ACORD 89 (2014/12) - Residential Section

ACORD 89 (2014/12) - Residential Section
ACORD 89, Residential Section, is used to apply for a policy with multiple types of coverage and must be attached to the base form, ACORD 88,
Personal Lines Application, Applicant Information Section. The underwriting process for any personal lines policy begins with the submission of a
completed application.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the National Association of
Insurance Commissioners (NAIC).
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
INSURANCE REQUESTED
Homeowners (checkbox)
Check the box (if applicable): Indicates the type of policy is homeowners.
INSURANCE REQUESTED
Dwelling Fire (checkbox)
Check the box (if applicable): Indicates the type of policy is dwelling fire.
INSURANCE REQUESTED
Mobile Home (checkbox)
Check the box (if applicable): Indicates the type of policy is mobile home.
INSURANCE REQUESTED
Form #
Enter code: Indicates the policy form being used (e.g. HO-2, HO-4, etc.)
INSURANCE REQUESTED
Fire (checkbox)
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Basic.
INSURANCE REQUESTED
Fire & EC (checkbox)
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Extended
Coverage.
INSURANCE REQUESTED
Fire, EC & VMM (checkbox)
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Extended
Coverage and Vandalism and Malicious Mischief.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 1 of 33
INSURANCE REQUESTED
Broad (checkbox)
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Broad
(HO-2).
INSURANCE REQUESTED
Special (checkbox)
Check the box (if applicable): Indicates the policy form being used is Dwelling Fire Special.
IDENTIFICATION SECTION
Payor Applicant (checkbox)
Check the box (if applicable): Indicates the payor of the policy is the insured.
IDENTIFICATION SECTION
Payor Mortgagee
(checkbox)
Check the box (if applicable): Indicates the payor of the policy is the mortgagee.
IDENTIFICATION SECTION
Payor Other (checkbox)
Check the box (if applicable): Indicates the payor of the policy is other than those listed.
IDENTIFICATION SECTION
Payor Other Description
Enter text: The description of the payor of the policy.
IDENTIFICATION SECTION
Date agent last inspected
property
Enter date: The date the producer last inspected the structure. (MM/DD/YYYY)
IDENTIFICATION SECTION
Estimated Annual Premium
Enter amount: The estimated annual premium for the residential line of business.
COVERAGES / LIMITS OF
LIABILITY
Dwelling Limit
Enter limit: The limit associated with dwelling coverage.
COVERAGES / LIMITS OF
LIABILITY
Dwelling Premium
Enter amount: The premium associated with dwelling coverage.
COVERAGES / LIMITS OF
LIABILITY
Other Structures Limit
Enter limit: The limit associated with other structures coverage.
COVERAGES / LIMITS OF
LIABILITY
Other Structures Premium
Enter amount: The premium associated with other structures coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Property Limit
Enter limit: The limit associated with personal property coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Property
Premiums
Enter amount: The premium associated with personal property coverage.
COVERAGES / LIMITS OF
LIABILITY
Loss of Use - Actual Loss
Sustained
Check the box (if applicable): Indicates the loss of use coverage is on an actual loss sustained
basis.
COVERAGES / LIMITS OF
LIABILITY
Loss of Use Limit
Enter limit: The limit associated with loss of use coverage.
COVERAGES / LIMITS OF
LIABILITY
Loss of Use Premiums
Enter amount: The premium associated with loss of use coverage.
COVERAGES / LIMITS OF
LIABILITY
Blanket Limit
Enter limit: The limit associated with blanket coverage which includes dwelling, other structures,
personal property, and loss of use).
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 2 of 33
COVERAGES / LIMITS OF
LIABILITY
Blanket Premium
Enter amount: The premium associated with blanket coverage.
COVERAGES / LIMITS OF
LIABILITY
Rental Value - Actual Loss
Sustained
Check the box (if applicable): Indicates the rental value coverage is on an actual loss sustained
basis.
COVERAGES / LIMITS OF
LIABILITY
Rental Value Limit
Enter limit: The limit associated with rental value (dwelling fire only) coverage.
COVERAGES / LIMITS OF
LIABILITY
Rental Value Premium
Enter amount: The premium associated with rental value (dwelling fire only) coverage.
COVERAGES / LIMITS OF
LIABILITY
Additional Expense Limit
Enter limit: The limit associated with additional expense coverage. As used here, for dwelling
fire only.
COVERAGES / LIMITS OF
LIABILITY
Additional Expense
Premium
Enter amount: The premium associated with additional expense coverage. As used here, for
dwelling fire only.
COVERAGES / LIMITS OF
LIABILITY
Personal Liability Each
Occurrence Limit
Enter limit: The limit associated with personal liability each occurrence coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Liability Each
Occurrence Premium
Enter amount: The premium associated with personal liability coverage.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments Each
Person Limit
Enter limit: The limit associated with medical payments each person coverage.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments Each
Person Premium
Enter amount: The premium associated with medical payments coverage.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost - Full
Value - Included
Check the box (if applicable): Indicates that replacement cost full value coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Max %
Enter percentage: The maximum percentage of increased replacement cost selected in
accordance with the company rules.
COVERAGES / LIMITS OF
LIABILITY
Premium
Enter amount: The premium for full value replacement cost coverage.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Dwelling - Included
Check the box (if applicable): Indicates that replacement cost - dwelling coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Dwelling - Premium
Enter amount: The premium for replacement cost - dwelling coverage.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Contents - Included
Check the box (if applicable): Indicates that replacement cost - contents coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Contents - Premium
Enter amount: The premium for replacement cost - contents coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 3 of 33
DEDUCTIBLES
Base Amount
Enter deductible: The base deductible amount if the deductible is expressed as a dollar amount.
DEDUCTIBLES
Base Percentage
Enter percentage: The base percentage deductible if the deductible is expressed as a
percentage.
