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ACORD Form 410 Small Farm/Ranch
Application Instructions
 

 

Universal wording updates to improve clarity and intent were made to all FIG text for this form on 03/27/2009.

ACORD 410 (2004/04) 1 of 34
Section Name Field Name Field and/or Section Description
TITLE ACORD 410 (2004/04) Small Farm/Ranch Application The title of the form. ACORD 410, Small Farm / Ranch Application, is intended to be used in lieu of ACORD 401 through 404, for small farm/ranch properties, not over three farm buildings and two residential buildings, and not over two different types of businesses (e.g., dairy, crops, livestock, etc.). Do not use if property is to be schedule or blanket rated.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Phone (A/C, No, Ext) Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax (A/C, No, Ext) Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
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).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Company 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.

ACORD 410 (2004/04) 2 of 34

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Company Policy or Program Name Enter text: The description of an independently filed policy or program that may be optionally available from the insurance company. It may also be used to name the subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Program Code Enter code: The product code of the insurer for the policy.
IDENTIFICATION SECTION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Billing Plan Direct Bill (Checkbox) Check the box (if applicable): Indicates if the policy is to be direct billed.
IDENTIFICATION SECTION Agency Bill (Checkbox) Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
IDENTIFICATION SECTION Payment Plan Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -Quarterly, etc.).
IDENTIFICATION SECTION Quote Check the box (if applicable): Indicates the response expected from the company is a quote.
IDENTIFICATION SECTION Bound Check the box (if applicable): Indicates the coverage has been bound.
IDENTIFICATION SECTION Date Enter date: The date the policy status becomes effective. This date is used for policy statuses of bound, change, and cancel.
IDENTIFICATION SECTION Issue Policy Check the box (if applicable): Indicates the response expected from the company is an issued policy.
IDENTIFICATION SECTION Policy Type Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Deposit Enter amount: The amount of the premium received as a deposit.
APPLICANT INFORMATION Name (First Named Insured & Other Named Insureds) * Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Enter text: The named insured(s) as it/they will appear on the policy declarations page.

ACORD 410 (2004/04) 3 of 34

Section Name Field Name Field and/or Section Description
APPLICANT INFORMATION Relationship Enter code: The relationship of the named insured to the first named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION Enter code: The relationship of the named insured to the first named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION Enter code: The relationship of the named insured to the first named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION Enter code: The relationship of the named insured to the first named insured. Examples are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION Mailing Address (of First Named Insured) Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION Phone (A/C, No, Ext) Enter number: The named insured's primary phone number.
APPLICANT INFORMATION E-Mail Address Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION Phone # on Premises Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Form of Business Organization: Individual Check the box (if applicable): Indicates the legal entity code for the named insured is "Individual".
APPLICANT INFORMATION Partnership Check the box (if applicable): Indicates the legal entity code for the named insured is "Partnership".
APPLICANT INFORMATION Corporation Check the box (if applicable): Indicates the legal entity code for the named insured is "Corporation".
APPLICANT INFORMATION Joint Venture Check the box (if applicable): Indicates the legal entity code for the named insured is "Joint Venture".

ACORD 410 (2004/04) 4 of 34

Section Name Field Name Field and/or Section Description
APPLICANT INFORMATION Other Checkbox Check the box (if applicable): Indicates the legal entity code for the named insured is not listed on the form.
APPLICANT INFORMATION Other Description Enter text: The description of the legal entity if not listed on the form.
APPLICANT INFORMATION Date Business Started Enter date: The date the current owners purchased or started the business.
APPLICANT INFORMATION SIC Enter code: The Standard Industry Classification code assigned to the business activity (if known). This is the code which represents the nature of the employer's business which is contained in the Standard Industrial Classification Manual published by the Federal Office of Management and Budget.
APPLICANT INFORMATION Federal ID # Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Contact Enter text: The full name of the contact.
APPLICANT INFORMATION Phone (A/C, No, Ext) Enter number: The primary phone number of the contact.
TYPE OF FARM/RANCH Field Crops Check the box (if applicable): Indicates the nature of the operation is a field crops farm / ranch.
TYPE OF FARM/RANCH Fruits Check the box (if applicable): Indicates the nature of the operation is a fruit / citrus farm / ranch.
TYPE OF FARM/RANCH Vegetables Check the box (if applicable): Indicates the nature of the operation is a vegetable farm / ranch.
TYPE OF FARM/RANCH Dairy Check the box (if applicable): Indicates the nature of the operation is a dairy farm / ranch.
TYPE OF FARM/RANCH Mushrooms Check the box (if applicable): Indicates the nature of the operation is a mushroom farm.
TYPE OF FARM/RANCH Nuts Check the box (if applicable): Indicates the nature of the operation is a nut farm / ranch.
TYPE OF FARM/RANCH Flowers Check the box (if applicable): Indicates the nature of the operation is a flowers farm / ranch.
TYPE OF FARM/RANCH Vineyards Check the box (if applicable): Indicates the nature of the operation is a vineyard.
TYPE OF FARM/RANCH Greenhouses Check the box (if applicable): Indicates the nature of the operation is a greenhouse farm / ranch.
TYPE OF FARM/RANCH Nursery Stock Check the box (if applicable): Indicates the nature of the operation is a nursery stock farm / ranch.
TYPE OF FARM/RANCH Sod Check the box (if applicable): Indicates the nature of the operation is a sod farm.

