ACORD 810 (2014/12) - Business Income / Extra Expense / Rental Value

ACORD 810 (2014/12) - Business Income / Extra Expense / Rental Value
ACORD 810, Business Income / Extra Expense / Rental Value, should be used as a supplement to ACORD 140, Property Section, when any form
of Business Income, Extra Expense or Rental Value coverage is to be provided.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant (First Name
Insured)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
PREMISES INFORMATION
Premises #
Enter number: The location number for the premises.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Business Income / Extra
Expense
Check the box (if applicable): Indicates business income with extra expense coverage applies to
a specific premises.
PREMISES INFORMATION
Business Income W/O Extra
Expense
Check the box (if applicable): Indicates business income without extra expense coverage
applies to a specific premises.
PREMISES INFORMATION
Extra Expense
Check the box (if applicable): Indicates extra expense coverage applies to a specific premises.
PREMISES INFORMATION
Business Income / Rental
Value
Check the box (if applicable): Indicates business income with rental value included coverage
applies to a specific premises.
PREMISES INFORMATION
Rental Value
Check the box (if applicable): Indicates rental value coverage applies to a specific premises.
ACORD 810 (2014/12) rev. 05-29-2014
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PREMISES INFORMATION
Type of Business Non Mfg
Check the box (if applicable): Indicates the nature of business is non-manufacturing.
PREMISES INFORMATION
Type of Business Mfg
Check the box (if applicable): Indicates the nature of business is manufacturing.
PREMISES INFORMATION
Type of Business Mining
Check the box (if applicable): Indicates the nature of business is mining.
PREMISES INFORMATION
Type of Business % Coins
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.
PREMISES INFORMATION
Ordinary Payroll Excl
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded.
PREMISES INFORMATION
Ordinary Payroll 90 Days
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for 90 days.
PREMISES INFORMATION
Ordinary Payroll 180 Days
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for 180 days.
PREMISES INFORMATION
Ordinary Payroll Other
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for a number of
days other than those listed.
PREMISES INFORMATION
Ordinary Payroll Other
Description
Enter number: The number of days for the Ordinary Payroll exclusion.
PREMISES INFORMATION
Ordinary Payroll Other
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for a payroll
amount.
PREMISES INFORMATION
Ordinary Payroll Amount
Enter amount: The amount of Ordinary Payroll to be excluded from coverage.
PREMISES INFORMATION
Ordinary Payroll Inc
Check the box (if applicable): Indicates Ordinary Payroll coverage is included.
PREMISES INFORMATION
Ext Period
Check the box (if applicable): Indicates Extended Period of Indemnity coverage applies.
PREMISES INFORMATION
Days
Enter number: The number of days the indemnity period is extended.
PREMISES INFORMATION
Mo Period
Check the box (if applicable): Indicates monthly period of indemnity coverage applies.
PREMISES INFORMATION
Limits
Enter amount: The monthly period of indemnity limit amount.
PREMISES INFORMATION
Max Period
Check the box (if applicable): Indicates maximum period of indemnity coverage applies.
PREMISES INFORMATION
Other
Enter amount: The maximum period of indemnity limit amount.
PREMISES INFORMATION
Days Period Rest
Enter number: The period of restoration, in days, selected.
PREMISES INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
PREMISES INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
PREMISES INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
PREMISES INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
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PREMISES INFORMATION
Power / Heat
Check the box (if applicable): Indicates a Power, Heat and Refrigeration deduction applies to the
premises.
PREMISES INFORMATION
Deduction
Enter amount: The amount of the Power, Heat and Refrigeration deduction for the premises.
PREMISES INFORMATION
Elec Media
Check the box (if applicable): Indicates EDP data / media coverage applies to a specific
premises.
PREMISES INFORMATION
Days
Enter number: The number of days the Electronic Data Processing equipment and media
coverage is to be extended.
PREMISES INFORMATION
Ord or Law
Check the box (if applicable): Indicates building ordinance or law coverage applies to a specific
premises.