DEDUCTIBLES
Base Type
Enter code: The deductible type (e.g. flat, percentage) for the base deductible.
DEDUCTIBLES
Wind / Hail Amount
Enter deductible: The wind / hail deductible amount if the deductible is expressed as a dollar
amount.
DEDUCTIBLES
Wind / Hail Percentage
Enter percentage: The wind / hail percentage deductible if the deductible is expressed as a
percentage.
DEDUCTIBLES
Wind / Hail Type
Enter code: The deductible type (e.g. flat, percentage) for the wind / hail deductible.
DEDUCTIBLES
Theft Amount
Enter deductible: The theft deductible amount if the deductible is expressed as a dollar amount.
DEDUCTIBLES
Theft Percentage
Enter percentage: The theft percentage deductible if the deductible is expressed as a
percentage.
DEDUCTIBLES
Theft Type
Enter code: The deductible type (e.g. flat, percentage) for the theft deductible.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
DEDUCTIBLES
Other Amount
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.
DEDUCTIBLES
Other Percentage
Enter percentage: The percentage deductible if the deductible is expressed as a percentage.
DEDUCTIBLES
Other Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
DEDUCTIBLES
Named Hurricane Amount
Enter deductible: The named hurricane deductible amount if the deductible is expressed as a
dollar amount. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Named Hurricane
Percentage
Enter percentage: The named hurricane percentage deductible if the deductible is expressed as
a percentage. As used here, in North Carolina this is the named storm percentage deductible.
DEDUCTIBLES
Named Hurricane Type
Enter code: The deductible type (e.g. flat, percentage) for the named hurricane deductible. As
used here, in North Carolina this is the named storm percentage deductible.
DEDUCTIBLES
Annual Hurricane Amount
Enter deductible: The annual hurricane deductible amount if the deductible is expressed as a
dollar amount. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Annual Hurricane
Percentage
Enter percentage: The annual hurricane percentage deductible if the deductible is expressed as
a percentage. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Annual Hurricane Type
Enter code: The deductible type (e.g. flat, percentage) for the annual hurricane deductible. As
used here, this is not applicable in North Carolina.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
DEDUCTIBLES
Other Amount
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 4 of 33
DEDUCTIBLES
Other Percentage
Enter percentage: The percentage deductible if the deductible is expressed as a percentage.
DEDUCTIBLES
Other Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
DEDUCTIBLES
Other Amount
Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.
DEDUCTIBLES
Other Percentage
Enter percentage: The percentage deductible if the deductible is expressed as a percentage.
DEDUCTIBLES
Other Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
RATING / UNDERWRITING
Construction Type -
Masonry Veneer (checkbox)
Check the box (if applicable): Indicates the construction of the structure is masonry veneer. As
used here, this is the primary construction type.
RATING / UNDERWRITING
Percent Masonry Veneer
(checkbox)
Enter percentage: The percentage of the structure that is masonry veneer. As used here, this is
the primary percentage of the primary construction type.
RATING / UNDERWRITING
Frame (checkbox)
Check the box (if applicable): Indicates the construction of the structure is frame. As used here,
this is the primary construction type.
RATING / UNDERWRITING
Percent Frame
Enter percentage: The percentage of the structure that is frame. As used here, this is the
primary percentage of the primary construction type.
RATING / UNDERWRITING
Masonry (checkbox)
Check the box (if applicable): Indicates the construction of the structure is masonry. As used
here, this is the primary construction type.
RATING / UNDERWRITING
Percent Masonry
Enter percentage: The percentage of the structure that is masonry. As used here, this is the
primary percentage of the primary construction type.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the construction of the structure is other than those
listed. As used here, this is the primary construction type.
RATING / UNDERWRITING
Other Description
Enter code: The primary construction type of the premises. Common construction classifications
are:
* Frame
* Joisted Masonry
* Non-Combustible
* Masonry Non-Combustible
* Modified Fire Resistive
* Fire Resistive
RATING / UNDERWRITING
Percent Other
Enter percentage: The percentage of the structure that is other than those types listed. As used
here, this is the primary percentage of the primary construction type.
RATING / UNDERWRITING
Siding - Aluminum Siding
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is aluminum.
RATING / UNDERWRITING
Percent Aluminum Siding
Enter percentage: The percentage of the structure that is sided in aluminum.
RATING / UNDERWRITING
Stucco (checkbox)
Check the box (if applicable): Indicates the siding on the structure is stucco.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
Percent Stucco
Enter percentage: The percentage of the structure that is sided in stucco.
RATING / UNDERWRITING
Vinyl Siding / Plastic
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic.
RATING / UNDERWRITING
Percent Vinyl Siding /
Plastic
Enter percentage: The percentage of the structure that is sided in vinyl or plastic.
RATING / UNDERWRITING
Cedar Wood Shingle
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is cedar or wood shingle.
RATING / UNDERWRITING
Percent Cedar Wood
Shingle
Enter percentage: The percentage of the structure that is sided in cedar or wood shingle.
RATING / UNDERWRITING
EIFSCB (on Cinder Block)
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and
finishing system on cinder block (EIFSCB).
RATING / UNDERWRITING
Percent EIFSCB (on Cinder
Block)
Enter percentage: The percentage of the structure that is sided in exterior insulation and
finishing system on cinder block (EIFSCB)
RATING / UNDERWRITING
EIFSS (on Studs)
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and
finishing system on studs (EIFSS).
RATING / UNDERWRITING
Percent EIFSS (on Studs)
Enter percentage: The percentage of the structure that is sided in exterior insulation and
finishing system on studs (EIFSS).
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the siding on the structure is other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The type of siding on the structure.
RATING / UNDERWRITING
Percent Other Siding
Enter percentage: The percentage of the structure that is sided in other than the those types
listed.