ACORD 410 (2004/04) 5 of 34

Section Name Field Name Field and/or Section Description
TYPE OF FARM/RANCH Worms Check the box (if applicable): Indicates the nature of the operation is a worm farm.
TYPE OF FARM/RANCH Bees Check the box (if applicable): Indicates the nature of the operation is a bee farm.
TYPE OF FARM/RANCH Fur Bearing Animals Check the box (if applicable): Indicates the nature of the operation is a fur bearing animals farm / ranch.
TYPE OF FARM/RANCH Livestock Check the box (if applicable): Indicates the nature of the operation is a livestock farm / ranch.
TYPE OF FARM/RANCH Type Enter text: The description of the livestock on the farm / ranch.
TYPE OF FARM/RANCH Tobacco Check the box (if applicable): Indicates the nature of the operation is a tobacco farm / ranch.
TYPE OF FARM/RANCH Poultry Check the box (if applicable): Indicates the nature of the operation is a poultry farm / ranch.
TYPE OF FARM/RANCH Other Check the box (if applicable): Indicates the nature of the farm / ranch operation is other than those listed.
TYPE OF FARM/RANCH Blank Field Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM/RANCH Other Check the box (if applicable): Indicates the nature of the farm / ranch operation is other than those listed.
TYPE OF FARM/RANCH Blank Field Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM/RANCH Describe Farm/Ranch Operations Enter text: The text description of the operations of this risk or insured.
PREMISES INFORMATION LOC # One Enter number: The producer assigned number of the location.
PREMISES INFORMATION BLD # One Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street, City, County, State, Zip One Enter text: The first address line of the physical location.
PREMISES INFORMATION Enter text: The county of the location.
PREMISES INFORMATION Enter text: The city of the physical location.
PREMISES INFORMATION Enter code: The state or province of the physical location.
PREMISES INFORMATION Enter code: The postal code of the physical location.
PREMISES INFORMATION Prot Class One Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PREMISES INFORMATION # Acres Total One Enter number: The size of the piece of land in acres.
PREMISES INFORMATION # Acres Cultivated One Enter number: The size of the piece of land that is cultivated in acres.
PREMISES INFORMATION # Acres in Pasture One Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION Farmed By One Enter text: The description of who the location is farmed by.
PREMISES INFORMATION Gross Receipts One Enter amount: The gross receipts amount for this location.

ACORD 410 (2004/04) 6 of 34

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION LOC # Two Enter number: The producer assigned number of the location.
PREMISES INFORMATION BLD # Two Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street, City, County, State, Zip Two Enter text: The first address line of the physical location.
PREMISES INFORMATION Enter text: The county of the location.
PREMISES INFORMATION Enter text: The city of the physical location.
PREMISES INFORMATION Enter code: The state or province of the physical location.
PREMISES INFORMATION Enter code: The postal code of the physical location.
PREMISES INFORMATION Prot Class Two Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PREMISES INFORMATION # Acres Total Two Enter number: The size of the piece of land in acres.
PREMISES INFORMATION # Acres Cultivated Two Enter number: The size of the piece of land that is cultivated in acres.
PREMISES INFORMATION # Acres in Pasture Two Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION Farmed By Two Enter text: The description of who the location is farmed by.
PREMISES INFORMATION Gross Receipts Two Enter amount: The gross receipts amount for this location.
PREMISES INFORMATION LOC # Three Enter number: The producer assigned number of the location.
PREMISES INFORMATION BLD # Three Enter number: The building number for the premises. Used when more than one building exists at an individual location.
PREMISES INFORMATION Street, City, County, State, Zip Three Enter text: The first address line of the physical location.
PREMISES INFORMATION Enter text: The county of the location.
PREMISES INFORMATION Enter text: The city of the physical location.
PREMISES INFORMATION Enter code: The state or province of the physical location.
PREMISES INFORMATION Enter code: The postal code of the physical location.
PREMISES INFORMATION Prot Class Three Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PREMISES INFORMATION # Acres Total Three Enter number: The size of the piece of land in acres.
PREMISES INFORMATION # Acres Cultivated Three Enter number: The size of the piece of land that is cultivated in acres.
PREMISES INFORMATION # Acres in Pasture Three Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION Farmed By Three Enter text: The description of who the location is farmed by.
PREMISES INFORMATION Gross Receipts Three Enter amount: The gross receipts amount for this location.
PREMISES INFORMATION Does applicant have other businesses? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant have any other business?".

ACORD 410 (2004/04) 7 of 34

Section Name Field Name Field and/or Section Description
PREMISES INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
PREMISES INFORMATION Does applicant have other businesses? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant have any other business?".
PREMISES INFORMATION Is business new to agency? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is the business new to the agency?".
PREMISES INFORMATION Is business new to agency? No Check the box (if applicable): Indicates a "No" response to the question, "Is the business new to the agency?".
PREMISES INFORMATION Date of last inspection Enter date: The date of the last inspection.
LOSS HISTORY Date of Occurrence One Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type of Loss One Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Description One Enter text: A brief description of the loss.
LOSS HISTORY Amount Paid One Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Date of Occurrence Two Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type of Loss Two Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Description Two Enter text: A brief description of the loss.
LOSS HISTORY Amount Paid Two Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Date of Occurrence Three Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type of Loss Three Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Description Three Enter text: A brief description of the loss.
LOSS HISTORY Amount Paid Three Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Date of Occurrence Four Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY Type of Loss Four Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY Description Four Enter text: A brief description of the loss.
LOSS HISTORY Amount Paid Four Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY Date of Occurrence Five Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.