PREMISES INFORMATION
Days
Enter number: The number of days Building Ordinance or Law coverage is applicable.
PREMISES INFORMATION
Civil Authority
Check the box (if applicable): Indicates Civil Authority coverage applies to a specific premises.
PREMISES INFORMATION
Days
Enter number: The number of days Civil Authority coverage is applicable.
PREMISES INFORMATION
Off Prem Power
Check the box (if applicable): Indicates Off Premises Power coverage applies to this premises.
PREMISES INFORMATION
Power
Check the box (if applicable): Indicates Off Premises Power coverage applies to power.
PREMISES INFORMATION
Water
Check the box (if applicable): Indicates Off Premises Power coverage applies to water.
PREMISES INFORMATION
Comm Describe Below
Check the box (if applicable): Indicates Off Premises Power coverage applies to
communications.
PREMISES INFORMATION
Tuition Fees
Check the box (if applicable): Indicates Tuition Fees coverage applies to this premises.
PREMISES INFORMATION
Students
Enter amount: The dollar amount applicable to coverage for student's tuition fees.
PREMISES INFORMATION
Other Ed Serv / Inc
Enter amount: The dollar amount applicable to coverage for other educational services or
income.
PREMISES INFORMATION
Depend Prop
Check the box (if applicable): Indicates Dependent Property coverage applies to a specific
premises.
PREMISES INFORMATION
Broad Form
Check the box (if applicable): Indicates Dependent Property coverage applies on a broad form
basis.
PREMISES INFORMATION
Limited Form
Check the box (if applicable): Indicates Dependent Property coverage applies on a limited form
basis.
PREMISES INFORMATION
Other
Check the box (if applicable): Indicates Dependent Property coverage applies on an other form
basis.
PREMISES INFORMATION
Other Description
Enter text: The description of the Dependent Property coverage form selected.
ACORD 810 (2014/12) rev. 05-29-2014
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PREMISES INFORMATION
Coin %
Enter percentage: The applicable coinsurance percentage for Dependent Property. This
percentage may be different from the percentage applicable to basic Business Income
coverage.
PREMISES INFORMATION
Cont Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to
Contributing Locations.
PREMISES INFORMATION
Rec Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to Recipient
Locations.
PREMISES INFORMATION
MFG Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to
Manufacturing Locations.
PREMISES INFORMATION
LDR Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to Leader
Locations.
PREMISES INFORMATION
Name and Address for Off
Prem Power or Depend Prop
Enter text: The name for each off premises power or dependent property provided coverage.
PREMISES INFORMATION
Address Line 1
Enter text: The first address line for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
Address Line 2
Enter text: The second address for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
City
Enter text: The city name for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
State
Enter code: The state or province code for each off premises power or dependent property
provided coverage.
PREMISES INFORMATION
Zip
Enter code: The postal code for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
Name and Address for Off
Prem Power or Depend Prop
Enter text: The name for each off premises power or dependent property provided coverage.
PREMISES INFORMATION
Address Line 1
Enter text: The first address line for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
Address Line 2
Enter text: The second address for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
City
Enter text: The city name for each off premises power or dependent property provided
coverage.
PREMISES INFORMATION
State
Enter code: The state or province code for each off premises power or dependent property
provided coverage.
PREMISES INFORMATION
Zip
Enter code: The postal code for each off premises power or dependent property provided
coverage.
ACORD 810 (2014/12) rev. 05-29-2014
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PREMISES INFORMATION
Other Coverages
Enter text: Information on any endorsements or options not already provided for this premises.
Also provide rating information required for these options, or by individual company programs
such as Class Rate, Rate Reference, Sales or Earnings.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ADDITIONAL PREMISES
INFORMATION
Premises #
Enter number: The location number for the premises.
ADDITIONAL PREMISES
INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
ADDITIONAL PREMISES
INFORMATION
Business Income/Extra
Expense
Check the box (if applicable): Indicates business income with extra expense coverage applies to
a specific premises.
ADDITIONAL PREMISES
INFORMATION
Business Income W/O Extra
Expense
Check the box (if applicable): Indicates business income without extra expense coverage
applies to a specific premises.