RATING / UNDERWRITING
Year EIFS Installed
Enter year: The year the EIFS (exterior insulation and finishing system) was installed.
RATING / UNDERWRITING
Usage Type - Primary
(checkbox)
Check the box (if applicable): Indicates that this is the primary residence.
RATING / UNDERWRITING
Secondary (checkbox)
Check the box (if applicable): Indicates that this is a secondary residence.
RATING / UNDERWRITING
Seasonal (checkbox)
Check the box (if applicable): Indicates that this is a seasonal residence.
RATING / UNDERWRITING
Farm (checkbox)
Check the box (if applicable): Indicates the residence is a farm.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the usage of the residence is other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the usage of the residence.
RATING / UNDERWRITING
Course of Construction -
Builders Risk (checkbox)
Check the box (if applicable): Indicates the structure is new construction (builders risk).
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
Renovation (checkbox)
Check the box (if applicable): Indicates the structure is being renovated.
RATING / UNDERWRITING
Reconstruction (checkbox)
Check the box (if applicable): Indicates the structure is being reconstructed.
RATING / UNDERWRITING
Occupancy - Owner
(checkbox)
Check the box (if applicable): Indicates the residence is occupied by the owner.
RATING / UNDERWRITING
Tenant (checkbox)
Check the box (if applicable): Indicates the residence is occupied by tenants.
RATING / UNDERWRITING
Unoccupied (checkbox)
Check the box (if applicable): Indicates the residence is unoccupied.
RATING / UNDERWRITING
Vacant (checkbox)
Check the box (if applicable): Indicates the residence is vacant.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the residence is occupied by other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the inhabitants of the residence.
RATING / UNDERWRITING
Residence Type - Dwelling
(checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a dwelling.
RATING / UNDERWRITING
Apartment (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is an apartment.
RATING / UNDERWRITING
Condominium (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a condominium or
multiplex.
RATING / UNDERWRITING
Townhouse (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a townhouse.
RATING / UNDERWRITING
Rowhouse (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a row house.
RATING / UNDERWRITING
Co-Op (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a cooperative.
RATING / UNDERWRITING
Mobile Home (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a mobile home.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is other than those
listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the type of residence (e.g., apartment, condominium, etc.).
RATING / UNDERWRITING
Housekeeping Condition -
Excellent (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
excellent.
RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
below average.
RATING / UNDERWRITING
Plumbing Condition -
Excellent (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is excellent.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is below average.
RATING / UNDERWRITING
Any Known Leaks? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates there are known leaks in the
plumbing system.
RATING / UNDERWRITING
Roof Condition - Excellent
(checkbox)
Check the box (if applicable): Indicates the condition of the roof is excellent.
RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the condition of the roof is good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the condition of the roof is average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the condition of the roof is below average.
RATING / UNDERWRITING
Roof Material
Enter code: The material used to construct the roof. Examples include:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake
(Please note this list is not all inclusive)
RATING / UNDERWRITING
Distance To Tidal Water
Enter number: The distance to the nearest tidal water.
RATING / UNDERWRITING
Miles (checkbox)
Check the box (if applicable): Indicates the distance to tidal water entered is in miles.
RATING / UNDERWRITING
Feet (checkbox)
Check the box (if applicable): Indicates the distance to tidal water entered is in feet.
RATING / UNDERWRITING
Purchase Price
Enter amount: The purchase price of the residence.
RATING / UNDERWRITING
Purchase Date
Enter date: The date the residence was purchased (MM/DD/YYYY).
RATING / UNDERWRITING
Security - Visible from road
(checkbox)
Check the box (if applicable): Indicates the structure is visible from the road.
RATING / UNDERWRITING
Visible to neighbors
(checkbox)
Check the box (if applicable): Indicates the structure is visible from another dwelling that is
occupied during the day.
RATING / UNDERWRITING
Occupied Daily (checkbox)
Check the box (if applicable): Indicates the residence usually has an adult home during the day.
RATING / UNDERWRITING
Protection Device Type -
Central / Smoke
Check the box (if applicable): Indicates the smoke alarm notifies an outside service that in turn
reports to the appropriate police or fire station.
RATING / UNDERWRITING
Central / Temp
Check the box (if applicable): Indicates the temperature alarm reports to an outside service that
in turn reports to the appropriate police or fire station.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
Central / Burglar
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
RATING / UNDERWRITING
Direct / Smoke
Check the box (if applicable): Indicates the smoke alarm reports directly to the appropriate fire
station.
RATING / UNDERWRITING
Direct / Temp
Check the box (if applicable): Indicates the temperature alarm reports directly to the appropriate
fire station.
RATING / UNDERWRITING
Direct / Burglar
Check the box (if applicable): Indicates the burglar alarm reports directly to the appropriate
police station.
RATING / UNDERWRITING
Local / Smoke
Check the box (if applicable): Indicates that the smoke alarm sounds or appears on the
premises.
RATING / UNDERWRITING
Local / Temp
Check the box (if applicable): Indicates the temperature alarm sounds or appears on the
premises.
RATING / UNDERWRITING
Local / Burglar
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
RATING / UNDERWRITING
Distance to Hydrant Feet
Enter number: The distance in feet from the nearest hydrant that supports the protection class
used.
RATING / UNDERWRITING
Distance to Fire Station
Miles
Enter number: The distance in miles from the nearest fire station that supports the protection
class used.
RATING / UNDERWRITING
# of Fire Divisions
Enter number: The number of fire divisions in the building.
RATING / UNDERWRITING
# Units Fire Div
Enter number: The number of units within a fire division.
RATING / UNDERWRITING
Door Locks - Deadbolt
(checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with deadbolt locks.
RATING / UNDERWRITING
Spring (checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with spring locks.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with locks other
than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The type of locks on exterior entry doors.