ACORD 410 (2004/04) 8 of 34

Section Name Field Name Field and/or Section Description
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
LOSS HISTORY Type of Loss Five General Liability).
LOSS HISTORY Description Five Enter text: A brief description of the loss.
LOSS HISTORY Amount Paid Five Enter amount: The amount that has been paid on this claim to date.
PRIOR INSURANCE
INFORMATION Prior Carrier One Enter text: The name of the previous insurer.
PRIOR INSURANCE Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
INFORMATION Type of Insurance One liability.
PRIOR INSURANCE
INFORMATION Policy # One Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION Amount of Coverage One Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION Prior Carrier Two Enter text: The name of the previous insurer.
PRIOR INSURANCE Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
INFORMATION Type of Insurance Two liability.
PRIOR INSURANCE
INFORMATION Policy # Two Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION Amount of Coverage Two Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION Prior Carrier Three Enter text: The name of the previous insurer.
PRIOR INSURANCE Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
INFORMATION Type of Insurance Three liability.
PRIOR INSURANCE
INFORMATION Policy # Three Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION Amount of Coverage Three Enter limit: The limit amount of the prior coverage.
Has any policy been cancelled or
PRIOR INSURANCE non-renewed in the past 5 years? Check the box (if applicable): Indicates a 'Yes" response to the question, "Has any policy
INFORMATION Yes been cancelled or non-renewed in the past mandated number of years?".
PRIOR INSURANCE Enter text: An explanation of a response to a general information or underwriting question.
INFORMATION Explain if Yes Normally, "Yes" responses require an explanation.
Has any policy been cancelled or
PRIOR INSURANCE non-renewed in the past 5 years? Check the box (if applicable): Indicates a 'No" response to the question, "Has any policy
INFORMATION No been cancelled or non-renewed in the past mandated number of years?".

ACORD 410 (2004/04) 9 of 34

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST PROPERTY Premises Number One Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST PROPERTY Building Number One Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST PROPERTY Name and Address One Enter text: The additional interest's full name.
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST PROPERTY Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST PROPERTY Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST PROPERTY Interest One Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST PROPERTY Evidence: Certificate One Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST PROPERTY Policy One Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST PROPERTY Other checkbox One Check the box (if applicable): Indicates the additional interest requires evidence other than those types listed.
ADDITIONAL INTEREST PROPERTY Other Description One Enter text: The description of the type of evidence required by the additional insured.
ADDITIONAL INTEREST PROPERTY Send Bill One Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST PROPERTY Building Number Two Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST PROPERTY Name and Address Two Enter text: The additional interest's full name.
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address line two.

ACORD 410 (2004/04) 10 of 34

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST PROPERTY Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST PROPERTY Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST PROPERTY Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST PROPERTY Interest Two Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST PROPERTY Evidence: Certificate Two Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST PROPERTY Policy Two Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST PROPERTY Other checkbox Two Check the box (if applicable): Indicates the additional interest requires evidence other than those types listed.
ADDITIONAL INTEREST PROPERTY Other Description Two Enter text: The description of the type of evidence required by the additional insured.
ADDITIONAL INTEREST PROPERTY Send Bill Two Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST PROPERTY Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST PROPERTY Loss Payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST PROPERTY Mortgagee Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST PROPERTY Lienholder Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST PROPERTY Employee As Lessor Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST PROPERTY Other Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTEREST PROPERTY Other Description Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST LIABILITY Rank Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTEREST LIABILITY Name and Address Enter text: The additional interest's full name.

ACORD 410 (2004/04) 11 of 34

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST LIABILITY Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST LIABILITY Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST LIABILITY Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST LIABILITY Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST LIABILITY Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST LIABILITY Reference Number Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST LIABILITY Certificate Required Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST LIABILITY Interest in Item Number: Location Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST LIABILITY Building Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST LIABILITY Vehicle Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST LIABILITY Boat Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST LIABILITY Scheduled Item Number Enter number: The producer assigned number of the scheduled item which has an additional interest.
ADDITIONAL INTEREST LIABILITY Other Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST LIABILITY Item Description Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
PROPERTY COVERAGE Location # Enter number: The producer assigned number of the location.
PROPERTY COVERAGE Fire District Name Enter text: The property's fire district name.
PROPERTY COVERAGE Distance to Hydrant Enter number: The distance in feet from the nearest hydrant that supports the protection class used.
PROPERTY COVERAGE Distance to Fire Station Enter number: The distance in miles from the nearest fire station that supports the protection class used.
PROPERTY COVERAGE Principal Dwelling Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).

ACORD 410 (2004/04) 12 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Principal Dwelling Construction Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PROPERTY COVERAGE Principal Dwelling Type of Heat Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Principal Dwelling Age of Bldg Enter number: The age of the building in years.
PROPERTY COVERAGE Principal Dwelling Age of Roof Enter number: The age of the roof in years.
PROPERTY COVERAGE Principal Dwelling Square Feet Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Principal Dwelling RC/ACV Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Principal Dwelling Coinsurance % Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Principal Dwelling Prot Class Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Principal Dwelling Cause of Loss Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Principal Dwelling Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Principal Dwelling Value Enter amount: The value of the premises or item.
Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Principal Dwelling Limit of Insurance Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Principal Dwelling Premium Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Household PP Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE Household PP RC/ACV Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Household PP Coinsurance % Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Household PP Prot Class Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Household PP Cause of Loss Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Household PP Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Household PP Value Enter amount: The value of the premises or item.
PROPERTY COVERAGE Household PP Limit of Insurance Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Household PP Premium Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Other Dwelling Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).