ADDITIONAL PREMISES
INFORMATION
Extra Expense
Check the box (if applicable): Indicates extra expense coverage applies to a specific premises.
ADDITIONAL PREMISES
INFORMATION
Business Income / Rental
Value
Check the box (if applicable): Indicates business income with rental value included coverage
applies to a specific premises.
ADDITIONAL PREMISES
INFORMATION
Rental Value
Check the box (if applicable): Indicates rental value coverage applies to a specific premises.
ADDITIONAL PREMISES
INFORMATION
Type of Business Non MFG
Check the box (if applicable): Indicates the nature of business is non-manufacturing.
ADDITIONAL PREMISES
INFORMATION
Type of Business MFG
Check the box (if applicable): Indicates the nature of business is manufacturing.
ADDITIONAL PREMISES
INFORMATION
Type of Business Mining
Check the box (if applicable): Indicates the nature of business is mining.
ADDITIONAL PREMISES
INFORMATION
Type of Business % Coins
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.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Excl
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded.
ACORD 810 (2014/12) rev. 05-29-2014
Page 5 of 9
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Inc
Check the box (if applicable): Indicates Ordinary Payroll coverage is included.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll 90 Days
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for 90 days.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll 180 Days
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for 180 days.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Other
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for a number of
days other than those listed.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Other
Description
Enter number: The number of days for the Ordinary Payroll exclusion.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Other
Check the box (if applicable): Indicates Ordinary Payroll coverage is excluded for a payroll
amount.
ADDITIONAL PREMISES
INFORMATION
Ordinary Payroll Amount
Enter amount: The amount of Ordinary Payroll to be excluded from coverage.
ADDITIONAL PREMISES
INFORMATION
Ext Period
Check the box (if applicable): Indicates Extended Period of Indemnity coverage applies.
ADDITIONAL PREMISES
INFORMATION
Days
Enter number: The number of days the indemnity period is extended.
ADDITIONAL PREMISES
INFORMATION
Mo Period
Check the box (if applicable): Indicates monthly period of indemnity coverage applies.
ADDITIONAL PREMISES
INFORMATION
Limits
Enter amount: The monthly period of indemnity limit amount.
ADDITIONAL PREMISES
INFORMATION
Max Period
Check the box (if applicable): Indicates maximum period of indemnity coverage applies.
ADDITIONAL PREMISES
INFORMATION
Other
Enter amount: The maximum period of indemnity limit amount.
ADDITIONAL PREMISES
INFORMATION
Days Period Rest
Enter number: The period of restoration, in days, selected.
ADDITIONAL PREMISES
INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
ADDITIONAL PREMISES
INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
ADDITIONAL PREMISES
INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
ACORD 810 (2014/12) rev. 05-29-2014
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ADDITIONAL PREMISES
INFORMATION
Limit Loss Pay %
Enter percentage: The loss payment percentage limitation selected.
ADDITIONAL PREMISES
INFORMATION
Power/Heat
Check the box (if applicable): Indicates a Power, Heat and Refrigeration deduction applies to the
premises.
ADDITIONAL PREMISES
INFORMATION
Deductible
Enter amount: The amount of the Power, Heat and Refrigeration deduction for the premises.
ADDITIONAL PREMISES
INFORMATION
Elec Media
Check the box (if applicable): Indicates EDP data / media coverage applies to a specific
premises.
ADDITIONAL PREMISES
INFORMATION
Days
Enter number: The number of days the Electronic Data Processing equipment and media
coverage is to be extended.
ADDITIONAL PREMISES
INFORMATION
Ord or Law
Check the box (if applicable): Indicates building ordinance or law coverage applies to a specific
premises.
ADDITIONAL PREMISES
INFORMATION
Days
Enter number: The number of days Building Ordinance or Law coverage is applicable.
ADDITIONAL PREMISES
INFORMATION
Civil Authority
Check the box (if applicable): Indicates Civil Authority coverage applies to a specific premises.