RATING / UNDERWRITING
Sprinkler: Partial (checkbox)
Check the box (if applicable): Indicates the building is equipped with a partial fire sprinkler
system.
RATING / UNDERWRITING
Full (checkbox)
Check the box (if applicable): Indicates the building is equipped with a full fire sprinkler system.
RATING / UNDERWRITING
Territory
Enter code: The industry or company specific code that identifies the rating territory for this item.
The source of this code is individual insurer, Insurance Services Office or State Insurance
Department manuals.
RATING / UNDERWRITING
Pers Liab Terr
Enter code: The personal liability territory code unique to owners, landlords and tenants needed
for liability coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
Prot Class
Enter code: The fire rating protection class for this location. Note: some structures may be
located too far from the nearest hydrant, or too far from the nearest fire station, for the
protection class of the community to apply.
RATING / UNDERWRITING
Fire Extinguisher (Y / N):
Enter Y for a Yes response. Input N for No response. Indicate if the residence is equipped
with fire extinguisher(s).
RATING / UNDERWRITING
Fire District Name
Enter text: The property's fire district name.
RATING / UNDERWRITING
Fire District Code
Enter code: The property's fire district code number which can be found in the individual states
manual pages.
RATING / UNDERWRITING
Primary Heat
Enter text: The primary type of fuel/power used for heating.
RATING / UNDERWRITING
None (checkbox)
Check the box (if applicable): Indicates the residence has no primary heat source.
RATING / UNDERWRITING
Secondary:
Enter text: The secondary type of fuel/power used for heating.
RATING / UNDERWRITING
None (checkbox)
Check the box (if applicable): Indicates the residence has no secondary heat source.
RATING / UNDERWRITING
Date Heating System Last
Serviced
Enter date: The date (MM/DD/YYYY) the heating system was last serviced.
RATING / UNDERWRITING
Wiring - Copper (checkbox)
Check the box (if applicable): Indicates the residence has copper wiring.
RATING / UNDERWRITING
Aluminum (checkbox)
Check the box (if applicable): Indicates the residence has aluminum wiring.
RATING / UNDERWRITING
Knob & Tube (checkbox)
Check the box (if applicable): Indicates the residence has knob and tube wiring.
RATING / UNDERWRITING
Last Inspected Date
Enter date: The date the wiring was last inspected.
RATING / UNDERWRITING
Electrical Systems - Circuit
Breakers (checkbox)
Check the box (if applicable): Indicates the electrical panel uses circuit breakers.
RATING / UNDERWRITING
Fuses (checkbox)
Check the box (if applicable): Indicates the electrical panel uses fuses.
RATING / UNDERWRITING
Number of Amps
Enter number: The electrical capacity of the wiring in amperes (amps).
RATING / UNDERWRITING
Year Built
Enter year: The year the structure was built (YYYY).
RATING / UNDERWRITING
Market Value ($)
Enter amount: The current market value for which the residence could be sold.
RATING / UNDERWRITING
Replacement Cost ($)
Enter amount: The estimated total dollar amount required to rebuild the residence without
depreciation.
RATING / UNDERWRITING
Total Living Area Sq Ft
Enter number: The residence's total square footage of living area (excluding basements).
RATING / UNDERWRITING
Basement Area
Enter number: The residence's total square footage of the basement.
RATING / UNDERWRITING
Garage Area
Enter number: The residence's total square footage of the garage.
RATING / UNDERWRITING
Breezeway Area
Enter number: The residence's total square footage of the breezeway.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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RATING / UNDERWRITING
# Rooms
Enter number: The total number of rooms in the residence, including full and half bathrooms.
RATING / UNDERWRITING
# Apartments
Enter number: The number of separate living units in structure.
RATING / UNDERWRITING
# Weeks Rented
Enter number: The number of weeks the unit on the residence premises is or will be rented to
others.
RATING / UNDERWRITING
# Families
Enter number: The number of separate family units in the dwelling.
RATING / UNDERWRITING
# Household Residents
Enter number: The number of residents in the household.
RATING / UNDERWRITING
Tax Code
Enter code: The code which normally represents the location for which a surcharge is being
applied (city, county or state).
RATING / UNDERWRITING
Bldg Code Grade
Enter code: The industry code used to collect the building code effectiveness grade code. The
source of this code list is public protection classification or individual insurer rating manuals.
RATING / UNDERWRITING
Inspected Y / N
Enter Y for a Yes response. Input N for No response. Indicate if the structure has been
inspected specific to its Building Code effectiveness grade.
RATING / UNDERWRITING
Fireplaces - Chimneys
Enter number: The total number of outside and inside chimneys in the residence. As used here,
enter '0' for none.
RATING / UNDERWRITING
Hearths
Enter number: The total number of hearths in the residence. As used here, enter '0' for none.
RATING / UNDERWRITING
Pre-Fab
Enter number: The total number of prefabricated fireplaces in the residence. As used here,
enter '0' for none.
RATING / UNDERWRITING
Wood stove insert
Enter number: The total number of wood stove inserts in the residence. As used here, enter '0'
for none.
RATING / UNDERWRITING
Rating Credits -
Non-Smoker (checkbox)
Check the box (if applicable): Indicates that a non-smoking rating credit may apply to the
location.
RATING / UNDERWRITING
Manned Security (checkbox)
Check the box (if applicable): Indicates that a manned security rating credit may apply to the
location.
RATING / UNDERWRITING
Lightning Protection
(checkbox)
Check the box (if applicable): Indicates that a lightning protection rating credit may apply to the
location.
RATING / UNDERWRITING
Off Premises Theft
Exclusion (checkbox)
Check the box (if applicable): Indicates that an off premises theft exclusion rating credit may
apply to the location.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that other rating credits may apply to the location.
RATING / UNDERWRITING
Other Description
Enter text: The description of the other rating credits that may apply.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that other rating credits may apply to the location.
