ACORD 815 (2009/02)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 815 (2009/02)
International Liability Exposure
Supplement
ACORD 815, International Liability Exposure Supplement, is used to
provide information about any liability coverage to be provided with respect to business
activities or exposures outside of the United States. This supplement gets attached to
ACORD 126, Commercial General Liability Section.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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.
IDENTIFICATION SECTION First Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page. As
used here, this is the first named insured.
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 Sell Products
List Countries Where Applicant or
Employees will Work, Travel to or
Enter text: The countries where applicant or employees will work, travel to or sell products.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Foreign Operations
Nature of Business / Description of
Enter text: The text description of the operations of this risk or insured. As used here, this
section is designed to inform the underwriter of what business each applicant performs
and the way it is conducted by premises. Operations which may not be apparent in a
general description of operations may be segmented by location (e.g., location #1 is a
sales office in Paris, France, location #2 is a warehouse in Berlin, Germany). Include
number of leased and owned premises outside of the United States. The section should
be completed in enough detail to enable the underwriter to understand and classify each
operation. Do not use the classification wording from the Commercial Lines Manual or
Workers Compensation Manual. They do not provide adequate detail. Example: a
manufacturer of pulley wheels used in sewing machines should be described as such and
not as Metal Goods Mfg. N.O.C.
IDENTIFICATION SECTION Foreign Subsidiaries? Y / N
Does the Applicant have any
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Does the applicant have any foreign subsidiaries?.
LOSS HISTORY OUTSIDE
OF THE US
Chk here if none
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 OUTSIDE
OF THE US
See attached loss summary
Check the box (if applicable): Indicates that a loss summary report is attached to the
policy.
LOSS HISTORY OUTSIDE
OF THE US
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY OUTSIDE
OF THE US
Line
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY OUTSIDE
OF THE US
Type / Description of Occurrence
or Claim
Enter text: A brief description of the loss.
LOSS HISTORY OUTSIDE
OF THE US
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY OUTSIDE
OF THE US
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY OUTSIDE
OF THE US
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY OUTSIDE
OF THE US
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY OUTSIDE
OF THE US
Line
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY OUTSIDE
OF THE US
Type / Description of Occurrence
or Claim
Enter text: A brief description of the loss.
LOSS HISTORY OUTSIDE
OF THE US
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY OUTSIDE
OF THE US
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY OUTSIDE
OF THE US
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY OUTSIDE
OF THE US
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY OUTSIDE
OF THE US
Line
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY OUTSIDE
OF THE US
Type / Description of Occurrence
or Claim
Enter text: A brief description of the loss.
LOSS HISTORY OUTSIDE
OF THE US
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY OUTSIDE
OF THE US
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY OUTSIDE
OF THE US
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY OUTSIDE
OF THE US
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY OUTSIDE
OF THE US
Line
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY OUTSIDE
OF THE US
Type / Description of Occurrence
or Claim
Enter text: A brief description of the loss.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY OUTSIDE
OF THE US
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY OUTSIDE
OF THE US
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY OUTSIDE
OF THE US
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY OUTSIDE
OF THE US
Claim Status - Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY OUTSIDE
OF THE US
Remarks
Enter text: The remarks associated with loss history information
PRIOR INTERNATIONAL
COVERAGE
Prior carrier and producer
Enter text: The name of the previous insurer.
PRIOR INTERNATIONAL
COVERAGE
Enter text: The name of the previous producer.
PRIOR INTERNATIONAL
COVERAGE
# of Years with Company
Enter number: The number of years with the previous insurer.
PRIOR INTERNATIONAL
COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR INTERNATIONAL
COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR INTERNATIONAL
COVERAGE
Premium
Enter amount: The annual modified premium charged (not including taxes or service
charges) for the specified line of business.
COVERAGES / LIMITS
Limits - Foreign Sales -
Occurrence
Enter limit: The commercial general liability international coverage, foreign sales each
occurrence limit amount.
