ACORD 5 (2011/07) rev. 6-30-2011
1 of 27
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 5 (2011/07)
Aircraft Loss Notice
ACORD 5, Aircraft Loss Notice, is used to report losses involving an
aircraft.
IDENTIFICATION SECTION Date (MM/DD/YYYY)
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
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 Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No)
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION 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 Loss Date
Enter date: The date that the loss occurred.
IDENTIFICATION SECTION Loss Time
Enter time: The approximate time that the loss occurred.
IDENTIFICATION SECTION AM
Check the box (if applicable): Indicates the loss occurred in the morning.
ACORD 5 (2011/07) rev. 6-30-2011
2 of 27
Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION PM
Check the box (if applicable): Indicates the loss occurred in the afternoon or evening.
IDENTIFICATION SECTION Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Aid
Policy Type - Aircraft - Industrial
Check the box (if applicable): Indicates the type of policy is aircraft - industrial aid.
IDENTIFICATION SECTION Business
Policy Type - Aircraft - Pleasure &
Check the box (if applicable): Indicates the type of policy is aircraft - pleasure and
business.
IDENTIFICATION SECTION Policy Type - Aircraft - Non-Owned
Check the box (if applicable): Indicates the type of policy is aircraft - non-owned.
IDENTIFICATION SECTION Policy Type - Aircraft - Commercial
Check the box (if applicable): Indicates the type of policy is aircraft - commercial.
IDENTIFICATION SECTION Policy Type - Other
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
listed.
IDENTIFICATION SECTION Policy Type Other Description
Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Carrier Claim Number
Enter identifier: The identifier assigned to the claim by the insurer.
IDENTIFICATION SECTION Agency Claim Number
Enter identifier: The identifier assigned to the claim by the agency / producer.
IDENTIFICATION SECTION Attachments - Witness Schedule
Check the box (if applicable): Indicates a witness schedule is attached to the loss notice /
claim.
IDENTIFICATION SECTION Attachments - Injured Schedule
Check the box (if applicable): Indicates an injured schedule is attached to the loss notice /
claim.
INSURED
Name of Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INSURED
FEIN
Enter identifier: The tax identifier of the named insured.
INSURED
Ownership %
Enter percentage: The percentage of ownership the named insured has in the item.
INSURED
Primary Phone
Enter number: The named insured's primary phone number.
ACORD 5 (2011/07) rev. 6-30-2011
3 of 27
Section Name
Field Name
Field and/or Section Description
INSURED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INSURED
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
INSURED
Secondary Phone
Enter number: The named insured's secondary phone number.
INSURED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INSURED
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
INSURED
Insured's Mailing Address
Enter text: The named insured's mailing address line one.
INSURED
Enter text: The named insured's mailing address line two.
INSURED
Enter text: The named insured's mailing address city name.
INSURED
Enter code: The named insured's mailing address state or province code.
INSURED
Enter code: The named insured's mailing address postal code.
INSURED
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
INSURED
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
CONTACT
Contact Insured
Check the box (if applicable): Indicates If the individual to contact is the same as the
insured, check this box and leave blank the areas for contact name, address and phone
numbers.
CONTACT
Name of Contact
Enter text: The full name (First, Middle, Last) of the individual to be contacted as a
representative of the insured on all subsequent business relating to this incident. No entry
is needed if the 'Contact Insured' option is checked.
CONTACT
Primary Phone
Enter number: The loss contact's primary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
CONTACT
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
CONTACT
Secondary Phone
Enter number: The loss contact's secondary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
ACORD 5 (2011/07) rev. 6-30-2011
4 of 27
Section Name
Field Name
Field and/or Section Description
CONTACT
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
CONTACT
When to Contact
Enter text: The best time of the day to contact this individual (e.g., evenings, days, noon to
3:00 P.M.).
CONTACT
Contact's Mailing Address
Enter text: The loss contact's first address line.
CONTACT
Enter text: The loss contact's second address line.
CONTACT
Enter text: The loss contact's city.
CONTACT
Enter code: The loss contact's state.
CONTACT
Enter code: The loss contact's postal code.
CONTACT
Primary E-Mail Address
Enter text: The loss contact's primary e-mail address.
CONTACT
Secondary E-Mail Address
Enter text: The loss contact's secondary e-mail address.
