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ACORD 83 (2008/11) 1 of 31
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/16/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 83 (2008/11) |
Personal Umbrella Application |
The title of the form. The ACORD 83 Personal Umbrella Application is used to capture Personal Umbrella or Personal Excess insurance policies. These policies are personal lines insurance contracts that provide for indemnification of third parties as a result of damages and/or injuries sustained due to the insured's negligence with respect to personal acts. Coverage for negligence arising out of any professional activities and nearly all business pursuits conducted by the insured is normally excluded. It is important to note that personal umbrellas normally provide personal injury in addition to bodily injury coverage. While the latter coverage deals solely with physical injuries, the former includes "injuries" sustained as a result of libel, slander, defamation of character, false arrest and other "non-physical" perils. |
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TITLE |
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Personal umbrellas typically operate in excess of or "overlay" the primary liability coverage contained in other personal lines insurance contracts such as private passenger auto, homeowners and watercraft. Coverage limits are written on a combined single limit (CSL) basis. In some cases, Personal umbrellas may provide basic or "first dollar" coverage for certain types of negligence for which there is no primary coverage. Personal umbrellas can also overlay coverages afforded under certain commercial insurance contracts such as owners, landlords and tenants liability policies. They also provide that the insurer will pay legal defense costs on a first-dollar basis in addition to the policy limits. The majority of personal umbrellas contain a provision for a retained limit which effectively operates as a per occurrence deductible. |
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TITLE |
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Although insurance coverage afforded by a personal umbrella is typically operative "worldwide" and specific units at risk (such as automobiles) may be related to locations in varying geographical locations (rotary territories), premiums are developed on the basis of unique personal umbrella rates applicable at the insured's primary residence. No known requirement for allocating premiums back to other exposure locations exists. The underwriting process for any personal lines policy begins with the submission of a completed application. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
ACORD 83 (2008/11) 2 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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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. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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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. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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UMBRELLA INFORMATION |
Policy Amount |
Enter limit: The policy liability limit for personal umbrella coverage. |
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UMBRELLA INFORMATION |
Retention |
Enter amount: The amount of liability retained by the insured. Retention is usually expressed in whole dollars, but can be a percentage. |
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UMBRELLA INFORMATION |
Uninsured Motorists |
Enter limit: The limit for personal umbrella uninsured motorists coverage (not applicable in all states). |
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UMBRELLA INFORMATION |
Underinsured Motorist |
Enter limit: The limit for personal umbrella underinsured motorists coverage (not applicable in all states). |
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UMBRELLA INFORMATION |
Other Coverage Code |
Enter code: The code associated with the type of coverage being requested. |
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UMBRELLA INFORMATION |
Other Description |
Enter text: The description of other underlying coverages. |
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UMBRELLA INFORMATION |
Other Limit |
Enter limit: The limit for the coverage. |
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UMBRELLA INFORMATION |
Other Coverage Code |
Enter code: The code associated with the type of coverage being requested. |
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UMBRELLA INFORMATION |
Other Description |
Enter text: The description of other underlying coverages. |
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UMBRELLA INFORMATION |
Other Limit |
Enter limit: The limit for the coverage. |
ACORD 83 (2008/11) 3 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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UMBRELLA INFORMATION |
Premiums - Basic |
Enter amount: The premium for basic personal umbrella coverage. |
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UMBRELLA INFORMATION |
Residences |
Enter amount: The premium for residences. |
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UMBRELLA INFORMATION |
Automobiles |
Enter amount: The premium for automobiles. |
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UMBRELLA INFORMATION |
Recreational Vehicles |
Enter amount: The premium for recreational vehicles. |
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UMBRELLA INFORMATION |
Uninsured Motorist |
Enter amount: The premium for uninsured motorists. |
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UMBRELLA INFORMATION |
Underinsured Motorist |
Enter amount: The premium for underinsured motorists. |
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UMBRELLA INFORMATION |
Watercraft |
Enter amount: The premium for watercraft. |
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UMBRELLA INFORMATION |
Other |