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ACORD 410 (2004/04) 14 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Dwelling Construction Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PROPERTY COVERAGE Other Dwelling Type of Heat Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Other Dwelling Age of Bldg Enter number: The age of the building in years.
PROPERTY COVERAGE Other Dwelling Age of Roof Enter number: The age of the roof in years.
PROPERTY COVERAGE Other Dwelling Square Feet Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Other Dwelling RC/ACV Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Other Dwelling Coinsurance % Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Other Dwelling Prot Class Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Other Dwelling Cause of Loss Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Other Dwelling Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Other Dwelling Value Enter amount: The value of the premises or item.
Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Dwelling Limit of Insurance Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Other Dwelling Premium Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Household PP Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE Household PP RC/ACV Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Household PP Coinsurance % Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Household PP Prot Class Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Household PP Cause of Loss Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Household PP Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Household PP Value Enter amount: The value of the premises or item.
PROPERTY COVERAGE Household PP Limit of Insurance Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Household PP Premium Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Snowmobiles Bldg Type Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).

ACORD 410 (2004/04) 16 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Snowmobiles RC/ACV Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Snowmobiles Coinsurance % Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Snowmobiles Prot Class Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Snowmobiles Cause of Loss Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Snowmobiles Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Snowmobiles Value Enter amount: The value of the premises or item.
PROPERTY COVERAGE Snowmobiles Limit of Insurance Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Snowmobiles Premium Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Other One Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE Other Bldg Type One Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE Other Construction One Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive

ACORD 410 (2004/04) 17 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Type of Heat One Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Other Age of Bldg One Enter number: The age of the building in years.
PROPERTY COVERAGE Other Age of Roof One Enter number: The age of the roof in years.
PROPERTY COVERAGE Other Square Feet One Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Other RC/ACV One Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Other Coinsurance % One Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Other Prot Class One Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Other Cause of Loss One Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Other Deductible One Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Other Value One Enter amount: The value of the premises or item.
PROPERTY COVERAGE Other Limit of Insurance One Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Other Premium One Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Other Two Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE Other Bldg Type Two Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).

ACORD 410 (2004/04) 18 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Construction Two Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PROPERTY COVERAGE Other Type of Heat Two Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Other Age of Bldg Two Enter number: The age of the building in years.
PROPERTY COVERAGE Other Age of Roof Two Enter number: The age of the roof in years.
PROPERTY COVERAGE Other Square Feet Two Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Other RC/ACV Two Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Other Coinsurance % Two Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Other Prot Class Two Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Other Cause of Loss Two Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Other Deductible Two Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Other Value Two Enter amount: The value of the premises or item.

ACORD 410 (2004/04) 19 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Limit of Insurance Two Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Other Premium Two Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Other Three Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE Other Bldg Type Three Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE Other Construction Three Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PROPERTY COVERAGE Other Type of Heat Three Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Other Age of Bldg Three Enter number: The age of the building in years.
PROPERTY COVERAGE Other Age of Roof Three Enter number: The age of the roof in years.
PROPERTY COVERAGE Other Square Feet Three Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Other RC/ACV Three Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY COVERAGE Other Coinsurance % Three Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Other Prot Class Three Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.

ACORD 410 (2004/04) 20 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Cause of Loss Three Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Other Deductible Three Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Other Value Three Enter amount: The value of the premises or item.
PROPERTY COVERAGE Other Limit of Insurance Three Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Other Premium Three Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Other Four Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE Other Bldg Type Four Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE Other Construction Four Enter code: The primary construction type of the premises. Common construction classifications are: * Frame * Joisted Masonry * Non-Combustible * Masonry Non-Combustible * Modified Fire Resistive * Fire Resistive
PROPERTY COVERAGE Other Type of Heat Four Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE Other Age of Bldg Four Enter number: The age of the building in years.
PROPERTY COVERAGE Other Age of Roof Four Enter number: The age of the roof in years.
PROPERTY COVERAGE Other Square Feet Four Enter number: The number of square feet of the building or area occupied at this location for which insurance is being requested.
PROPERTY COVERAGE Other RC/ACV Four Enter code: Indicate the method which will be used to determine the amount paid on a claim. Valuation methods are: ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value

ACORD 410 (2004/04) 21 of 34

Section Name Field Name Field and/or Section Description
PROPERTY COVERAGE Other Coinsurance % Four Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage.
PROPERTY COVERAGE Other Prot Class Four Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply.
PROPERTY COVERAGE Other Cause of Loss Four Enter code: The causes of loss the subject of insurance is to be covered for. Examples: * Basic * Broad * Special excluding theft * Earthquake
PROPERTY COVERAGE Other Deductible Four Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE Other Value Four Enter amount: The value of the premises or item.
PROPERTY COVERAGE Other Limit of Insurance Four Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option.
PROPERTY COVERAGE Other Premium Four Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE Additional Coverages, Restrictions, Endorsements and Rating Information Enter text: The remarks associated with a specific location or sublocation.
LIABILITY COVERAGE Bodily Injury and Property Damage Liability: Each Occurrence Amount Enter limit: The each occurrence limit amount for bodily injury and property damage coverage.
LIABILITY COVERAGE General Aggregate Limit Enter limit: The general aggregate limit amount for bodily injury and property damage coverage.
LIABILITY COVERAGE Personal and Advertising Injury Liability Enter limit: The each occurrence limit amount for personal and advertising injury coverage.
LIABILITY COVERAGE General Aggregate Limit Enter limit: The general aggregate limit amount for personal and advertising injury coverage.
LIABILITY COVERAGE Medical Payments Enter limit: The each person limit amount for medical payments coverage.
LIABILITY COVERAGE General Aggregate Limit Enter limit: The each occurrence limit amount for medical payments coverage.
LIABILITY COVERAGE Property Damage Liability Fire Damage Limit 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.