LOSS
Airport ID
Enter identifier: The Federal Aviation Administration's designator for the airport where the
loss occurred (e.g. ORD - O'Hare International Airport).
LOSS
Name
Enter text: The name of the location. As used here, this is the name of the airport.
LOSS
Street
Enter text: The loss location's physical street address.
LOSS
City
Enter text: The loss location's city.
LOSS
County
Enter text: The loss location's county name.
LOSS
State / Province
Enter code: The loss location's state or province code.
LOSS
Postal Code
Enter code: The loss location's postal code.
LOSS
Country
Enter code: The loss location's country code.
LOSS
Location Description
Enter text: The description of the location of loss if not at a specific street address.
LOSS
Police or Fire Department
Contacted
Enter text: The name of the municipal, county or other police department, fire department
or other authority to which the accident was reported, including any precinct or station
number, if available.
LOSS
Report Number
Enter identifier: The report number assigned by the authority contacted. For example, the
number of the vehicle incident report filed by the police after an automobile accident.
LOSS
Description of Accident (Attach
ACORD 101, Additional Remarks
Schedule if more space is
required)
Enter text: The description of the incident resulting in a potential loss to the insured.
INSURED AIRCRAFT
Aircraft #
Enter identifier: The producer assigned aircraft number.
INSURED AIRCRAFT
Registration Number
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
ACORD 5 (2011/07) rev. 6-30-2011
5 of 27
Section Name
Field Name
Field and/or Section Description
INSURED AIRCRAFT
Base Airport ID
Enter code: The Federal Aviation Administration's designator for the airport where this
aircraft is based (e.g. ORD - O'Hare International Airport).
INSURED AIRCRAFT
Year
Enter year: The year of the aircraft.
INSURED AIRCRAFT
Make
Enter text: The manufacturer of the aircraft.
INSURED AIRCRAFT
Model
Enter text: The model of the aircraft.
INSURED AIRCRAFT
Serial #
Enter identifier: The serial number of the aircraft.
INSURED AIRCRAFT
Aircraft Type
Enter code: The type of aircraft. Valid codes are:
1 - Glider
2 - Balloon
3 - Blimp-Dirigible
4 - Fixed Wing Single Engine
5 - Fixed Wing Multi Engine
6 - Rotorcraft
7 - Weight Shift Control
8 - Powered Parachute
9 - Gyroplane
OT - Other
INSURED AIRCRAFT
Aircraft Use
Enter code: The primary use of the aircraft (i.e. AA - Air Ambulance, BT - Banner Towing,
CH - Charter, CO - Cargo Only, FC - Full Commercial, IA - Industrial Aid, PB - Pleasure
and Business, etc.).
INSURED AIRCRAFT
Check if same as insured.
Check the box (if applicable): Indicates if the owner of the insured vehicle or aircraft is the
same as the named insured.
INSURED AIRCRAFT
Owners Name & Address
Enter text: The full name of the individual or business that is the owner of the vehicle or
property.
INSURED AIRCRAFT
Enter text: The first address line of the owner of the vehicle or property.
INSURED AIRCRAFT
Enter text: The city of the owner of the vehicle or property.
INSURED AIRCRAFT
Enter code: The state or province code of the owner of the vehicle or property.
INSURED AIRCRAFT
Enter code: The postal code of the owner of the vehicle or property.
INSURED AIRCRAFT
Primary Phone
Enter number: The primary phone number for the owner of the vehicle or property.
INSURED AIRCRAFT
Home
Check the box (if applicable): Indicates the primary phone number for the owner is a home
phone.
INSURED AIRCRAFT
Business
Check the box (if applicable): Indicates the primary phone number for the owner is a
business phone.
INSURED AIRCRAFT
Cell
Check the box (if applicable): Indicates the primary phone number for the owner is a cell
phone.
INSURED AIRCRAFT
Secondary Phone
Enter number: The secondary phone number for the owner of the vehicle or property.
ACORD 5 (2011/07) rev. 6-30-2011
6 of 27
Section Name
Field Name
Field and/or Section Description
INSURED AIRCRAFT
Home
Check the box (if applicable): Indicates the secondary phone number for the owner is a
home phone.