Enter text: The description of other underlying coverages. |
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UMBRELLA INFORMATION |
Other Amount |
Enter amount: The premium for the coverage. |
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UMBRELLA INFORMATION |
Other |
Enter text: The description of other underlying coverages. |
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UMBRELLA INFORMATION |
Other Amount |
Enter amount: The premium for the coverage. |
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UMBRELLA INFORMATION |
Estimated Total Premium |
Enter amount: The estimated total cost amount of the policy. |
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UMBRELLA INFORMATION |
Calculations |
Enter text: The insurance company may require use of specific multipliers or factors which can be shown here. |
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PRIMARY POLICY INFORMATION |
Company/Policy Number |
Enter text: The full name of the insurer of the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Liability Ea Per |
Enter limit: The bodily injury each person limit on the underlying automobile policy. |
ACORD 83 (2008/11) 4 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PRIMARY POLICY INFORMATION |
Liability Ea Acc |
Enter limit: The bodily injury each accident limit or combined single limit on the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Property Damage Ea Acc |
Enter limit: The property damage each accident limit on the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Motorists Ea Per |
Enter limit: The uninsured motorists bodily injury each person limit on the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Motorists Ea Acc |
Enter limit: The uninsured motorists bodily injury each accident or combined single limit on the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
PD Acc |
Enter limit: The uninsured motorists property damage on the underlying automobile policy. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer of the underlying homeowners policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying homeowners policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying homeowners policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying homeowners policy. |
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PRIMARY POLICY INFORMATION |
Personal Liability Ea Occ |
Enter limit: The liability limit on the underlying homeowners policy. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer of the underlying dwelling fire policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying dwelling fire policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying dwelling fire policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying dwelling fire policy. |
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PRIMARY POLICY INFORMATION |
Personal Liability Ea Occ |
Enter limit: The liability limit on the underlying dwelling fire policy. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying watercraft policy. |
ACORD 83 (2008/11) 5 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Liability Ea Per |
Enter limit: The bodily injury each person limit on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Liability Ea Acc |
Enter limit: The bodily injury each accident or combined single limit on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Boaters Ea Per |
Enter limit: The uninsured motorists (boaters) bodily injury each person limit on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Boaters Ea Acc |
Enter limit: The uninsured motorists (boaters) bodily injury each accident or combined single limit on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
PD Ea Acc |
Enter limit: The uninsured motorists (boaters) property damage each accident limit on the underlying watercraft policy. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer on the underlying recreation vehicle policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Liability Ea Per |
Enter limit: The bodily injury each person limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Liability Ea Acc |
Enter limit: The bodily injury each accident or combined single limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Property Damage |
Enter limit: The property damage limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Motorists Ea Per |
Enter limit: The uninsured motorists bodily injury each person limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Uninsured Motorists Ea Acc |
Enter limit: The uninsured motorists bodily injury each accident or combined single limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
PD Ea Acc |
Enter limit: The property damage limit on the underlying recreational vehicle policy. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer of the underlying employers liability policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying employers liability policy. |
ACORD 83 (2008/11) 6 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying employers liability policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying employers liability policy. |
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PRIMARY POLICY INFORMATION |
Employers Liability Limit |
Enter limit: The limit of the underlying employers liability policy. |
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PRIMARY POLICY INFORMATION |
Type of Policy |
Enter text: The description of the underlying policy type. |
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PRIMARY POLICY INFORMATION |
Company Name |
Enter text: The full name of the insurer of the underlying policy. |
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PRIMARY POLICY INFORMATION |
Policy Number |
Enter identifier: The policy number of the underlying policy. |
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PRIMARY POLICY INFORMATION |
Eff |
Enter date: The effective date of the underlying policy. |
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PRIMARY POLICY INFORMATION |
Exp |
