Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 67 NJ (2010/08)
New Jersey Insurance
Underwriting Association
Dwelling Fire Application
ACORD 67 NJ, Dwelling Fire Application, is used to apply for
dwelling fire insurance through the New Jersey Insurance Underwriting Association. For
further information, contact the New Jersey Insurance Underwriting Association at 744
Broad Street, Newark, New Jersey 07102-3881 or at their web site, www.njiua.org.
IDENTIFICATION SECTION Date
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 Address 1
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Address 2
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION CITY
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION STATE
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION ZIP
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Telephone Number
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION License No
Enter identifier: The State License Number of the producer.
PRODUCERS SIGNATURE Producers 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.
PRODUCERS SIGNATURE Date
Enter date: The date the producer signed the form.
IDENTIFICATION SECTION Address (Include county & ZIP+4 )
Applicant's Name and Mailing
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Address 1
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Zip
Enter code: The named insured's mailing address postal code.
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 Checkbox New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION Checkbox Renewal
Check the box (if applicable): Indicates this form is for a renewal change request.
IDENTIFICATION SECTION Home Phone
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION Checkbox Home Phone Day
Check the box (if applicable): Indicates the home phone number is where the named
insured can be reached during the day.
IDENTIFICATION SECTION Checkbox Home Phone Eve
Check the box (if applicable): Indicates the home phone number is where the named
insured can be reached during the evening.
IDENTIFICATION SECTION Business Phone
Enter number: The named insured's business phone number.
IDENTIFICATION SECTION Checkbox Bus Phone Day
Check the box (if applicable): Indicates the business phone number is where the named
insured can be reached during the day.
IDENTIFICATION SECTION Checkbox Bus Phone Eve
Check the box (if applicable): Indicates the business phone number is where the named
insured can be reached during the evening.
IDENTIFICATION SECTION Address 1
Enter text: The first address line of the physical location.
IDENTIFICATION SECTION Address 2
Enter text: The second address line of the physical location.
IDENTIFICATION SECTION City
Enter text: The city of the physical location.
IDENTIFICATION SECTION County
Enter text: The county of the location.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION State
Enter code: The state or province of the physical location.
IDENTIFICATION SECTION Zip
Enter code: The postal code of the physical location.
IDENTIFICATION SECTION Building No
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION Person to Contact for Inspection
Enter text: The name of the person to contact to arrange for a premises inspection. This
should be an individual under the insured's employment, not the insurance agent's name
and number.
IDENTIFICATION SECTION Telephone Number
Enter number: The telephone number of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment.
APPLICANT INFORMATION Applicants Occupation
Enter text: The named insured's primary occupation or business activity.
APPLICANT INFORMATION Marital Status
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union
* U Unknown
* O Other
APPLICANT INFORMATION Date of Birth
Enter date: The date of birth of the insured.
COVERAGES/LIMITS OF
LIABILITY
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Basic.
COVERAGES/LIMITS OF
LIABILITY
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire
Extended Coverage.
COVERAGES/LIMITS OF
LIABILITY
Dwelling
Enter limit: The limit associated with dwelling coverage.
COVERAGES/LIMITS OF
LIABILITY
PersonalProperty
Enter limit: The limit associated with other structures coverage.
COVERAGES/LIMITS OF
LIABILITY
Replacement Cost
Enter amount: The estimated total dollar amount required to rebuild the residence without
depreciation.
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Section Name
Field Name
Field and/or Section Description
COVERAGES/LIMITS OF
LIABILITY
Deductible Type
Check the box (if applicable): Indicates the all peril deductible has been selected.
COVERAGES/LIMITS OF
LIABILITY
Deductible Type
Enter deductible: The all perils deductible amount.
COVERAGES/LIMITS OF
LIABILITY
Deductible Type
Enter code: The deductible type (e.g. flat, percentage) for the named hurricane deductible.
COVERAGES/LIMITS OF
LIABILITY
Deductible Type
Enter deductible: The named hurricane deductible amount if the deductible is expressed
as a dollar amount.