ADDITIONAL PREMISES
INFORMATION
Days
Enter number: The number of days Civil Authority coverage is applicable.
ADDITIONAL PREMISES
INFORMATION
Off Prem Power
Check the box (if applicable): Indicates Off Premises Power coverage applies to this premises.
ADDITIONAL PREMISES
INFORMATION
Power
Check the box (if applicable): Indicates Off Premises Power coverage applies to power.
ADDITIONAL PREMISES
INFORMATION
Water
Check the box (if applicable): Indicates Off Premises Power coverage applies to water.
ADDITIONAL PREMISES
INFORMATION
Comm Describe Below
Check the box (if applicable): Indicates Off Premises Power coverage applies to
communications.
ADDITIONAL PREMISES
INFORMATION
Tuition Fees
Check the box (if applicable): Indicates Tuition Fees coverage applies to this premises.
ADDITIONAL PREMISES
INFORMATION
Students
Enter amount: The dollar amount applicable to coverage for student's tuition fees.
ADDITIONAL PREMISES
INFORMATION
Other Ed Serv / Inc
Enter amount: The dollar amount applicable to coverage for other educational services or
income.
ADDITIONAL PREMISES
INFORMATION
Depend Prop
Check the box (if applicable): Indicates Dependent Property coverage applies to a specific
premises.
ACORD 810 (2014/12) rev. 05-29-2014
Page 7 of 9
ADDITIONAL PREMISES
INFORMATION
Broad Form
Check the box (if applicable): Indicates Dependent Property coverage applies on a broad form
basis.
ADDITIONAL PREMISES
INFORMATION
Limited Form
Check the box (if applicable): Indicates Dependent Property coverage applies on a limited form
basis.
ADDITIONAL PREMISES
INFORMATION
Other
Check the box (if applicable): Indicates Dependent Property coverage applies on an other form
basis.
ADDITIONAL PREMISES
INFORMATION
Other Description
Enter text: The description of the Dependent Property coverage form selected.
ADDITIONAL PREMISES
INFORMATION
Coin %
Enter percentage: The applicable coinsurance percentage for Dependent Property. This
percentage may be different from the percentage applicable to basic Business Income
coverage.
ADDITIONAL PREMISES
INFORMATION
Cont Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to
Contributing Locations.
ADDITIONAL PREMISES
INFORMATION
Rec Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to Recipient
Locations.
ADDITIONAL PREMISES
INFORMATION
MFG Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to
Manufacturing Locations.
ADDITIONAL PREMISES
INFORMATION
LDR Loc
Check the box (if applicable): Indicates the Dependent Property coverage applies to Leader
Locations.
ADDITIONAL PREMISES
INFORMATION
Name and Address for Off
Prem Power or Depend Prop
Enter text: The name for each off premises power or dependent property provided coverage.
ADDITIONAL PREMISES
INFORMATION
Address Line 1
Enter text: The first address line for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
Address Line 2
Enter text: The second address for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
City
Enter text: The city name for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
State
Enter code: The state or province code for each off premises power or dependent property
provided coverage.
ADDITIONAL PREMISES
INFORMATION
Zip
Enter code: The postal code for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
Name and Address for Off
Prem Power or Depend Prop
Enter text: The name for each off premises power or dependent property provided coverage.
ACORD 810 (2014/12) rev. 05-29-2014
Page 8 of 9
ADDITIONAL PREMISES
INFORMATION
Address Line 1
Enter text: The first address line for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
Address Line 2
Enter text: The second address for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
City
Enter text: The city name for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
State
Enter code: The state or province code for each off premises power or dependent property
provided coverage.
ADDITIONAL PREMISES
INFORMATION
Zip
Enter code: The postal code for each off premises power or dependent property provided
coverage.
ADDITIONAL PREMISES
INFORMATION
Other Coverages
Enter text: Information on any endorsements or options not already provided for this premises.
Also provide rating information required for these options, or by individual company programs
such as Class Rate, Rate Reference, Sales or Earnings.
Form Page 3
Section Name
Field Name
Description
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in Florida)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 810 (2014/12) rev. 05-29-2014
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