COVERAGES / LIMITS
Limits - Foreign Sales - Aggregate
Enter limit: The commercial general liability international coverage, foreign sales
aggregate limit amount.
COVERAGES / LIMITS
Limits - Foreign Sales - Excess
Enter limit: The commercial general liability international coverage, foreign sales excess
limit amount.
COVERAGES / LIMITS
Limits - Contract Cost -
Occurrence
Enter limit: The commercial general liability international coverage, contract cost each
occurrence limit amount.
COVERAGES / LIMITS
Limits - Contract Cost - Aggregate
Enter limit: The commercial general liability international coverage, contract cost
aggregate limit amount.
COVERAGES / LIMITS
Limits - Contract Cost - Excess
Enter limit: The commercial general liability international coverage, contract cost excess
limit amount.
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Section Name
Field Name
Field and/or Section Description
COVERAGES / LIMITS
Coverages - Contingent Auto -
Number of foreign owned autos:
Enter number: The number of foreign owned vehicles.
COVERAGES / LIMITS
Limits - Contingent Auto -
Occurrence
Enter limit: The commercial general liability international coverage, contingent auto each
occurrence limit amount.
COVERAGES / LIMITS
Limits - Contingent Auto - Excess
Enter limit: The commercial general liability international coverage, contingent auto excess
limit amount.
COVERAGES / LIMITS
Limits - Employers Liability -
Occurrence
Enter limit: The commercial general liability international coverage, employers liability each
occurrence limit amount.
COVERAGES / LIMITS
Limits - Employers Liability -
Excess
Enter limit: The commercial general liability international coverage, employers liability
excess limit amount.
OTHER COVERAGES
Employers Responsibility - Limit
Enter limit: The commercial general liability international coverage, employers
responsibility limit amount.
OTHER COVERAGES
Per Employee
Check the box (if applicable): Indicates the employers responsibility limit is per employee.
OTHER COVERAGES
Per Occurrence
Check the box (if applicable): Indicates the employers responsibility limit is per
occurrence.
OTHER COVERAGES
Trip Purpose
Enter text: The purpose of the trip.
OTHER COVERAGES
Number of Trips
Enter number: The number of trips.
OTHER COVERAGES
Duration (Average Length of Stay)
Enter text: The average length of stay per trip.
OTHER COVERAGES
Days
Check the box (if applicable): Indicates the trip duration count is in days.
OTHER COVERAGES
Weeks
Check the box (if applicable): Indicates the trip duration count is in weeks.
OTHER COVERAGES
Months
Check the box (if applicable): Indicates the trip duration count is in months.
OTHER COVERAGES
Trip Purpose
Enter text: The purpose of the trip.
OTHER COVERAGES
Number of Trips
Enter number: The number of trips.
OTHER COVERAGES
Duration (Average Length of Stay)
Enter text: The average length of stay per trip.
OTHER COVERAGES
Days
Check the box (if applicable): Indicates the trip duration count is in days.
OTHER COVERAGES
Weeks
Check the box (if applicable): Indicates the trip duration count is in weeks.
OTHER COVERAGES
Months
Check the box (if applicable): Indicates the trip duration count is in months.
OTHER COVERAGES
Trip Purpose
Enter text: The purpose of the trip.
OTHER COVERAGES
Number of Trips
Enter number: The number of trips.
OTHER COVERAGES
Duration (Average Length of Stay)
Enter text: The average length of stay per trip.
OTHER COVERAGES
Days
Check the box (if applicable): Indicates the trip duration count is in days.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Weeks
Check the box (if applicable): Indicates the trip duration count is in weeks.
OTHER COVERAGES
Months
Check the box (if applicable): Indicates the trip duration count is in months.
OTHER COVERAGES
Employees Abroad - Job
Functions performed
Enter text: The description of the job functions performed.
OTHER COVERAGES
Number of U.S. Nationals
Enter number: The number of United States nationals on the payroll.
OTHER COVERAGES
Payroll - U.S. Nationals
Enter amount: The total annual payroll of United States nationals outside of the United
States.