ACORD 410 (2004/04) 22 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE AAIS Personal Liability Coverage Name of Insured (s) Enter text: The additional interest's full name. As used here, this is a named insured covered by personal liability coverage.
LIABILITY COVERAGE Enter text: The additional interest's full name. As used here, this is a named insured covered by personal liability coverage.
LIABILITY COVERAGE Other Coverage Enter code: The code for the coverage.
LIABILITY COVERAGE Enter text: The description of the coverage.
LIABILITY COVERAGE Amount Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE Other Coverage Enter code: The code for the coverage.
LIABILITY COVERAGE Enter text: The description of the coverage.
LIABILITY COVERAGE Amount Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE Commercial General Liability Yes Check the box (if applicable): Indicates commercial general liability coverage is requested.
LIABILITY COVERAGE Commercial General Liability No Check the box (if applicable): Indicates commercial general liability coverage is not requested.
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 AAIS Yes Check the box (if applicable): Indicates farm commercial liability coverage is requested.
LIABILITY COVERAGE Farm Commercial Liability AAIS No Check the box (if applicable): Indicates farm commercial liability coverage is not requested.
LIABILITY COVERAGE Initial Farm Premises Code Enter code: The code for the coverage.
LIABILITY COVERAGE Not More Than _ Acres Enter number: The maximum number of acres for the initial farm premises coverage.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the initial farm premises.
LIABILITY COVERAGE Enter rate: The rate for the initial farm premises.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the initial farm premises.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Loc # Enter identifier: The producer assigned location identifier for the additional farm premises maintained by the named insured.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the initial farm premises.

ACORD 410 (2004/04) 23 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE Enter rate: The rate for the initial farm premises.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the initial farm premises.
LIABILITY COVERAGE Additional Farm Premises Maintained by Named Insured: Code Enter code: The code for the coverage.
LIABILITY COVERAGE Seasonal Check the box (if applicable): Indicates the additional non-farm premises occupied by the insured is seasonal.
LIABILITY COVERAGE Permanent Check the box (if applicable): Indicates if the additional non-farm premises occupied by the insured is permanent.
LIABILITY COVERAGE Loc # Enter identifier: The producer assigned location identifier for the additional non-farm premises occupied by the insured.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for additional non-farm premises occupied by the insured.
LIABILITY COVERAGE Enter rate: The rate for additional non-farm premises occupied by the insured.
LIABILITY COVERAGE Premium Enter amount: The premium amount for additional non-farm premises occupied by the insured.
LIABILITY COVERAGE Additional Residence Rented To Others Code Enter code: The code for the coverage.
LIABILITY COVERAGE Number of Families Enter number: The number of families in the additional residence rented to others.
LIABILITY COVERAGE Loc # Enter identifier: The producer assigned location identifier for the additional residence rented to others.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the additional residence rented to others.
LIABILITY COVERAGE Enter rate: The rate for the additional residence rented to others.
LIABILITY COVERAGE Premium Enter amount: The premium amount for additional residence rented to others.
LIABILITY COVERAGE Custom Farming Receipts (Rate Per $1,000) Enter code: The code for the coverage.
LIABILITY COVERAGE Receipts Amount Enter amount: The receipts amount for custom farming.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.

ACORD 410 (2004/04) 24 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for custom farming.
LIABILITY COVERAGE Enter rate: The rate for custom farming.
LIABILITY COVERAGE Premium Enter amount: The premium amount for custom farming.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Sales Enter amount: The receipts amount for the incidental business activity.
LIABILITY COVERAGE Coverage Enter text: The description of any other information required by the insurer for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the incidental business activity.
LIABILITY COVERAGE Enter rate: The rate for the incidental business activity.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the incidental business activity.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Incr Limits Factor 1-3 Persons Enter percentage: The increased limits factor for the coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Basis/Rate 1-3 Persons Enter code: The premium basis code for day care coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Enter rate: The rate for day care coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Premium 1-3 Persons Enter amount: The premium amount for day care coverage. As used here, this is for a day care with 1 to 6 persons.
LIABILITY COVERAGE Incr Limits Factor 1-6 Persons Enter percentage: The increased limits factor for the coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Basis/Rate 1-6 Persons Enter code: The premium basis code for day care coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Enter rate: The rate for day care coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Premium 1-6 Persons Enter amount: The premium amount for day care coverage. As used here, this is for a day care with 1 to 3 persons.
LIABILITY COVERAGE Limited Farm Pollution Liability (Refer To Company): Code Enter code: The code for the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for limited farm pollution liability.
LIABILITY COVERAGE Enter rate: The rate for limited farm pollution liability.
LIABILITY COVERAGE Premium Enter amount: The premium amount for limited farm pollution liability.