RATING / UNDERWRITING
Other Description
Enter text: The description of the other rating credits that may apply.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 11 of 33
RATING / UNDERWRITING
Swimming Pool - None
(checkbox)
Check the box (if applicable): Indicates there is no swimming pool on the premises.
RATING / UNDERWRITING
Above ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is above ground.
RATING / UNDERWRITING
In-Ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is in the ground.
RATING / UNDERWRITING
Approved Fence (checkbox)
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an
approved height.
RATING / UNDERWRITING
Diving Board (checkbox)
Check the box (if applicable): Indicates the swimming pool has a diving board.
RATING / UNDERWRITING
Slide (checkbox)
Check the box (if applicable): Indicates the swimming pool has a slide.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates there is additional information to describe the pool.
RATING / UNDERWRITING
Other Description
(checkbox)
Enter text: The additional information to describe the swimming pool.
RATING / UNDERWRITING
Dwelling Location - In City
Limits (checkbox)
Check the box (if applicable): Indicates the residence is within the city limits.
RATING / UNDERWRITING
In Fire District (checkbox)
Check the box (if applicable): Indicates the residence is within a fire district.
RATING / UNDERWRITING
In Protected Suburb
(checkbox)
Check the box (if applicable): Indicates the residence is within a protected suburb.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the residence is other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the residence location.
RATING / UNDERWRITING
Rating- Class (checkbox)
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is
class rating.
RATING / UNDERWRITING
Specific (checkbox)
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is
specific rating.
RATING / UNDERWRITING
Foundation - None
Check the box (if applicable): Indicates there is no foundation on the structure.
RATING / UNDERWRITING
Foundation - Open
(checkbox)
Check the box (if applicable): Indicates the foundation of the structure is open.
RATING / UNDERWRITING
Closed (checkbox)
Check the box (if applicable): Indicates the foundation of the structure is closed.
RATING / UNDERWRITING
Fuel Storage Tank Location
- None (checkbox)
Check the box (if applicable): Indicates there is no fuel storage tank on the premises.
RATING / UNDERWRITING
Indoors, Above ground
masonry floor (checkbox)
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground
on a masonry floor.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 12 of 33
RATING / UNDERWRITING
Indoors, Above ground no
masonry floor (checkbox)
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground
not on a masonry floor.
RATING / UNDERWRITING
Outdoors, Above ground
(checkbox)
Check the box (if applicable): Indicates the fuel storage tank is outdoors and above ground.
RATING / UNDERWRITING
Outdoors, Below ground
(checkbox)
Check the box (if applicable): Indicates the fuel storage tank is outdoors and below ground.
RATING / UNDERWRITING
Fuel Line Location -
Underground (checkbox)
Check the box (if applicable): Indicates the fuel line is underground.
RATING / UNDERWRITING
Through foundation
(checkbox)
Check the box (if applicable): Indicates the fuel line goes through the foundation.
RATING / UNDERWRITING
Renovations - Wiring - Part
Check the box (if applicable): Indicates if partial wiring improvements have been made since the
original construction.
RATING / UNDERWRITING
Wiring - Complete
Check the box (if applicable): Indicates if complete wiring improvements have been made since
the original construction.
RATING / UNDERWRITING
Wiring - Year
Enter year: The year the wiring improvements took place.
RATING / UNDERWRITING
Plumbing - Part
Check the box (if applicable): Indicates if partial plumbing improvements have been made since
the original construction.
RATING / UNDERWRITING
Plumbing - Complete
Check the box (if applicable): Indicates if complete plumbing improvements have been made
since the original construction.
RATING / UNDERWRITING
Plumbing - Year
Enter year: The year the plumbing improvements took place.
RATING / UNDERWRITING
Heating - Part
Check the box (if applicable): Indicates if partial heating improvements have been made since
the original construction.
RATING / UNDERWRITING
Heating - Complete
Check the box (if applicable): Indicates if complete heating improvements have been made
since the original construction.
RATING / UNDERWRITING
Heating - Year
Enter year: The year the heating improvements took place.
RATING / UNDERWRITING
Roofing - Part
Check the box (if applicable): Indicates if partial roofing improvements have been made since
the original construction.
RATING / UNDERWRITING
Roofing - Complete
Check the box (if applicable): Indicates if complete roofing improvements have been made
since the original construction.
RATING / UNDERWRITING
Roofing - Year
Enter year: The year the roofing improvements took place.
RATING / UNDERWRITING
Exterior Paint - Year
Enter year: The year the exterior of the structure was last painted.
RATING / UNDERWRITING
Wind Class - Resistive
(checkbox)
Check the box (if applicable): Indicates the wind class is resistive.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 13 of 33
RATING / UNDERWRITING
Semi-resistive (checkbox)
Check the box (if applicable): Indicates the wind class is semi-resistive.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the wind class is other than those listed.
RATING / UNDERWRITING
Other Description.
Enter text: The description of the other wind class.
RATING / UNDERWRITING
Windstorm - Storm Shutters
- A (checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class that provides
protection from wind and debris.
RATING / UNDERWRITING
B (checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class that provides
protection from wind only.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class other than those
listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the wind storm shutter class.
RATING / UNDERWRITING
Hurricane Resistive Glass
(checkbox)
Check the box (if applicable): Indicates the glass is resistive to hurricanes.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
OPTIONAL COVERAGES -
ENDORSEMENTS
Additional Premises Liability
Extension - # Premises
Enter number: The number of premises covered by the additional premises liability extension.
This is used when you don't have the full detail about the individual locations.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 14 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Additional Residence
Rented To Others - # of
Premises
Enter number: The number of premises covered by the additional residence rented to others.
This is used when you don't have the full detail about the individual locations.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
residence rented to others.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
# Families
Enter number: The number of families of the additional residence rented to others .
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
residence rented to others.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
# Families
Enter number: The number of families of the additional residence rented to others .