INSURED AIRCRAFT
Business
Check the box (if applicable): Indicates the secondary phone number for the owner is a
business phone.
INSURED AIRCRAFT
Cell
Check the box (if applicable): Indicates the secondary phone number for the owner is a
cell phone.
INSURED AIRCRAFT
Primary E-Mail Address
Enter text: The primary e-mail address of the owner of the vehicle or property.
INSURED AIRCRAFT
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
INSURED AIRCRAFT
Check if same as owner.
Check the box (if applicable): Indicates if the pilot of the insured aircraft is the same as the
owner.
INSURED AIRCRAFT
Pilots Name & Address
Enter text: The full name of the pilot.
INSURED AIRCRAFT
Enter text: The pilot's mailing address line one.
INSURED AIRCRAFT
Enter text: The pilot's mailing address city name.
INSURED AIRCRAFT
Enter code: The pilot's mailing address state or province code.
INSURED AIRCRAFT
Enter code: The pilot's mailing address postal code.
INSURED AIRCRAFT
Primary Phone
Enter number: The pilot's primary phone number.
INSURED AIRCRAFT
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INSURED AIRCRAFT
Business
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
INSURED AIRCRAFT
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
INSURED AIRCRAFT
Secondary Phone
Enter number: The pilot's secondary phone number.
INSURED AIRCRAFT
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INSURED AIRCRAFT
Business
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INSURED AIRCRAFT
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
INSURED AIRCRAFT
Primary E-Mail Address
Enter text: The pilot's primary e-mail address.
INSURED AIRCRAFT
Secondary E-Mail Address
Enter text: The pilot's secondary e-mail address.
INSURED AIRCRAFT
Describe Damage
Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender
crushed).
INSURED AIRCRAFT
Estimate Amount
Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property.
INSURED AIRCRAFT
Where can aircraft be seen?
Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If
other than at the insureds address, include the address.
INSURED AIRCRAFT
When can aircraft be seen?
Enter text: The time period the vehicle, aircraft or property is available for inspection.
ACORD 5 (2011/07) rev. 6-30-2011
7 of 27
Section Name
Field Name
Field and/or Section Description
INSURED AIRCRAFT
Other Insurance on Aircraft -
Carrier
Enter text: The insurer name on any other applicable insurance.
INSURED AIRCRAFT
Other Insurance on Aircraft -
Policy Number
Enter identifier: The policy number on any other applicable insurance.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
OTHER AIRCRAFT /
PROPERTY DAMAGED
Non-Aircraft ?
Check the box (if applicable): Indicates the damage is not to an aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Aircraft #
Enter identifier: The producer assigned aircraft number.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Registration Number
Enter identifier: The registration number of the aircraft (a.k.a. tail number).
OTHER AIRCRAFT /
PROPERTY DAMAGED
Base Airport ID
Enter code: The Federal Aviation Administration's designator for the airport where this
aircraft is based (e.g. ORD - O'Hare International Airport).
OTHER AIRCRAFT /
PROPERTY DAMAGED
Year
Enter year: The year of the aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Make
Enter text: The manufacturer of the aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Model
Enter text: The model of the aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Serial #
Enter identifier: The serial number of the aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Aircraft Type
Enter code: The type of aircraft. Valid codes are:
1 - Glider
2 - Balloon
3 - Blimp-Dirigible
4 - Fixed Wing Single Engine
5 - Fixed Wing Multi Engine
6 - Rotorcraft
7 - Weight Shift Control
8 - Powered Parachute
9 - Gyroplane
OT - Other
OTHER AIRCRAFT /
PROPERTY DAMAGED
Aircraft Use
Enter code: The primary use of the aircraft (i.e. AA - Air Ambulance, BT - Banner Towing,
CH - Charter, CO - Cargo Only, FC - Full Commercial, IA - Industrial Aid, PB - Pleasure
and Business, etc.).
ACORD 5 (2011/07) rev. 6-30-2011
8 of 27
Section Name
Field Name
Field and/or Section Description
OTHER AIRCRAFT /
PROPERTY DAMAGED
Describe Property
Enter text: A brief description of the type of property damaged, such as home or fence.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Insured?
Enter code: Indicates if the damaged property, vehicle or aircraft is insured or not.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Company or Agency Name
Enter text: The insurer name on any other applicable insurance.
