|
ADDITIONAL INTEREST |
Certificate Required Three |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Location Three |
Enter number: The producer assigned number of the location which has an additional interest. |
|
ADDITIONAL INTEREST |
Building Three |
Enter number: The producer assigned number of the building which has an additional interest. |
ACORD 407 (2007/09) 19 of 20
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Section Name |
Field Name |
Field and/or Section Description |
|
ADDITIONAL INTEREST |
Vehicle Three |
Enter number: The producer assigned number of the vehicle which has an additional interest. |
|
ADDITIONAL INTEREST |
Boat Three |
Enter number: The producer assigned number of the boat which has an additional interest. |
|
ADDITIONAL INTEREST |
Scheduled Item Number Three |
Enter number: The producer assigned number of the scheduled item which has an additional interest. |
|
ADDITIONAL INTEREST |
Other Field Three |
Enter text: The description of the item which has an additional interest. |
|
ADDITIONAL INTEREST |
Item Description Three |
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. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
ATTACHMENTS |
Remarks |
Enter text: The general remarks associated with the livestock mortality line of business. |
|
ATTACHMENTS |
Racing Record |
Check the box (if applicable): Indicates that a racing record is attached to the policy. |
|
ATTACHMENTS |
Show Record |
Check the box (if applicable): Indicates that a show record is attached to the policy. |
|
ATTACHMENTS |
Vet Certificate |
Check the box (if applicable): Indicates that a vet certificate is attached to the policy. |
|
ATTACHMENTS |
Substantiation of Value |
Check the box (if applicable): Indicates that a substantiation of value is attached to the policy. |
|
ATTACHMENTS |
Other One |
Check the box (if applicable): Indicates there is an attachment to the policy other than those listed. |
|
ATTACHMENTS |
Describe Other One |
Enter text: The description of the attachment to the policy. |
|
ATTACHMENTS |
Other Two |
Check the box (if applicable): Indicates there is an attachment to the policy other than those listed. |
|
ATTACHMENTS |
Describe other Two |
Enter text: The description of the attachment to the policy. |
|
TOTAL PREMIUM |
Total Amount of Coverage |
Enter limit: The total limit amount for the livestock mortality line of business. |
|
TOTAL PREMIUM |
Rate |
Enter rate: The rate used to determine the premium for the livestock mortality line of business. |
|
TOTAL PREMIUM |
Premium |
Enter amount: The premium amount before taxes and surcharges for the livestock mortality line of business. |
|
TOTAL PREMIUM |
Taxes/Surcharges |
Enter amount: The amount of taxes and / or surcharges for the livestock mortality line of business. |
|
TOTAL PREMIUM |
Total Premium |
Enter amount: The total premium amount, including taxes and surcharges, for the mortality line of business. |
|
Section Name |
Field Name |
Field and/or Section Description |
|
TOTAL PREMIUM |
Minimum Premium |
Enter amount: The minimum premium amount for the livestock mortality line of business. |
|
SIGNATURES |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
|
SIGNATURES |
Date |
Enter date: The date the form was signed by the named insured. |
|
SIGNATURES |
Producer's Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
|
SIGNATURES |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
|
Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 407 (2007/09) 20 of 20
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