COVERAGES/LIMITS OF
LIABILITY
Checkbox
Check the box (if applicable): Indicates coverage is requested for fire, lightning and
explosion perils.
COVERAGES/LIMITS OF
LIABILITY
Checkbox
Check the box (if applicable): Indicates coverage is requested for extended coverage
perils.
COVERAGES/LIMITS OF
LIABILITY
Checkbox
Check the box (if applicable): Indicates coverage is requested for vandalism and malicious
mischief perils.
COVERAGES/LIMITS OF
LIABILITY
Purchase price of building
including improvements
Enter amount: The purchase price of the residence.
COVERAGES/LIMITS OF
LIABILITY
Perils Insured Against
Enter date: The date the residence was purchased, (MM/DD/YYYY).
COVERAGES/LIMITS OF
LIABILITY
Whole or part vacant or
unoccupied?
Check the box (if applicable): Indicates part of the building is vacant or unoccupied.
COVERAGES/LIMITS OF
LIABILITY
Whole or part vacant or
unoccupied?
Check the box (if applicable): Indicates no part of the building is vacant or unoccupied.
COVERAGES/LIMITS OF
LIABILITY
Whole or part vacant or
unoccupied?
Enter percentage: The percentage of the structure that is vacant or unoccupied.
RATING/UNDERWRITING
Checkbox Owner Occupied
Check the box (if applicable): Indicates the residence is occupied by the owner.
RATING/UNDERWRITING
Checkbox Tenant Occupied
Check the box (if applicable): Indicates the residence is occupied by tenants.
RATING/UNDERWRITING
Occupany for Building or Personal
Property
Enter number: The number of weeks the residence is occupied or rented to others.
RATING/UNDERWRITING
Checkbox Secondary Residence
Check the box (if applicable): Indicates that this is a secondary residence.
RATING/UNDERWRITING
Checkbox Seasonal Residence
Check the box (if applicable): Indicates that this is a seasonal residence.
RATING/UNDERWRITING
Checkbox Under Construction
Check the box (if applicable): Indicates the structure is new construction (builders risk).
RATING/UNDERWRITING
Occupany for Building or Personal
Property
Enter date: The estimated completion date for this construction project.
RATING/UNDERWRITING
Checkbox Number of Families 1
Check the box (if applicable): Indicates the residence is occupied by one family.
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Section Name
Field Name
Field and/or Section Description
RATING/UNDERWRITING
Checkbox Number of Families 2
Check the box (if applicable): Indicates the residence is occupied by two families.
RATING/UNDERWRITING
Checkbox Number of Families 3
Check the box (if applicable): Indicates the residence is occupied by three families.
RATING/UNDERWRITING
Checkbox Number of Families 4
Check the box (if applicable): Indicates the residence is occupied by four families.
RATING/UNDERWRITING
Checkbox Number of Families 5
Check the box (if applicable): Indicates the residence is occupied by five families.
RATING/UNDERWRITING
Checkbox In Mercantile Building
Check the box (if applicable): Indicates personal property coverage is desired in a
mercantile building.
RATING/UNDERWRITING
Checkbox Frame
Check the box (if applicable): Indicates the construction of the structure is frame.
RATING/UNDERWRITING
Checkbox Masonry
Check the box (if applicable): Indicates the construction of the structure is masonry.
RATING/UNDERWRITING
Checkbox Masonry Veneer
Check the box (if applicable): Indicates the construction of the structure is masonry
veneer.
RATING/UNDERWRITING
Checkbox Other
Check the box (if applicable): Indicates the construction of the structure is other than
those listed.
RATING/UNDERWRITING
Other Type Description
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
RATING/UNDERWRITING
Checkbox Plastic Siding
Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic.
RATING/UNDERWRITING
Checkbox Asbestos Siding
Check the box (if applicable): Indicates the siding on the structure is asbestos.
RATING/UNDERWRITING
Checkbox Fire Res
Check the box (if applicable): Indicates the construction of the structure is fire resistive.