OTHER AIRCRAFT /
PROPERTY DAMAGED
NAIC Code
Enter code: The NAIC code of the insurance company that issued the policy.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Policy #
Enter identifier: The policy number on any other applicable insurance.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Owners Name & Address
Enter text: The full name of the individual or business that is the owner of the vehicle or
property. As used here, this is the owner of the other aircraft or property that was
damaged.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter text: The first address line of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter text: The city of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter code: The state or province code of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter code: The postal code of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Primary Phone
Enter number: The primary phone number for the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Home
Check the box (if applicable): Indicates the primary phone number for the owner is a home
phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Business
Check the box (if applicable): Indicates the primary phone number for the owner is a
business phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Cell
Check the box (if applicable): Indicates the primary phone number for the owner is a cell
phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Secondary Phone
Enter number: The secondary phone number for the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Home
Check the box (if applicable): Indicates the secondary phone number for the owner is a
home phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Business
Check the box (if applicable): Indicates the secondary phone number for the owner is a
business phone.
ACORD 5 (2011/07) rev. 6-30-2011
9 of 27
Section Name
Field Name
Field and/or Section Description
OTHER AIRCRAFT /
PROPERTY DAMAGED
Cell
Check the box (if applicable): Indicates the secondary phone number for the owner is a
cell phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Primary E-Mail Address
Enter text: The primary e-mail address of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Check if same as owner.
Check the box (if applicable): Indicates if the pilot of the insured aircraft is the same as the
owner.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Pilots Name & Address
Enter text: The full name of the pilot. As used here, this is the pilot of the other aircraft.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter text: The pilot's mailing address line one.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter text: The pilot's mailing address city name.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter code: The pilot's mailing address state or province code.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Enter code: The pilot's mailing address postal code.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Primary Phone
Enter number: The pilot's primary phone number.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Business
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Secondary Phone
Enter number: The pilot's secondary phone number.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Business
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Primary E-Mail Address
Enter text: The pilot's primary e-mail address.
ACORD 5 (2011/07) rev. 6-30-2011
10 of 27
Section Name
Field Name
Field and/or Section Description
OTHER AIRCRAFT /
PROPERTY DAMAGED
Secondary E-Mail Address
Enter text: The pilot's secondary e-mail address.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Describe Damage
Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender
crushed).
OTHER AIRCRAFT /
PROPERTY DAMAGED
Estimate Amount
Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property.
OTHER AIRCRAFT /
PROPERTY DAMAGED
Where can aircraft be seen?
Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If
other than at the insureds address, include the address.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
#
Enter number: The producer assigned number for the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The first address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The second address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The city of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The state or province of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The postal code of the injured party.
ACORD 5 (2011/07) rev. 6-30-2011
11 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
ACORD 5 (2011/07) rev. 6-30-2011
12 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
#
Enter number: The producer assigned number for the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The first address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The second address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The city of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The state or province of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The postal code of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
ACORD 5 (2011/07) rev. 6-30-2011
13 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
#
Enter number: The producer assigned number for the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
ACORD 5 (2011/07) rev. 6-30-2011
14 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The first address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The second address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The city of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The state or province of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The postal code of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
ACORD 5 (2011/07) rev. 6-30-2011
15 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
#
Enter number: The producer assigned number for the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The first address line of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The second address line of the injured party.
ACORD 5 (2011/07) rev. 6-30-2011
16 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter text: The city of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The state or province of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Enter code: The postal code of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Home Phone
Enter number: The primary phone number of the injured party. As used here, this is the
home phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Business Phone
Enter number: The secondary phone number of the injured party. As used here, this is the
business phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Cell Phone
Enter number: The third phone number of the injured party. As used here, this is the cell
phone number.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Insured Aircraft
Check the box (if applicable): Indicates if the injured party was in the insured's aircraft.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Aircraft
Check the box (if applicable): Indicates if the injured party was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Checkbox
Check the box (if applicable): Indicates if the injured party was in a location other than
those listed.
ACORD 5 (2011/07) rev. 6-30-2011
17 of 27
Section Name
Field Name
Field and/or Section Description
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Other Description
Enter text: The location of the injured party at the time of the incident or accident.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED (Attach ACORD 7,
Aviation Injured Schedule,
for additional injured
parties)
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
#
Enter number: The producer assigned number for the witness.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The second address line of a person that was a witness to the incident.