OTHER COVERAGES
Number of Third Country Nationals
Enter number: The number of third country nationals on the payroll.
OTHER COVERAGES
Payroll - Third Country Nationals
Enter amount: The total annual payroll of third country nationals outside of the United
States.
OTHER COVERAGES
Number of Local Nationals
Enter number: The number of local nationals on the payroll.
OTHER COVERAGES
Payroll - Local Nationals
Enter amount: The total annual payroll of local nationals outside of the United States.
OTHER COVERAGES
Employees Abroad - Job
Functions performed
Enter text: The description of the job functions performed.
OTHER COVERAGES
Number of U.S. Nationals
Enter number: The number of United States nationals on the payroll.
OTHER COVERAGES
Payroll - U.S. Nationals
Enter amount: The total annual payroll of United States nationals outside of the United
States.
OTHER COVERAGES
Number of Third Country Nationals
Enter number: The number of third country nationals on the payroll.
OTHER COVERAGES
Payroll - Third Country Nationals
Enter amount: The total annual payroll of third country nationals outside of the United
States.
OTHER COVERAGES
Number of Local Nationals
Enter number: The number of local nationals on the payroll.
OTHER COVERAGES
Payroll - Local Nationals
Enter amount: The total annual payroll of local nationals outside of the United States.
OTHER COVERAGES
Employees Abroad - Job
Functions performed
Enter text: The description of the job functions performed.
OTHER COVERAGES
Number of U.S. Nationals
Enter number: The number of United States nationals on the payroll.
OTHER COVERAGES
Payroll - U.S. Nationals
Enter amount: The total annual payroll of United States nationals outside of the United
States.
OTHER COVERAGES
Number of Third Country Nationals
Enter number: The number of third country nationals on the payroll.
OTHER COVERAGES
Payroll - Third Country Nationals
Enter amount: The total annual payroll of third country nationals outside of the United
States.
OTHER COVERAGES
Number of Local Nationals
Enter number: The number of local nationals on the payroll.
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Section Name
Field Name
Field and/or Section Description
OTHER COVERAGES
Payroll - Local Nationals
Enter amount: The total annual payroll of local nationals outside of the United States.
OTHER COVERAGES
Medical $
Enter limit: The commercial general liability international coverage, employers medical and
accidental death and dismemberment, medical limit amount.
OTHER COVERAGES
AD&D $
Enter limit: The commercial general liability international coverage, employers medical and
accidental death and dismemberment, accidental death and dismemberment limit amount.
OTHER COVERAGES
Number of Employees
Enter number: The number of employees.
OTHER COVERAGES
Number of Trips
Enter number: The number of trips.
OTHER COVERAGES
Duration (Average Length of Stay)
Enter text: The average length of stay per trip.
OTHER COVERAGES
Days
Check the box (if applicable): Indicates the employers medical and AD&D trip duration
count is in days.
OTHER COVERAGES
Weeks
Check the box (if applicable): Indicates the employers medical and AD&D trip duration
count is in weeks.
OTHER COVERAGES
Months
Check the box (if applicable): Indicates the employers medical and AD&D trip duration
count is in months.
OTHER COVERAGES
Separate Applications required for:
Kidnap and Extortion
Check the box (if applicable): Indicates the Kidnap/Ransom section is attached to this
policy.
OTHER COVERAGES
Separate Applications required for:
Property
Check the box (if applicable): Indicates the Property section is attached to this policy.
OTHER COVERAGES
Separate Applications required for:
Defense Base Act
Check the box (if applicable): Indicates the Defense Base Act section is attached to this
policy.
OTHER COVERAGES
Separate Applications required for:
Other
Check the box (if applicable): Indicates that a section that is not listed specifically on the
form is attached to this policy.
OTHER COVERAGES
Separate Applications required for:
Other Description
Enter text: The type of section being attached to the policy.
OTHER COVERAGES
Remarks
Enter text: The remarks associated with the general liability line of business.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Applicant's Title
Enter text: The title of the individual in the organization or his relationship to the
organization.
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).
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