Enter date: The expiration date of the underlying policy. |
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PRIMARY POLICY INFORMATION |
Other Coverage Description |
Enter text: The description of the coverage. |
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PRIMARY POLICY INFORMATION |
Other Coverage Limit |
Enter limit: The limit on the underlying policy. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
ACORD 83 (2008/11) 7 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
ACORD 83 (2008/11) 8 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
ACORD 83 (2008/11) 9 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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PROPERTY |
# |
Enter number: The producer assigned number of the location. |
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PROPERTY |
Location |
Enter text: The first address line of the physical location. |
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PROPERTY |
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Enter text: The second address line of the physical location. |
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PROPERTY |
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Enter text: The city of the physical location. |
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PROPERTY |
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Enter text: The county of the location. |
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PROPERTY |
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Enter code: The state or province of the physical location. |
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PROPERTY |
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Enter code: The postal code of the physical location. |
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PROPERTY |
Description |
Enter text: The description of the location used to differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land. |
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PROPERTY |
Yr Built |
Enter year: The year the structure was built (YYYY). |
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PROPERTY |
Interest |
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.) |
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PROPERTY |
Occupancy |
Enter text: The description of the inhabitants of the residence. |
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PROPERTY |
Usage |
Enter text: The description of the usage of the residence. |
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IDENTIFICATION |
Initials |
Initial here: The named insured's initials. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
ACORD 83 (2008/11) 10 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
ACORD 83 (2008/11) 11 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
ACORD 83 (2008/11) 12 of 31
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Section Name |
Field Name |
Field and/or Section Description |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
ACORD 83 (2008/11) 13 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
ACORD 83 (2008/11) 14 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
# |
Enter number: The producer assigned vehicle number. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Year |
Enter year: The model year of the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Body |
Enter code: The body type of the vehicle. |
|
AUTOMOBILES AND RECREATIONAL VEHICLES |
Rec Veh Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the vehicle is a recreational vehicle. |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Year |
Enter year: The model year of the watercraft. |
|
WATERCRAFT |
Manufacturer |
Enter text: The manufacturer of the watercraft. |
|
WATERCRAFT |
Model |
Enter text: The manufacturer's model name for the watercraft. |
|
WATERCRAFT |
Length |
Enter number: The length of the watercraft expressed in feet. |
|
WATERCRAFT |
Horsepower |
Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks. |
|
WATERCRAFT |
Max Speed |
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles per hour or knots per hour. |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Power - Inboard |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor. |
ACORD 83 (2008/11) 15 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
WATERCRAFT |
Power - Outboard |
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor. |
|
WATERCRAFT |
Power - Inboard / Outdrive |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor. |
|
WATERCRAFT |
Power - Waterjet |
Check the box (if applicable): Indicates the watercraft is propelled by a water jet. |
|
WATERCRAFT |
Power - Sail |
Check the box (if applicable): Indicates the watercraft is propelled by a sail. |
|
WATERCRAFT |
Power - Other |
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those listed. |
|
WATERCRAFT |
Power - Other Description |
Enter text: The method of propulsion of the watercraft. |
|
WATERCRAFT |
Waters Navigated - Atlantic |
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean. |
|
WATERCRAFT |
Waters Navigated - Great Lakes |
Check the box (if applicable): Indicates the waters navigated are the Great Lakes. |
|
WATERCRAFT |
Waters Navigated - Inland Waterways |
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding rivers and the great lakes. |
|
WATERCRAFT |
Waters Navigated - Pacific |
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean. |
|
WATERCRAFT |
Waters Navigated - Rivers |
Check the box (if applicable): Indicates the waters navigates are rivers. |
|
WATERCRAFT |
Waters Navigated - Gulf of Mexico |
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico. |
|
WATERCRAFT |
Waters Navigated - Other |
Check the box (if applicable): Indicates the waters navigated are other than those listed. |
|
WATERCRAFT |
Waters Navigated - Other Description |
Enter text: The waters where the watercraft is predominantly used (e.g. Atlantic, Great Lakes, Inland Waterways, etc.). |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Year |
Enter year: The model year of the watercraft. |