RATING/UNDERWRITING
For Personal Property
Enter amount: The current market value for which the residence could be sold.
RATING/UNDERWRITING
For Personal Property
Enter code: The material used to construct the roof. Examples:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake/Shingle
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is a dwelling.
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is an
apartment.
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Section Name
Field Name
Field and/or Section Description
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is a
condominium.
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is a mobile
home.
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is a
townhouse.
RATING/UNDERWRITING
Structure Type
Check the box (if applicable): Indicates the type of residence being insured is a row
house.
RATING/UNDERWRITING
Structure Type
Enter year: The year the structure was built (YYYY).
RATING/UNDERWRITING
Structure Type
Enter number: The residence's total square footage of living area (excluding basements).
RATING/UNDERWRITING
Structure Type
Enter number: The total number of rooms in the residence, including full and half
bathrooms.
RATING/UNDERWRITING
Structure Type
Enter number: The number of separate living units in structure.
IDENTIFICATION SECTION
Enter text: The property's fire district name.
IDENTIFICATION SECTION
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
RATING/UNDERWRITING
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.
RATING/UNDERWRITING
Distance to Hydrant
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
RATING/UNDERWRITING
Distance to Fire Station
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
RATING/UNDERWRITING
Number of
Enter number: The number of fire divisions in the building.
RATING/UNDERWRITING
Number of
Enter number: The number of units within a fire division.
RATING/UNDERWRITING
Enter code: The industry or company specific code that identifies the rating territory for
this item. The source of this code is individual insurer, Insurance Services Office or State
Insurance Department manuals.
RATING/UNDERWRITING
Heat Type
Enter text: The primary type of fuel/power used for heating.
RATING/UNDERWRITING
Heat Type
Enter text: The secondary type of fuel/power used for heating.
RATING/UNDERWRITING
Renovation Type.Wiring
Check the box (if applicable): Indicates if partial wiring improvements have been made
since the original construction.
RATING/UNDERWRITING
Renovation Type.Wiring
Check the box (if applicable): Indicates if complete wiring improvements have been made
since the original construction.
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Section Name
Field Name
Field and/or Section Description
RATING/UNDERWRITING
Renovation Type.Wiring
Enter year: The year the wiring improvements took place.
RATING/UNDERWRITING
Renovation Type.Plumbing
Check the box (if applicable): Indicates if partial plumbing improvements have been made
since the original construction.
RATING/UNDERWRITING
Renovation Type.Plumbing
Check the box (if applicable): Indicates if complete plumbing improvements have been
made since the original construction.
RATING/UNDERWRITING
Renovation Type.Plumbing
Enter year: The year the plumbing improvements took place.
RATING/UNDERWRITING
Renovation Type: Heating
Check the box (if applicable): Indicates if partial heating improvements have been made
since the original construction.
IDENTIFICATION SECTION Renovation Type: Heating
Check the box (if applicable): Indicates if complete heating improvements have been
made since the original construction.
RATING/UNDERWRITING
Renovation Type: Heating
Enter year: The year the heating improvements took place.
RATING/UNDERWRITING
Renovation Type:Roofing
Check the box (if applicable): Indicates if partial roofing improvements have been made
since the original construction.
RATING/UNDERWRITING
Renovation Type:Roofing
Check the box (if applicable): Indicates if complete roofing improvements have been
made since the original construction.
RATING/UNDERWRITING
Renovation Type:Roofing
Enter year: The year the roofing improvements took place.
RATING/UNDERWRITING
Renovation Type: Exterior Paint
Enter year: The year the exterior of the structure was last painted.
LOSS HISTORY
Any Losses, whether or not paid
by insurance during the last 3
years, at this or at any other
location?
Check the box (if applicable): Indicates there are prior losses or occurrences that may
give rise to claims for the mandated number of years.
LOSS HISTORY
Any Losses, whether or not paid
by insurance during the last 3
years, at this or at any other
location?: - No
Check the box (if applicable): Indicates there are no prior losses or occurrences that may
give rise to claims for the mandated number of years.