ACORD 5 (2011/07) rev. 6-30-2011
18 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Home Phone
Enter number: The primary phone number of a person that was a witness to the incident.
As used here, this is the home phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Business Phone
Enter number: The secondary phone number of the witness. As used here, this is the
business phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Cell Phone
Enter number: The third phone number of the witness. As used here, this is the cell phone
number.
ACORD 5 (2011/07) rev. 6-30-2011
19 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Insured Aircraft
Check the box (if applicable): Indicates if the witness was in the insured's aircraft at the
time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Aircraft
Check the box (if applicable): Indicates if the witness was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Checkbox
Enter text: Indicates the witness was in a location other than those listed. As used here, if
other, enter the location in Other Location Details.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Location Details
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
#
Enter number: The producer assigned number for the witness.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
ACORD 5 (2011/07) rev. 6-30-2011
20 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The second address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Home Phone
Enter number: The primary phone number of a person that was a witness to the incident.
As used here, this is the home phone number.
ACORD 5 (2011/07) rev. 6-30-2011
21 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Business Phone
Enter number: The secondary phone number of the witness. As used here, this is the
business phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Cell Phone
Enter number: The third phone number of the witness. As used here, this is the cell phone
number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Insured Aircraft
Check the box (if applicable): Indicates if the witness was in the insured's aircraft at the
time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Aircraft
Check the box (if applicable): Indicates if the witness was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Checkbox
Enter text: Indicates the witness was in a location other than those listed. As used here, if
other, enter the location in Other Location Details.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Location Details
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
ACORD 5 (2011/07) rev. 6-30-2011
22 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
#
Enter number: The producer assigned number for the witness.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The second address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The state or province code of a person that was a witness to the incident.
ACORD 5 (2011/07) rev. 6-30-2011
23 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Home Phone
Enter number: The primary phone number of a person that was a witness to the incident.
As used here, this is the home phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Business Phone
Enter number: The secondary phone number of the witness. As used here, this is the
business phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Cell Phone
Enter number: The third phone number of the witness. As used here, this is the cell phone
number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Insured Aircraft
Check the box (if applicable): Indicates if the witness was in the insured's aircraft at the
time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Aircraft
Check the box (if applicable): Indicates if the witness was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
ACORD 5 (2011/07) rev. 6-30-2011
24 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Checkbox
Enter text: Indicates the witness was in a location other than those listed. As used here, if
other, enter the location in Other Location Details.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Location Details
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
#
Enter number: The producer assigned number for the witness.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The second address line of a person that was a witness to the incident.
ACORD 5 (2011/07) rev. 6-30-2011
25 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Home Phone
Enter number: The primary phone number of a person that was a witness to the incident.
As used here, this is the home phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Business Phone
Enter number: The secondary phone number of the witness. As used here, this is the
business phone number.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Cell Phone
Enter number: The third phone number of the witness. As used here, this is the cell phone
number.
ACORD 5 (2011/07) rev. 6-30-2011
26 of 27
Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Insured Aircraft
Check the box (if applicable): Indicates if the witness was in the insured's aircraft at the
time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Aircraft
Check the box (if applicable): Indicates if the witness was in an aircraft other than the
insured's aircraft at the time of the incident or accident.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Checkbox
Enter text: Indicates the witness was in a location other than those listed. As used here, if
other, enter the location in Other Location Details.
WITNESSES OR
PASSENGERS (Attach
ACORD 6, Aviation Witness
/ Passenger Schedule, for
additional witnesses or
passengers)
Other Location Details
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
REMARKS
Remarks
Enter text: The aircraft loss notice general remarks. Describe any other additional
information that will assist in properly reporting and settling this claim. Include the
adjusters name if known. Attach ACORD 101, Additional Remarks Schedule, if more
space is required.
REMARKS
Reported By
Enter text: The name of the individual that reported the loss.
REMARKS
Reported To
Enter text: The name of the individual within the agency or company to whom this loss
was reported.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (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).
ACORD 5 (2011/07) rev. 6-30-2011
27 of 27
Section Name
Field Name
Field and/or Section Description
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).