|
WATERCRAFT |
Manufacturer |
Enter text: The manufacturer of the watercraft. |
|
WATERCRAFT |
Model |
Enter text: The manufacturer's model name for the watercraft. |
|
WATERCRAFT |
Length |
Enter number: The length of the watercraft expressed in feet. |
|
WATERCRAFT |
Horsepower |
Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks. |
|
WATERCRAFT |
Max Speed |
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles per hour or knots per hour. |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Power - Inboard |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor. |
ACORD 83 (2008/11) 16 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
WATERCRAFT |
Power - Outboard |
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor. |
|
WATERCRAFT |
Power - Inboard / Outdrive |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor. |
|
WATERCRAFT |
Power - Waterjet |
Check the box (if applicable): Indicates the watercraft is propelled by a water jet. |
|
WATERCRAFT |
Power - Sail |
Check the box (if applicable): Indicates the watercraft is propelled by a sail. |
|
WATERCRAFT |
Power - Other |
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those listed. |
|
WATERCRAFT |
Power - Other Description |
Enter text: The method of propulsion of the watercraft. |
|
WATERCRAFT |
Waters Navigated - Atlantic |
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean. |
|
WATERCRAFT |
Waters Navigated - Great Lakes |
Check the box (if applicable): Indicates the waters navigated are the Great Lakes. |
|
WATERCRAFT |
Waters Navigated - Inland Waterways |
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding rivers and the great lakes. |
|
WATERCRAFT |
Waters Navigated - Pacific |
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean. |
|
WATERCRAFT |
Waters Navigated - Rivers |
Check the box (if applicable): Indicates the waters navigates are rivers. |
|
WATERCRAFT |
Waters Navigated - Gulf of Mexico |
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico. |
|
WATERCRAFT |
Waters Navigated - Other |
Check the box (if applicable): Indicates the waters navigated are other than those listed. |
|
WATERCRAFT |
Waters Navigated - Other Description |
Enter text: The waters where the watercraft is predominantly used (e.g. Atlantic, Great Lakes, Inland Waterways, etc.). |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Year |
Enter year: The model year of the watercraft. |
|
WATERCRAFT |
Manufacturer |
Enter text: The manufacturer of the watercraft. |
|
WATERCRAFT |
Model |
Enter text: The manufacturer's model name for the watercraft. |
|
WATERCRAFT |
Length |
Enter number: The length of the watercraft expressed in feet. |
|
WATERCRAFT |
Horsepower |
Enter number: The horsepower of the engine. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in remarks. |
|
WATERCRAFT |
Max Speed |
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles per hour or knots per hour. |
|
WATERCRAFT |
# |
Enter number: The producer assigned number for the watercraft. |
|
WATERCRAFT |
Power - Inboard |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor. |
ACORD 83 (2008/11) 17 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
WATERCRAFT |
Power - Outboard |
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor. |
|
WATERCRAFT |
Power - Inboard / Outdrive |
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor. |
|
WATERCRAFT |
Power - Waterjet |
Check the box (if applicable): Indicates the watercraft is propelled by a water jet. |
|
WATERCRAFT |
Power - Sail |
Check the box (if applicable): Indicates the watercraft is propelled by a sail. |
|
WATERCRAFT |
Power - Other |
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those listed. |
|
WATERCRAFT |
Power - Other Description |
Enter text: The method of propulsion of the watercraft. |
|
WATERCRAFT |
Waters Navigated - Atlantic |
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean. |
|
WATERCRAFT |
Waters Navigated - Great Lakes |
Check the box (if applicable): Indicates the waters navigated are the Great Lakes. |
|
WATERCRAFT |
Waters Navigated - Inland Waterways |
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding rivers and the great lakes. |
|
WATERCRAFT |
Waters Navigated - Pacific |
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean. |
|
WATERCRAFT |
Waters Navigated - Rivers |
Check the box (if applicable): Indicates the waters navigates are rivers. |
|
WATERCRAFT |
Waters Navigated - Gulf of Mexico |
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico. |
|
WATERCRAFT |
Waters Navigated - Other |
Check the box (if applicable): Indicates the waters navigated are other than those listed. |
|
WATERCRAFT |
Waters Navigated - Other Description |
Enter text: The waters where the watercraft is predominantly used (e.g. Atlantic, Great Lakes, Inland Waterways, etc.). |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 18 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 19 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 20 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 21 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 22 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
First Name |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
Middle Name |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Last Name |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
Sex |
Enter code: The gender of the driver. |
|
OPERATOR INFORMATION |
Mar Stat |
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other |
ACORD 83 (2008/11) 23 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date of Birth |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
# |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date Lic |
Enter date: The original date on which a driver's license was issued to this driver. |
|
OPERATOR INFORMATION |
Drivers License #/Licensed State |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
Lic State |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Social Security # |
Enter identifier: The tax identifier (social security number) of the driver. |