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Builders Risk - Theft of
Building Materials Included
(checkbox)
Check the box (if applicable): Indicates the builders risk theft of building materials coverage is
included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for builders risk theft of building materials coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 15 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for builders risk theft of building materials coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Builders Risk - Collapse Due
to Hydro-Static Pressure -
Included
Check the box (if applicable): Indicates the builders risk collapse due to hydro-static pressure
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for builders risk collapse due to hydro-static pressure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for builders risk collapse due to hydro-static pressure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Building Ordinance or Law
Coverage - Aggregate Limit
Enter limit: The aggregate limit for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increase Limit
Enter limit: The increased limit for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Included (checkbox)
Check the box (if applicable): Indicates the building ordinance or law coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Rebuild %
Enter percentage: The rebuild percentage for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Business Property At Home
- Included
Check the box (if applicable): Indicates the business property at home coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for business property at home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for business property at home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Business Property Away
From Home - Included
Check the box (if applicable): Indicates the business property away from home coverage is
included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for business property away from home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for business property away from home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Debris Removal - Included
Check the box (if applicable): Indicates the debris removal coverage is included.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 16 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for debris removal coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for debris removal coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - % Ded
Enter percentage: The percentage deductible for earthquake coverage if the deductible is
expressed as a percentage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - Deductible
Amount
Enter deductible: The deductible amount for earthquake coverage if the deductible is expressed
in dollars.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - Territory
Enter code: The earthquake zone (territory) associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - Retrofit Type
Enter text: The type of earthquake retrofit for the residence.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - % Masonry
Veneer
Enter percentage: The percentage of construction that is masonry veneer.
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - Premium
Enter amount: The premium for earthquake coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability - Limit
Enter limit: The limit amount for employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability - # of
Employees
Enter number: The number of employees associated with employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability -
Premium
Enter amount: The premium for employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown -
Included (checkbox)
Check the box (if applicable): Indicates the equipment breakdown coverage is included. As
used here, not applicable in North Carolina.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown
Deductible
Enter deductible: The deductible associated with equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown Limit
Enter limit: The limit associated with equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown
Premium
Enter amount: The premium for equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fire Department Service
Charge - Included
(checkbox)
Check the box (if applicable): Indicates the fire department service charge coverage is included.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 17 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for fire department service charge coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Building Limit
Enter limit: The building limit for flood coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Contents Limit
Enter limit: The contents limit for flood coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Premium
Enter amount: The premium for flood coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Excl
Liability
Check the box (if applicable): Indicates that liability is excluded from fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Excl
Prop Damage
Check the box (if applicable): Indicates that property damage is excluded from fungus and mold
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Property
Enter limit: The property limit for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Liability
Enter limit: The liability limit for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Premium
Enter amount: The premium for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Liability -
Included (checkbox)
Check the box (if applicable): Indicates the golf cart liability coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - # of Golf Carts
Enter number: The number of golf carts to be covered.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Description
Enter text: The description of the golf carts.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Premium
Enter amount: The premium for golf cart liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Physical
Damage - Limit
Enter limit: The limit for golf cart physical damage coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Physical
Damage - Premium
Enter amount: The premium for golf cart physical damage coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Included (checkbox)
Check the box (if applicable): Indicates identity fraud expense coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Limit
Enter limit: The limit for identity fraud expense coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 18 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Premium
Enter amount: The premium for identity fraud expense coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Incidental Farming Pers
Liab - Medical Payments
Enter Y for a Yes response. Input N for No response. Indicates if medical payments is
included in the incidental farming personal liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Incidental Farming Pers
Liab - Premium
Enter amount: The premium for incidental farming coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability Limits - Electronic
Apparatus In and Out of
Vehicle - Total Limit
Enter limit: The total limit amount for increased coverage c special liability limit - electronic
apparatus in and out of vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage c special liability limit - electronic
apparatus in and out of vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - electronic apparatus
in and out of vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability Limits - Electronic
Apparatus In Vehicle - Total
Limit
Enter limit: The total limit amount for increased coverage C special liability limit - electronic
apparatus in vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - electronic
apparatus in vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - electronic apparatus
in vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability - Guns - Total Limit
Enter limit: The total limit amount for increased coverage C special liability limit - guns.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - guns.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - guns.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability - Money - Total
Limit
Enter limit: The total limit amount for increased coverage C special liability limit - money.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - money.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - money.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 19 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability - Securities - Total
Limit
Enter limit: The total limit amount for increased coverage C special liability limit - securities.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - securities.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - securities.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Cov C Special
Liability - Silverware - Total
Limit
Enter limit: The total limit amount for increased coverage C special liability limit - silverware.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit -silverware.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit -silverware.