LOSS HISTORY
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
Amount
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
Amount
Enter amount: The amount that has been paid on this claim to date.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
Amount
Enter amount: The amount that has been paid on this claim to date.
PRIOR COVERAGE
Prior Coverage
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior PolicyNumber
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
Risk New to Agency?
Check the box (if applicable): Indicates a Yes response to the question, Risk new to
agency?
PRIOR COVERAGE
Risk New to Agency?
Check the box (if applicable): Indicates a No response to the question, Risk new to
agency?
ADDITIONAL INTEREST
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Check the box (if applicable): Indicates the additional interest type is an additional interest.
ADDITIONAL INTEREST
Addl Int NAME
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
ADDRESS 1
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
CITY
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
STATE
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
ZIP
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Loan Number
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Check the box (if applicable): Indicates the additional interest type is an additional interest.
ADDITIONAL INTEREST
Addl Int NAME
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
ADDRESS 1
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
CITY
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
STATE
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
ZIP
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Loan Number
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Are Property Taxes unpaid for two
(2) quarters or more?
Check the box (if applicable): Indicates a Yes response to the question, Are property
taxes unpaid for two (2) quarters or more?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Are property
taxes unpaid for two (2) quarters or more?
GENERAL INFORMATION
Does the property have any
outstanding fire or other code
violations which have been
brought to the applicants attention
by any authority?
Check the box (if applicable): Indicates a Yes response to the question, Does the
property have any outstanding fire or other code violations which have been brought to the
applicant's attention by any authority?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Does the
property have any outstanding fire or other code violations which have been brought to the
applicant's attention by any authority?
GENERAL INFORMATION
Has the property been condemned
or ordered uninhabitable by any
authority?
Check the box (if applicable): Indicates a Yes response to the question, Is this property
condemned or ordered uninhabitable?.
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is this property
condemned or ordered uninhabitable?.
GENERAL INFORMATION
Is any business conducted on the
premises?
Check the box (if applicable): Indicates a Yes response to the question, Is any business
conducted on premises? (including day/child care)?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is any business
conducted on premises ?(including day/child care)
GENERAL INFORMATION
Was the structured originally built
for other than private residence
and then converted?
Check the box (if applicable): Indicates a Yes response to the question, Was the
structure originally built for other than a private residence and then converted?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Was the
structure originally built for other than a private residence and then converted?
GENERAL INFORMATION
Any other insurance with this
company?
Check the box (if applicable): Indicates a Yes response to the question, Any other
insurance with this company?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Any other
insurance with this company?
GENERAL INFORMATION
Enter identifier: The policy number on any other applicable insurance.
GENERAL INFORMATION
Any coverage declined, cancelled
or non-renewed during the last
three (3) years?
Check the box (if applicable): Indicates a Yes response to the question, Any coverage
declined, cancelled or non-renewed during the specified number of years?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Any coverage
declined, cancelled or non-renewed during the specified number of years?
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Is there any unpaid, uncontested
premium due?
Check the box (if applicable): Indicates a Yes response to the question, Is there any
unpaid, uncontested premium due?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is there any
unpaid, uncontested premium due?
GENERAL INFORMATION
Is building undergoing
renovations or reconstruction?
Check the box (if applicable): Indicates a Yes response to the question, Is building
undergoing renovations or reconstruction?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is building
undergoing renovations or reconstruction?
GENERAL INFORMATION
Enter date: The date of the substantial improvements to the building.
GENERAL INFORMATION
Is house for sale?
Check the box (if applicable): Indicates a Yes response to the question, Is house for
sale?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is house for
sale?
GENERAL INFORMATION
Is there any existing property
damage?
Check the box (if applicable): Indicates a Yes response to the question, Is there any
existing property damage?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is there any
existing property damage?
GENERAL INFORMATION
Is building awaiting demolition?
Check the box (if applicable): Indicates a Yes response to the question, Is the building
awaiting demolition?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Is the building
awaiting demolition?