|
OPERATOR INFORMATION |
Vehicle |
Enter number: The producer assigned vehicle number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses. |
|
OPERATOR INFORMATION |
Craft |
Enter number: The producer assigned watercraft number that this driver primarily uses. |
|
OPERATOR INFORMATION |
% Use |
Enter percentage: Indicates the percentage of driving done by this driver in the primary watercraft that this driver uses. |
|
OPERATOR INFORMATION |
Other |
Enter text: The annual mileage or any other information required by the insurance company for the driver. |
|
OPERATOR INFORMATION |
Losses |
Enter number: The number of years of loss information required by the insurer. |
|
OPERATOR INFORMATION |
Has any loss occurred |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if there have been any losses at any location, whether paid or not paid by insurance, in the last mandated number of years. As used here, indicates if there has been an auto accident or liability loss on a primary or excess policy, regardless of fault. |
|
OPERATOR INFORMATION |
Driver # |
Enter number: The producer assigned number for the driver involved in the loss, if applicable. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
OPERATOR INFORMATION |
Description |
Enter text: A brief description of the loss. |
|
OPERATOR INFORMATION |
Cost |
Enter amount: The amount that has been paid on this claim to date. |
ACORD 83 (2008/11) 24 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Driver # |
Enter number: The producer assigned number for the driver involved in the loss, if applicable. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
OPERATOR INFORMATION |
Description |
Enter text: A brief description of the loss. |
|
OPERATOR INFORMATION |
Cost |
Enter amount: The amount that has been paid on this claim to date. |
|
OPERATOR INFORMATION |
Driver # |
Enter number: The producer assigned number for the driver involved in the loss, if applicable. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
OPERATOR INFORMATION |
Description |
Enter text: A brief description of the loss. |
|
OPERATOR INFORMATION |
Cost |
Enter amount: The amount that has been paid on this claim to date. |
|
OPERATOR INFORMATION |
Driver # |
Enter number: The producer assigned number for the driver involved in the loss, if applicable. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
OPERATOR INFORMATION |
Description |
Enter text: A brief description of the loss. |
|
OPERATOR INFORMATION |
Cost |
Enter amount: The amount that has been paid on this claim to date. |
|
OPERATOR INFORMATION |
2. Any operators convicted for any traffic violations during the last three (3) years? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any operators convicted for any traffic violations during the mandated number of years?". |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date of the accident or conviction. |
|
OPERATOR INFORMATION |
Description |
Enter text: The description of the accident or conviction. |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
ACORD 83 (2008/11) 25 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Date |
Enter date: The date of the accident or conviction. |
|
OPERATOR INFORMATION |
Description |
Enter text: The description of the accident or conviction. |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date of the accident or conviction. |
|
OPERATOR INFORMATION |
Description |
Enter text: The description of the accident or conviction. |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Date |
Enter date: The date of the accident or conviction. |
|
OPERATOR INFORMATION |
Description |
Enter text: The description of the accident or conviction. |
|
OPERATOR INFORMATION |
3. Any operator have physical /mental impairment? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any driver have physical/mental impairment?". |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Description of Special Equipment |
Enter text: The description of any special equipment for a driver with physical or mental impairments. |
|
OPERATOR INFORMATION |
Medication / Treatment |
Enter text: The description of any medication or treatments for a driver with physical or mental impairments. |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Description of Special Equipment |
Enter text: The description of any special equipment for a driver with physical or mental impairments. |
|
OPERATOR INFORMATION |
Medication / Treatment |
Enter text: The description of any medication or treatments for a driver with physical or mental impairments. |
|
OPERATOR INFORMATION |
Drv # |
Enter number: The number assigned to the driver by the producer. |
|
OPERATOR INFORMATION |
Description of Special Equipment |
Enter text: The description of any special equipment for a driver with physical or mental impairments. |
|
OPERATOR INFORMATION |
Medication / Treatment |
Enter text: The description of any medication or treatments for a driver with physical or mental impairments. |
ACORD 83 (2008/11) 26 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
IDENTIFICATION |
Initials |
Initial here: The named insured's initials. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
GENERAL INFORMATION |
1. Any swimming pool, spa or hot tub on premises? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is there a swimming pool, spa or hot tub on the premises?". |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Description |
Enter text: The description of the swimming pool. |
|
GENERAL INFORMATION |
Above Ground |
Check the box (if applicable): Indicates the swimming pool is above ground. |
|
GENERAL INFORMATION |
In Ground |
Check the box (if applicable): Indicates the swimming pool is in the ground. |
|
GENERAL INFORMATION |
Approved Fence |
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an approved height. |
|
GENERAL INFORMATION |
Diving Board |
Check the box (if applicable): Indicates the swimming pool has a diving board. |
|
GENERAL INFORMATION |
Slide |