ACORD 410 (2004/04) 25 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE Contingent Liability For Crop Dusting By Independent Aircraft (Rate Per $1,000 Cost): Code Enter code: The code for the coverage.
LIABILITY COVERAGE Cost Enter amount: The cost for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE Limit Enter limit: The limit amount for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE Enter rate: The rate for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE Premium Enter amount: The premium amount for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Inservant Check the box (if applicable): Indicates coverage is requested for inservants.
LIABILITY COVERAGE Outservant Check the box (if applicable): Indicates coverage is requested for outservants.
LIABILITY COVERAGE # of Residential Employees Enter number: The number of residential employees for domestic workers compensation coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for domestic workers compensation coverage.
LIABILITY COVERAGE Enter rate: The rate for domestic workers compensation coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for domestic workers compensation coverage.
LIABILITY COVERAGE Animal Collision: Code Enter code: The code for the coverage.
LIABILITY COVERAGE Limit per Head Enter limit: The per head limit for animal collision coverage.
LIABILITY COVERAGE # of Head Enter number: The head count for animal collision coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for animal collision coverage.
LIABILITY COVERAGE Enter rate: The rate for animal collision coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for animal collision coverage.
LIABILITY COVERAGE Employers Liability Code Enter code: The code for the coverage.
LIABILITY COVERAGE # Full Time Employees Enter number: The number of full time employees for employers liability coverage.
LIABILITY COVERAGE # Part Time Employees Enter number: The number of part time employees for employers liability coverage.
LIABILITY COVERAGE Total Payroll Enter amount: The total payroll amount for employers liability coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for employers liability coverage.
LIABILITY COVERAGE Enter rate: The rate for employers liability coverage.

ACORD 410 (2004/04) 26 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE Premium Enter amount: The premium amount for employers liability coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE Code Enter code: The code for the coverage.
LIABILITY COVERAGE Blank Field Enter text: The description of the coverage.
LIABILITY COVERAGE Incr Limits Factor Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE Basis/Rate Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE Enter rate: The rate for the coverage.

ACORD 410 (2004/04) 27 of 34

Section Name Field Name Field and/or Section Description
LIABILITY COVERAGE Premium Enter amount: The premium amount for the coverage.
GENERAL INFORMATION Is there is a year-round water source available for fire protection? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a year-round water supply usable for fire protection?",
GENERAL INFORMATION Is there is a year-round water source available for fire protection? No Check the box (if applicable): Indicates a "No" response to the question, "Is there a year-round water supply usable for fire protection?",
GENERAL INFORMATION Source: Well Check the box (if applicable): Indicates the source of water is a well.
GENERAL INFORMATION Pond/Lake Check the box (if applicable): Indicates the source of water is a pond or lake.
GENERAL INFORMATION Hydrant Within 1000 Ft Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000 feet.
GENERAL INFORMATION Other checkbox Check the box (if applicable): Indicates the source of water is other than those listed.
GENERAL INFORMATION Other Description Enter text: The source of water for fire protection.
GENERAL INFORMATION Quantity: Less Than 1000 Gallons Check the box (if applicable): Indicates the quantity of the water supply for fire protection is under 1,000 gallons.
GENERAL INFORMATION 1000 - 3000 Gallons Check the box (if applicable): Indicates the quantity of the water supply for fire protection is 1,000 - 3,000 gallons.
GENERAL INFORMATION Over 3000 Gallons Check the box (if applicable): Indicates the quantity of the water supply for fire protection is over 3,000 gallons.
GENERAL INFORMATION Are any wood or coal fired stoves are used in any buildings? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any wood or coal fired stoves used?".
GENERAL INFORMATION Are any wood or coal fired stoves are used in any buildings? NO Check the box (if applicable): Indicates a "No" response to the question, "Are any wood or coal fired stoves used?".
GENERAL INFORMATION Explain if Yes Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Are there are any burglary and/or fire alarms on the premises? Yes This question cannot be asked in Missouri. Check the box (if applicable): Indicates a "Yes" response to the question, "Are there any burglar and / or fire alarms?".
GENERAL INFORMATION Are there are any burglary and/or fire alarms on the premises? No This question cannot be asked in Missouri. Check the box (if applicable): Indicates a "No" response to the question, "Are there any burglar and / or fire alarms?".

ACORD 410 (2004/04) 28 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION If Yes Type of Alarm Enter text: The description of the type of alarm.
GENERAL INFORMATION Diagram # Enter identifier: The producer assigned identifier for the diagram of the location.
GENERAL INFORMATION Does applicant perform maintenance on equipment? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant perform maintenance on equipment?".
GENERAL INFORMATION Does applicant perform maintenance on equipment? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant perform maintenance on equipment?".
GENERAL INFORMATION If no, please indicate type of repairs done, where done and by whom Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
GENERAL INFORMATION Is entire premises occupied year round? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is entire premises occupied year round?".
GENERAL INFORMATION Is entire premises occupied year round? No Check the box (if applicable): Indicates a "No" response to the question, "Is entire premises occupied year round?".
GENERAL INFORMATION During the last ten years has any applicant been convicted of any degree of the crime of arson? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "During the last mandated number of year, has any applicant been convicted of any degree of the crime of arson?".
GENERAL INFORMATION During the last ten years has any applicant been convicted of any degree of the crime of arson? No Check the box (if applicable): Indicates a "No" response to the question, "During the last mandated number of year, has any applicant been convicted of any degree of the crime of arson?".
GENERAL INFORMATION Are independent contractors hired to perform any farming operations? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are independent contractors hired to perform any farming operations?".
GENERAL INFORMATION Are independent contractors hired to perform any farming operations? No Check the box (if applicable): Indicates a "No" response to the question, "Are independent contractors hired to perform any farming operations?".
GENERAL INFORMATION Is any part of farm used or leased for organized recreational use? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Any part of farm used or leased for organized recreational use?".
GENERAL INFORMATION Is any part of farm used or leased for organized recreational use? No Check the box (if applicable): Indicates a "No" response to the question, "Any part of farm used or leased for organized recreational use?".