OPTIONAL COVERAGES -
ENDORSEMENTS
Inflation Guard -
Percentage Increase
Enter percentage: The increase percentage for inflation guard coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Inflation Guard Premium
Enter amount: The premium for inflation guard coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loss Assessment - Limit
Enter limit: The limit amount for loss assessment coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loss Assessment - Premium
Enter amount: The premium for loss assessment coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Limit
Enter limit: The limit for mine subsidence coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Const
Material
Enter code: The type of construction material.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Property
Desc
Enter text: The description of the property.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Premium
Enter amount: The premium for mine subsidence coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Office, Professional Private
School, Studio - Residence
Premises - Requires Incr
Contents (checkbox)
Check the box (if applicable): Indicates that increased contents is required for office,
professional private school, studio - residence premises coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 20 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Office, Professional Private
School, Studio - Residence
Premises - Incr Contents
Limit
Enter limit: The increased contents limit for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Incr Cont Not Required
(checkbox)
Check the box (if applicable): Indicates that increased contents is not required for office,
professional private school, studio - residence premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Other Structures
Enter limit: The other structures limit for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay
Enter Y for a Yes response. Input N for No response. Indicates if medical payments is
included in the office, professional private school, studio - residence premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The territory for office, professional private school, studio - residence premises
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Structure Type
Enter code: The type of structure for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Business / Structure
Description
Enter text: The description of the business or structure for office, professional private school,
studio - residence premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for office, professional private school, studio - residence premises
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Other Structures - Individual
Structure - Limit
Enter limit: The limit for other structures - individual structure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Structure Desc
Enter text: The description of the individual structure for other structures - individual structure
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for other structures - individual structure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Included (checkbox)
Check the box (if applicable): Indicates that plants, shrubs and trees coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Limit
Enter limit: The limit for plants, shrubs and trees coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Premium
Enter amount: The premium for plants, shrubs and trees coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Included
Check the box (if applicable): Indicates that refrigerated food products coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Limit
Enter amount: The limit for refrigerated food products coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 21 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Premium
Enter amount: The premium for refrigerated food products coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Sink Hole Collapse -
Included
Check the box (if applicable): Indicates sink hole collapse coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Sink Hole Collapse -
Premium
Enter amount: The premium for sink hole collapse.
OPTIONAL COVERAGES -
ENDORSEMENTS
Unit-Owners Additions &
Alterations Special
Coverage - Included
Check the box (if applicable): Indicates unit owners additions and alterations special coverage is
included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for unit owners additions and alterations special coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for unit owners additions and alterations special coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Unscheduled Jewelry,
Watches, Furs - Aggregate
Enter limit: The aggregate limit for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased
Enter limit: The increased limit for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Water Backup of Sewers &
Drains - Included
Check the box (if applicable): Indicates water backup of sewers and drains coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for water backup of sewers and drains coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for water backup of sewers and drains coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Liability - Limit
Enter limit: The limit for watercraft liability coverage if you are not using a Watercraft application.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Liability -
Premium
Enter amount: The premium for watercraft liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Physical Damage
- Limit
Enter limit: The limit for watercraft physical damage coverage if you are not using a Watercraft
application.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Physical Damage
- Premium
Enter amount: The premium for watercraft physical damage coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 22 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Windstorm Exclusion - Yes
Check the box (if applicable): Indicates that windstorm exclusion applies. As used here, this is
not applicable in Arkansas.
OPTIONAL COVERAGES -
ENDORSEMENTS
Windstorm Exclusion -
Premium
Enter amount: The premium for windstorm exclusion.
OPTIONAL COVERAGES -
ENDORSEMENTS
Workers Compensation -
Full Time Inservant - # of
Employees
Enter number: The number of employees associated with workers compensation full time In
Servant coverage. As used here, applicable only in CA, MT, NV, NH, NJ, NY, ND, OH, OR,
WA, WV and WY.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for workers compensation full time In Servant coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 23 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 24 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 25 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 26 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 27 of 33
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
GENERAL INFORMATION
1. Any business conducted
on premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any business conducted on premises?.
GENERAL INFORMATION
Farming (checkbox)
Check the box (if applicable): Indicates farming is done on the premises.
GENERAL INFORMATION
Telecommuter (checkbox)
Check the box (if applicable): Indicates an individual telecommutes from the premises.
GENERAL INFORMATION
Day Care (checkbox)
Check the box (if applicable): Indicates a day care is run from the premises.
GENERAL INFORMATION
Day Care # of children
(checkbox)
Enter number: The number of children attending the day care.
GENERAL INFORMATION
Home Office / business
(checkbox)
Check the box (if applicable): Indicates a home office or business is on the premises.
GENERAL INFORMATION
Other
Check the box (if applicable): Indicates business is conducted on the premises other than those
listed.
GENERAL INFORMATION
Other Description
Enter text: The description of the business conducted on the premises.
GENERAL INFORMATION
2. Any residence
employees?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any residence employees?.
GENERAL INFORMATION
# of Full Time Employees
Enter number: The number of full time residence employees.
GENERAL INFORMATION
Description of Full Time
Employees
Enter text: The description of the type of work performed by full time residence employees.
GENERAL INFORMATION
# of Part Time Employees
Enter number: The number of part time residence employees.
GENERAL INFORMATION
Description of Part Time
Employees
Enter text: The description of the type of work performed by part time residence employees.
GENERAL INFORMATION
3. Any flooding, brush,
forest fire or landslide
hazard?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any flooding, brush, forest fire or landslide hazard?. As used here, Kansas Applicants - Do
not answer this question.
GENERAL INFORMATION
Hazards - Description
Enter text: An explanation of any flooding, brush, forest fire or landslide hazard.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 28 of 33
GENERAL INFORMATION
4. Are there any animals or
exotic pets kept on the
premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Are there any animals or exotic pets on the premises?.
GENERAL INFORMATION
Animals - Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION
Animals - Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION
Animals - Bite History
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
Animals - Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION
Animals - Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION
Animals - Bite History
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.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
5. Is property situated on
more than one acre?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is property situated on more than 1 acre?.
GENERAL INFORMATION
Number of acres
Enter number: The total area of the land in acres.
GENERAL INFORMATION
Land Used for
Enter text: The description of what the land is used for.
GENERAL INFORMATION
6. Any uncorrected fire or
building code violations?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any uncorrected fire or building code violations?.
GENERAL INFORMATION
Description
Enter text: An explanation of or any uncorrected fire or building code violations.
GENERAL INFORMATION
7. Is the dwelling / mobile
home for sale?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the dwelling/mobile home for sale?.
GENERAL INFORMATION
8. Is property within 300 ft.
of a commercial or
non-residential property?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the property within 300 feet of a commercial or non-residential property?.
GENERAL INFORMATION
Description
Enter text: An explanation if property is within 300 ft. of a commercial or non-residential property.