Check the box (if applicable): Indicates the swimming pool has a slide. |
|
GENERAL INFORMATION |
Other |
Check the box (if applicable): Indicates there is additional information to describe the pool. |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Description |
Enter text: The description of the swimming pool. |
|
GENERAL INFORMATION |
Above Ground |
Check the box (if applicable): Indicates the swimming pool is above ground. |
|
GENERAL INFORMATION |
In Ground |
Check the box (if applicable): Indicates the swimming pool is in the ground. |
|
GENERAL INFORMATION |
Approved Fence |
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an approved height. |
|
GENERAL INFORMATION |
Diving Board |
Check the box (if applicable): Indicates the swimming pool has a diving board. |
|
GENERAL INFORMATION |
Slide |
Check the box (if applicable): Indicates the swimming pool has a slide. |
|
GENERAL INFORMATION |
Other |
Check the box (if applicable): Indicates there is additional information to describe the pool. |
|
GENERAL INFORMATION |
2. Any employees? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any employees?". |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Full Time # Employees Inside |
Enter number: The number of full time employees that work inside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week full time inside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the full time employees that work inside the structure. |
|
GENERAL INFORMATION |
Full Time # Employees Outside |
Enter number: The number of full time employees that work outside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week full time outside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the full time employees that work outside the structure. |
ACORD 83 (2008/11) 27 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
Part Time # Employees Inside |
Enter number: The number of part time employees that work inside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week part time inside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the part time employees that work inside the structure. |
|
GENERAL INFORMATION |
Part Time # Employees Outside |
Enter number: The number of part time employees that work outside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week part time outside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the part time employees that work outside the structure. |
|
GENERAL INFORMATION |
Total Payroll All Employees |
Enter amount: The total annual payroll amount for all employees. |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Full Time # Employees Inside |
Enter number: The number of full time employees that work inside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week full time inside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the full time employees that work inside the structure. |
|
GENERAL INFORMATION |
Full Time # Employees Outside |
Enter number: The number of full time employees that work outside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week full time outside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the full time employees that work outside the structure. |
|
GENERAL INFORMATION |
Part Time # Employees Inside |
Enter number: The number of part time employees that work inside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week part time inside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the part time employees that work inside the structure. |
|
GENERAL INFORMATION |
Part Time # Employees Outside |
Enter number: The number of part time employees that work outside the structure. |
|
GENERAL INFORMATION |
# Hours Per Week |
Enter number: The number of hours per week part time outside employees work. |
|
GENERAL INFORMATION |
Duties |
Enter text: The description of the duties performed by the part time employees that work outside the structure. |
|
GENERAL INFORMATION |
Total Payroll All Employees |
Enter amount: The total annual payroll amount for all employees. |
|
GENERAL INFORMATION |
3. Does applicant or tenants have any animals or exotic pets? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does the applicant or any tenant have any animals or exotic pets?". |
|
GENERAL INFORMATION |
Animal Type |
Enter code: The type of animal (e.g. cat, dog, horse, etc.) |
|
GENERAL INFORMATION |
Breed |
Enter code: The breed of the animal (e.g. Doberman, German shepherd, etc.) |
|
GENERAL INFORMATION |
Bite History Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any animal currently in the household has ever been involved in a bite incident. |
|
GENERAL INFORMATION |
Animal Type |
Enter code: The type of animal (e.g. cat, dog, horse, etc.) |
|
GENERAL INFORMATION |
Breed |
Enter code: The breed of the animal (e.g. Doberman, German shepherd, etc.) |
ACORD 83 (2008/11) 28 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
Bite History Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any animal currently in the household has ever been involved in a bite incident. |
|
GENERAL INFORMATION |
Animal Type |
Enter code: The type of animal (e.g. cat, dog, horse, etc.) |
|
GENERAL INFORMATION |
Breed |
Enter code: The breed of the animal (e.g. Doberman, German shepherd, etc.) |
|
GENERAL INFORMATION |
Bite History Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any animal currently in the household has ever been involved in a bite incident. |
|
GENERAL INFORMATION |
4. Is there a trampoline on the premises? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Is there a trampoline on the premises?". |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Safety Net Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the trampoline on the premises has a safety net. |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Safety Net Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the trampoline on the premises has a safety net. |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Safety Net Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the trampoline on the premises has a safety net. |