ACORD 410 (2004/04) 29 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Does applicant build, repair or design machinery equipment or systems for anyone at a charge or fee? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant build, repair or design machinery, equipment or systems for anyone at a charge or fee?".
GENERAL INFORMATION Does applicant build, repair or design machinery equipment or systems for anyone at a charge or fee? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant build, repair or design machinery, equipment or systems for anyone at a charge or fee?".
GENERAL INFORMATION Does applicant mix, process, slaughter, butcher or otherwise prepare for any "end consumer" his or any other grower's product? Yes Check the box (if applicable): Indicates a "Yes" 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 Does applicant mix, process, slaughter, butcher or otherwise prepare for any "end consumer" his or any other grower's product? No Check the box (if applicable): Indicates a "No" 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 Does applicant handle any product, such as seed, fertilizer, sprays etc for resale? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant handle any product, such as seed, fertilizer, sprays, etc. for resale?".
GENERAL INFORMATION Does applicant handle any product, such as seed, fertilizer, sprays etc for resale? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant handle any product, such as seed, fertilizer, sprays, etc. for resale?".
GENERAL INFORMATION Are any contract or service operations performed for others, such as snow removal, tilling, excavating or ditching? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any contract or service operations performed for others such as snow removal, tilling, excavating, or ditching?".
GENERAL INFORMATION Are any contract or service operations performed for others, such as snow removal, tilling, excavating or ditching? No Check the box (if applicable): Indicates a "No" response to the question, "Are any contract or service operations performed for others such as snow removal, tilling, excavating, or ditching?".

ACORD 410 (2004/04) 30 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Are the farm premises open to the public for activities such as roadside stands? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are the farm premises open to the public for activities such as, road side stands, "U-Pick", recreational, "Rent-a-Garden", auction, sales, show, food, or beverage service, hay rides, fishing, kennels, animal boarding, or Christmas tree sales uses?".
GENERAL INFORMATION Are the farm premises open to the public for activities such as roadside stands? No Check the box (if applicable): Indicates a "No" response to the question, "Are the farm premises open to the public for activities such as, road side stands, "U-Pick", recreational, "Rent-a-Garden", auction, sales, show, food, or beverage service, hay rides, fishing, kennels, animal boarding, or Christmas tree sales uses?".
GENERAL INFORMATION Are any portions of the farm rented or leased or used by any other individual or corporation or interest for other than farming? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other than farming?".
GENERAL INFORMATION Are any portions of the farm rented or leased or used by any other individual or corporation or interest for other than farming? No Check the box (if applicable): Indicates a "No" response to the question, "Are any portions of the farm rented or leased or used by any other individual, corporation or interest for other than farming?".
GENERAL INFORMATION Is there any unusual hazard such as open dump pits, silage pits, sump holes, ponds, lakes or reservoirs? Yes Check the box (if applicable): Indicates a "Yes" 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 Is there any unusual hazard such as open dump pits, silage pits, sump holes, ponds, lakes or reservoirs? No Check the box (if applicable): Indicates a "No" 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 Is there an airstrip on the premises? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is there an airstrip on the premises?".
GENERAL INFORMATION Is there an airstrip on the premises? No Check the box (if applicable): Indicates a "No" response to the question, "Is there an airstrip on the premises?".
GENERAL INFORMATION Are any "hold harmless" or "indemnifying" agreements in effect? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any "Hold Harmless" or "Indemnifying" agreements in effect?".
GENERAL INFORMATION Are any "hold harmless" or "indemnifying" agreements in effect? No Check the box (if applicable): Indicates a "No" response to the question, "Are any "Hold Harmless" or "Indemnifying" agreements in effect?".

ACORD 410 (2004/04) 31 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION If livestock is kept, are all areas adequately fenced and are fences in a good state of repair? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "If livestock is kept, are all areas adequately fenced and are fences in a good state of repair?".
GENERAL INFORMATION If livestock is kept, are all areas adequately fenced and are fences in a good state of repair? No Check the box (if applicable): Indicates a "No" response to the question, "If livestock is kept, are all areas adequately fenced and are fences in a good state of repair?".
GENERAL INFORMATION Open range area Check the box (if applicable): Indicates the premises is in an open range area.
GENERAL INFORMATION Closed range area Check the box (if applicable): Indicates the premises is in a closed range area.
GENERAL INFORMATION Are the described premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other than business property? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are the described insured premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other than business property?".
GENERAL INFORMATION Are the described premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other than business property? No Check the box (if applicable): Indicates a "No" response to the question, "Are the described insured premises the only premises which the applicant or spouse owns, rents or operates as a farm or ranch, or maintains as a residence, other than business property?".
GENERAL INFORMATION Any non-owned horses on any insured premises? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Any non-owned horses on any insured premises?".
GENERAL INFORMATION Any non-owned horses on any insured premises? No Check the box (if applicable): Indicates a "No" response to the question, "Any non-owned horses on any insured premises?".
GENERAL INFORMATION Does insured board, race breed or rent horses? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does insured own, board, race, breed or rent horses?".
GENERAL INFORMATION Does insured board, race breed or rent horses? No Check the box (if applicable): Indicates a "No" response to the question, "Does insured own, board, race, breed or rent horses?".
GENERAL INFORMATION Is any land held for real estate development or speculation? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is any land held for real estate development or speculation?".