GENERAL INFORMATION
Has the applicant had a
foreclosure, reposession or
bankrupcy during the past five (5)
years?
Check the box (if applicable): Indicates a Yes response to the question, Has the
applicant had a foreclosure, repossession or bankruptcy during the last mandated number
of years?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Has the
applicant had a foreclosure, repossession or bankruptcy during the last mandated number
of years?
GENERAL INFORMATION
During the last ten (10) years, has
any applicant been convicted of
any degree of the crime of arson?
Check the box (if applicable): Indicates a Yes response to the question, During the last
specified number of years, has any applicant been convicted of any degree of the crime of
arson?.
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, During the last
specified number of years, has any applicant been convicted of any degree of the crime of
arson?.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Any fire code violations in the last
twelve (12) months?
Check the box (if applicable): Indicates a Yes response to the question, Any fire code
violations in the last specified number of months?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Any fire code
violations in the last specified number of months?
GENERAL INFORMATION
Are space heaters, kerosene
heaters vented and away from
furniture?
Check the box (if applicable): Indicates a Yes response to the question, Are space
heaters, kerosene heaters vented and away from furniture?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Are space
heaters, kerosene heaters vented and away from furniture?
GENERAL INFORMATION
Are electrical cords, extension
cords in good condition?
Check the box (if applicable): Indicates a Yes response to the question, Are electrical
cords, extension cords in good condition?
GENERAL INFORMATION
Check the box (if applicable): Indicates a No response to the question, Are electrical
cords, extension cords in good condition?
GENERAL INFORMATION
Provide name of an admitted
voluntary market insurer that
declined to provide homeowners
coverage to the applicant?
Enter text: The full name of a carrier that declined to provide homeowners coverage to the
applicant.
GENERAL INFORMATION
Reason for declination
Enter text: The reason the insurer declined coverage.
GENERAL INFORMATION
Reason for declination
Enter text: The reason the insurer declined coverage.
GENERAL INFORMATION
Reason for declination
Enter text: The reason the insurer declined coverage.
GENERAL INFORMATION
Enter text: The general remarks associated with this line of business. Use this section to
provide any additional information required for underwriting or rating. Attach ACORD 101,
Additional Remarks Schedule, is more space is required.
PARK AND MOBILE HOME
IDENTIFICATION
Year
Enter year: The model year of the mobile home.
PARK AND MOBILE HOME
IDENTIFICATION
Make
Enter text: The name of the manufacturer of the mobile home.
PARK AND MOBILE HOME
IDENTIFICATION
Model
Enter text: The manufacturer's model name for the mobile home.
PARK AND MOBILE HOME
IDENTIFICATION
Serial Number
Enter identifier: The serial number for this mobile home.
PARK AND MOBILE HOME
IDENTIFICATION
Length
Enter number: The length of the mobile home expressed in feet.
PARK AND MOBILE HOME
IDENTIFICATION
Width
Enter number: The width of the mobile home expressed in feet.
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Section Name
Field Name
Field and/or Section Description
PARK AND MOBILE HOME
IDENTIFICATION
Full
Check the box (if applicable): Indicates the mobile home tie downs are full.
PARK AND MOBILE HOME
IDENTIFICATION
Chassis Only
Check the box (if applicable): Indicates the mobile home tie downs are chassis only.
PARK AND MOBILE HOME
IDENTIFICATION
Overtop only
Check the box (if applicable): Indicates the mobile home tie downs are overtop only.
PARK AND MOBILE HOME
IDENTIFICATION
None
Check the box (if applicable): Indicates the mobile home has no tie downs.
PARK AND MOBILE HOME
IDENTIFICATION
Yes
Check the box (if applicable): Indicates the foundation is continuous masonry.
PARK AND MOBILE HOME
IDENTIFICATION
No
Check the box (if applicable): Indicates the foundation is not continuous masonry.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Name
Enter text: The full name of the director or officer of the organization.
SIGNATURE
Title
Enter text: The title of the director or officer.
SIGNATURE
Signature of Applicant
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 67 NJ (2010/08) rev. 08-31-2010
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