|
GENERAL INFORMATION |
Loc # |
Enter number: The producer assigned number of the location. |
|
GENERAL INFORMATION |
Safety Net Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the trampoline on the premises has a safety net. |
|
GENERAL INFORMATION |
5. Any aircraft owned, leased, chartered or furnished for regular use? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any aircraft owned, leased, chartered or furnished for regular use?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
6. Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
7. Any real estate, vehicles watercraft, aircraft owned, hired, leased or regularly used, not covered by primary policies? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any real estate, vehicles, watercraft, aircraft, owned, hired, leased or regularly used, not covered by primary policies?". |
ACORD 83 (2008/11) 29 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
8. Do you engage in farming operation? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do you engage in any type of farming operation?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
9. Do you hold any non-compensated positions? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Do you hold any non-compensated positions?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
10. Any non-owned property exceeding $1,000 in value in your custody? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any non-owned property exceeding $1,000 in value, in your care, custody or control?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
11. Any business and/or professional activities included in primary policies? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any business and/or professional activities included in the primary policies?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
12. Any primary policy have reduced limits of liability? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Does any primary policy have reduced limits of liability or eliminated coverage for specific exposures?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
13. Any pending litigation, court proceedings or judgements? |
Enter Y for a “Yes” response. Input N for “No” response. The response to the question, "Any pending litigation, court proceedings or judgments?". |
|
GENERAL INFORMATION |
Remarks |
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
REMARKS |
Remarks |
Enter text: The remarks associated with the personal umbrella line of business. |
|
IDENTIFICATION |
Initials |
Initial here: The named insured's initials. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
REMARKS |
Remarks |
Enter text: The remarks associated with the personal umbrella line of business. |
|
REMARKS |
Attachments - State Supplement(s) |
Check the box (if applicable): Indicates a state supplemental form is attached. |
ACORD 83 (2008/11) 30 of 31
|
Section Name |
Field Name |
Field and/or Section Description |
|
REMARKS |
Other |
Check the box (if applicable): Indicates there is an attachment to the policy other than those listed. |
|
REMARKS |
Other Description |
Enter text: The description of an attachment. |
|
REMARKS |
Other |
Check the box (if applicable): Indicates there is an attachment to the policy other than those listed. |
|
REMARKS |
Other Description |
Enter text: The description of an attachment. |
|
SIGNATURE |
Notice of Information Practices |
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices has been given to the applicant. |
|
SIGNATURE |
Producer's Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
|
SIGNATURE |
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. |
|
SIGNATURE |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
SIGNATURE |
Applicable Only in Indiana |
Initial here: The named insured's initials. As used here, in Indiana, indicates the uninsured motorists limits indicated in this application have been selected. |
|
SIGNATURE |
I Reject UM Coverage |
Initial here: The named insured's initials. As used here, in Indiana, indicates uninsured motorists coverage in its entirety has been rejected. |
|
SIGNATURE |
I Select UIM Coverage |
Initial here: The named insured's initials. As used here, in Indiana, indicates the underinsured motorists limits indicated in this application have been selected. |
|
SIGNATURE |
I Reject UIM Coverage |
Initial here: The named insured's initials. As used here, in Indiana, indicates underinsured motorists coverage in its entirety has been rejected. |
|
SIGNATURE |
Applicable Only in Louisiana |
Initial here: The named insured's initials. As used here, in Louisiana, indicates the uninsured motorists limits indicated in this application have been selected. |
|
SIGNATURE |
I Reject UM Coverage |
Initial here: The named insured's initials. As used here, in Louisiana, indicates uninsured motorists coverage in its entirety has been rejected. |
|
SIGNATURE |
Applicable Only in New Hampshire |
Initial here: The named insured's initials. As used here, in New Hampshire, indicates the uninsured motorists limits indicated in this application have been selected. |
|
Section Name |
Field Name |
Field and/or Section Description |
|
SIGNATURE |
I Reject UM Coverage |
Initial here: The named insured's initials. As used here, in New Hampshire, indicates uninsured motorists coverage in its entirety has been rejected. |
|
SIGNATURE |
Applicable Only in Wisconsin (UM) |
Check the box (if applicable): Indicates that uninsured motorists coverage is available. |
|
SIGNATURE |
Is Not Available |
Check the box (if applicable): Indicates that uninsured motorists coverage is not available. |
|
SIGNATURE |
Applicable Only in Wisconsin (UIM) |
Check the box (if applicable): Indicates that underinsured motorists coverage is available. |
|
SIGNATURE |
Is Not Available |
Check the box (if applicable): Indicates that underinsured motorists coverage is not available. |
|
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. |
|
Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 83 (2008/11) 31 of 31
|