ACORD 410 (2004/04) 32 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Is any land held for real estate development or speculation? No Check the box (if applicable): Indicates a "No" response to the question, "Is any land held for real estate development or speculation?".
GENERAL INFORMATION Does applicant maintain any vacation or seasonal premises? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant maintain any vacation or seasonal premises?".
GENERAL INFORMATION Does applicant maintain any vacation or seasonal premises? No Check the box (if applicable): Indicates a "No" response to the question, ""Does applicant maintain any vacation or seasonal premises?".
GENERAL INFORMATION If dairy farm, is there any processing of milk? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "If dairy farm, is there any processing of milk?".
GENERAL INFORMATION If dairy farm, is there any processing of milk? No Check the box (if applicable): Indicates a "No" response to the question, "If dairy farm, is there any processing of milk?".
GENERAL INFORMATION If dairy farm, is there any retail sales of milk products to public? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "If dairy farm, is there any retail sales of milk products to public?".
GENERAL INFORMATION If dairy farm, is there any retail sales of milk products to public? No Check the box (if applicable): Indicates a "No" response to the question, "If dairy farm, is there any retail sales of milk products to public?".
GENERAL INFORMATION Receipts Amount Enter amount: The total amount of receipts gained from the sale of milk products.
GENERAL INFORMATION Number of Cows Milked Enter number: The number of animals milked. As used here, this is the number of cows milked.
GENERAL INFORMATION Are any premises used for hunting purposes? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are any premises used for hunting purposes?".
GENERAL INFORMATION Are any premises used for hunting purposes? No Check the box (if applicable): Indicates a "No" response to the question, "Are any premises used for hunting purposes?".
GENERAL INFORMATION By Owners Check the box (if applicable): Indicates the premises is used for hunting by the owners.
GENERAL INFORMATION No Charge Check the box (if applicable): Indicates the premises is used for hunting for no charge.
GENERAL INFORMATION Fee Check the box (if applicable): Indicates the premises is used for hunting for a fee.
GENERAL INFORMATION Rented to Others Check the box (if applicable): Indicates the premises is rented to others for hunting.
GENERAL INFORMATION Receipts Amount Enter amount: The receipts amount for hunting on the premises.
GENERAL INFORMATION Does applicant maintain a nonfarm office or private school in an insured building? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant maintain a non-farm office or private school in an insured building?".

ACORD 410 (2004/04) 33 of 34

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Does applicant maintain a nonfarm office or private school in an insured building? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant maintain a non-farm office or private school in an insured building?".
GENERAL INFORMATION Is there a swimming pool on premises? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a swimming pool on the premises?".
GENERAL INFORMATION Is there a swimming pool on premises? No Check the box (if applicable): Indicates a "No" response to the question, "Is there a swimming pool on the premises?".
GENERAL INFORMATION Is it fenced? Yes Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an approved height.
GENERAL INFORMATION Is it fenced? No Check the box (if applicable): Indicates the swimming pool is not surrounded by a fence that is an approved height.
GENERAL INFORMATION Is there a diving board? Yes Check the box (if applicable): Indicates the swimming pool has a diving board.
GENERAL INFORMATION Is there a diving board? No Check the box (if applicable): Indicates the swimming pool does not have a diving board.
GENERAL INFORMATION Does applicant serve on any boards of remuneration? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant serve on any boards for remuneration?".
GENERAL INFORMATION Does applicant serve on any boards of remuneration? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant serve on any boards for remuneration?".
GENERAL INFORMATION Is the applicant a subsidiary of another or does the applicant have subsidiary? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is the applicant a subsidiary of another or does the applicant have subsidiaries?".
GENERAL INFORMATION Is the applicant a subsidiary of another or does the applicant have subsidiary? No Check the box (if applicable): Indicates a "No" response to the question, "Is the applicant a subsidiary of another or does the applicant have subsidiaries?".
GENERAL INFORMATION Is a formal safety program in existence? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is there a formal safety program in existence?".
GENERAL INFORMATION Is a formal safety program in existence? No Check the box (if applicable): Indicates a "No" response to the question, "Is there a formal safety program in existence?".
GENERAL INFORMATION Does the applicant have any potentially dangerous animals or exotic pets? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Does applicant have any potentially dangerous animals or exotic pets?".
GENERAL INFORMATION Does the applicant have any potentially dangerous animals or exotic pets? No Check the box (if applicable): Indicates a "No" response to the question, "Does applicant have any potentially dangerous animals or exotic pets?".
GENERAL INFORMATION Is there any watercraft snowmobile exposure? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is there any watercraft or snowmobile exposure?".
Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Is there any watercraft snowmobile exposure? No Check the box (if applicable): Indicates a "No" response to the question, "Is there any watercraft or snowmobile exposure?".
GENERAL INFORMATION Are there any elevators on the premises? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Are there any elevators on the premises?".
GENERAL INFORMATION Are there any elevators on the premises? NO Check the box (if applicable): Indicates a "No" response to the question, "Are there any elevators on the premises?".
GENERAL INFORMATION 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.
ATTACHMENTS State Supplements Check the box (if applicable): Indicates a state supplement is attached to the policy.
ATTACHMENTS Photos Check the box (if applicable): Indicates a photograph is attached to the policy.
ATTACHMENTS Bill of Sale Check the box (if applicable): Indicates a bill of sale is attached to the policy.
ATTACHMENTS Appraisals Check the box (if applicable): Indicates an appraisal is attached to the policy.
ATTACHMENTS Inventories Check the box (if applicable): Indicates an inventory is attached to the policy.
ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Enter text: The description of an attachment to the policy.
ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments to the policy other than those listed.
ATTACHMENTS Other Description Enter text: The description of an attachment to the policy.
SIGNATURE SECTION Applicant's Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION Date Enter date: The date the form was signed by the named insured.
SIGNATURE SECTION 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.
SIGNATURE SECTION 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).