GENERAL INFORMATION
9. Is there a trampoline on
the premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a trampoline on the premises?.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 29 of 33
GENERAL INFORMATION
Trampoline - Safety Net
Enter Y for a Yes response. Input N for No response. Indicates whether the trampoline on the
premises has a safety net.
GENERAL INFORMATION
10. Was the structure
originally built for other than
private residence and then
converted?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Was the structure originally built for other than a private residence and then converted?.
GENERAL INFORMATION
Original Occupancy
Enter text: The description of the original occupancy of the building.
GENERAL INFORMATION
11. Any lead paint?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any lead paint?.
GENERAL INFORMATION
Lead Paint - Description
Enter text: An explanation of any lead paint on the premises.
GENERAL INFORMATION
12. If a fuel tank is on
premises, has other
insurance been obtained for
the tank?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, If
a fuel tank is on premises, has other insurance been obtained for the tank?.
GENERAL INFORMATION
Insurance Company
Enter text: The insurer name on any other applicable insurance. As used here, the name of the
insurer providing coverage for the fuel tank.
GENERAL INFORMATION
Limit
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing insurer(s).
GENERAL INFORMATION
Clean-up / Sub Limit
Enter limit: The other policy, coverage sub limit amount.
GENERAL INFORMATION
13. Is the residence in a
gated community?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the residence in a gated community?.
GENERAL INFORMATION
Community - Name of
Community
Enter text: The name of the gated community.
GENERAL INFORMATION
14. If building is under
construction, is the
applicant the general
contractor?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, If
building is under construction, is the applicant the general contractor?.
GENERAL INFORMATION
General Contractor - Start
Date
Enter date: The date construction began.
GENERAL INFORMATION
General Contractor -
Completion Date
Enter date: The estimated completion date for this construction project.
GENERAL INFORMATION
General Contractor - Int %
Enter percentage: The percentage of construction taking place in the interior of the structure.
GENERAL INFORMATION
General Contractor - Ext %
Enter percentage: The percentage of construction taking place in the exterior of the structure.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 30 of 33
GENERAL INFORMATION
General Contractor -
Addition Sq. Ft.
Enter number: The total area of the addition under construction in square feet.
GENERAL INFORMATION
General Contractor -
Additional Level Sq. Ft.
Enter number: The total area of the additional level under construction in square feet.
GENERAL INFORMATION
Any structural changes?
Enter Y for a Yes response. Input N for No response. Indicates if there will be structural
changes as part of the construction.
GENERAL INFORMATION
General Contractor -
Material Unattached
Included
Check the box (if applicable): Indicates materials that are not attached to the structure are
included.
GENERAL INFORMATION
General Contractor -
Material Unattached
Excluded
Check the box (if applicable): Indicates materials that are not attached to the structure are
excluded.
GENERAL INFORMATION
House occupied during
renovation?
Enter Y for a Yes response. Input N for No response. Indicates if the structure will be
occupied during construction and renovation.
GENERAL INFORMATION
General Contractor - Cost of
Project.
Enter amount: The total cost of construction of the structure
GENERAL INFORMATION
15. Is there a carbon
monoxide alarm, in
operating condition, within
the mandated number of
feet of every room used for
sleeping purposes?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there an approved carbon monoxide alarm in operating condition within the mandated
number of feet of every room used for sleeping purposes?.
GENERAL INFORMATION
16. Is the named insured the
owner of the property? (If
NO, provide the name of
the owner).
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the named insured the owner of the property?. As used here, if no, provide the name of the
owner.
GENERAL INFORMATION
Owner's Name
Enter text: The additional interest's full name. As used here, this is the name of the owner of the
property.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
1. Is there is a manager on
the premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a manager on the premises?. As used here, if YES, provide the full name of the
manager and the manager's phone number, including area code.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Manager's Name
Enter text: Provide the full name of the manger. A No response does not require an
explanation.
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 31 of 33
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Phone Number
Enter number: The phone number of the manager of the structure.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
2. Is there a security
attendant?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a security attendant?. As used here, explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Description
Enter text: An explanation if no security attendant is provided on the premises. As used here,
explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY (Continued)
3. Is the building entrance
locked?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the building entrance locked?. As used here, explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY (Continued)
Description
Enter text: An explanation if building entrance is not locked. As used here, explain a No
response to the question.
REMARKS
Remarks
Enter text: The general remarks associated with this line of business. Use this section to
provide any additional information required for underwriting or rating. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required.
BINDER / NOTICE OF
INFORMATION PRACTICES
Effective Date
Enter date: The date on which the terms and conditions of the binder commenced. This date
normally coincides with the effective date of the policy or of an endorsement to the policy.
BINDER / NOTICE OF
INFORMATION PRACTICES
Time
Enter time: The time of day on the effective date in which the terms and conditions of the binder
will commence.
BINDER / NOTICE OF
INFORMATION PRACTICES
Expiration Date
Enter date: The date on which the terms and conditions of the policy will or have expired.
Certain state laws limit the terms of a binder, so this date may not coincide with the policy
expiration date.
BINDER / NOTICE OF
INFORMATION PRACTICES
12:01 AM
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
BINDER / NOTICE OF
INFORMATION PRACTICES
Noon
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
BINDER / NOTICE OF
INFORMATION PRACTICES
Coverage is not bound
Check the box (if applicable): Indicates the coverage has not been bound.
Form Page 4
Section Name
Field Name
Description
ACORD 89 (2014/12) FIG rev. 08-20-2014
Page 32 of 33
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The producer assigned number of the location.
FRAUD STATEMENTS /
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
FRAUD STATEMENTS /
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
FRAUD STATEMENTS /
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
FRAUD STATEMENTS /
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
FRAUD STATEMENTS /
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
FRAUD STATEMENTS /
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 89 (2014/12) FIG rev. 08-20-2014
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