ACORD 146 (2013/09)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 146 (2013/09)
Equipment Floater Section
ACORD 146, Equipment Floater Section, is used to collect
underwriting and rating information for contractors' equipment schedules. It may also be
used for any other applicable Inland Marine coverage and schedule including those for
cameras, musical instruments and physician and surgeon equipment.
This form was designed to be used in conjunction with ACORD 125, Commercial
Insurance Application - Applicant Information Section. Refer to ACORD 125 for
information on that form. Most information for the Identification Section should match the
data found within the Applicant Information Section of ACORD 125. However, it is still
important to complete the section. Many companies, for rating purposes, separate the
applications by line of business. Not completing this part of the application makes it
difficult to keep track of the full account.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant / First Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
TERRITORY OF
OPERATION
Territory Of Operation
Enter text: The description of exactly where the equipment or schedule of items is normally
located. For a specific location, give the address, or information such as the construction
site name and address, city, county or state.
TYPE OF OPERATION
Type Of Operation
Enter text: The description of the type of work performed by the applicant and nature of
this business. This information may also appear on the Application Section (ACORD 125).
If so, enter see ACORD 125.
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Section Name
Field Name
Field and/or Section Description
COVERAGE / DEDUCTIBLE Coverage Deductible
Enter text: The form of coverage desired and all appropriate deductibles in the space
provided. Indicate if the Floater is to be written on a Scheduled or Blanket basis. If
scheduled, list all the items. Specify if All Risk or Named Perils. Enter any other options
chosen as Replacement Cost or Actual Cash Value and the desired deductible.
Deductibles may be written on a dollar amount or percentage basis. Specify how the
deductible is to be applied if not familiar with each company's policy (e.g., Contractors'
Equipment, Commercial Articles Floater or Musical Instrument Dealers).
EQUIPMENT STORAGE
Loc. # One
Enter number: The location number for the premises. As used here, collect limit
information applicable to contractor's equipment. If other limits for coverages as
Commercial Article Floaters fit, enter them here. Limits that don't fit within these section
headings should be listed within the Coverage and Deductible section.
EQUIPMENT STORAGE
Months in Storage One
Enter number: The number of months the equipment is kept in storage. (If less than one
month, enter one. All partial months should be rounded up).
EQUIPMENT STORAGE
Maximum Value in Building One
Enter amount: The maximum value of the items stored inside a building.
EQUIPMENT STORAGE
Maximum Value Outside One
Enter amount: The maximum value of all items stored outside.
EQUIPMENT STORAGE
Type of Security One
Enter text: The brief description of the kind of security employed by the applicant at each
location. Specify guards, alarms, fences, dogs, etc.
EQUIPMENT STORAGE
Loc. # Two
Enter number: The location number for the premises.
EQUIPMENT STORAGE
Months in Storage Two
Enter number: The number of months the equipment is kept in storage. (If less than one
month, enter one. All partial months should be rounded up).
EQUIPMENT STORAGE
Maximum Value in Building Two
Enter amount: The maximum value of the items stored inside a building.
EQUIPMENT STORAGE
Maximum Value Outside Two
Enter amount: The maximum value of all items stored outside.
EQUIPMENT STORAGE
Type of Security Two
Enter text: The brief description of the kind of security employed by the applicant at each
location. Specify guards, alarms, fences, dogs, etc.
EQUIPMENT STORAGE
Loc. # Three
Enter number: The location number for the premises.
EQUIPMENT STORAGE
Months in Storage Three
Enter number: The number of months the equipment is kept in storage. (If less than one
month, enter one. All partial months should be rounded up).
EQUIPMENT STORAGE
Maximum Value in Building Three
Enter amount: The maximum value of the items stored inside a building.
EQUIPMENT STORAGE
Maximum Value Outside Three
Enter amount: The maximum value of all items stored outside.
EQUIPMENT STORAGE
Type of Security Three
Enter text: The brief description of the kind of security employed by the applicant at each
location. Specify guards, alarms, fences, dogs, etc.
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Section Name
Field Name
Field and/or Section Description
UNSCHEDULED
EQUIPMENT
Description One
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item One
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance One
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins One
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Two
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Two
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Two
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Two
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Three
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Three
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Three
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Three
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Four
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Four
Enter amount: The maximum value of a single item within the class / grouping.
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Section Name
Field Name
Field and/or Section Description
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Four
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Four
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Five
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Five
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Five
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Five
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Six
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Six
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Six
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Six
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
UNSCHEDULED
EQUIPMENT
Description Seven
Enter text: The description of the property class / grouping to be covered. As used here,
describe the unscheduled grouping (e.g., Miscellaneous Hand Tools or Camera Lens).
UNSCHEDULED
EQUIPMENT
Maximum Item Seven
Enter amount: The maximum value of a single item within the class / grouping.
UNSCHEDULED
EQUIPMENT
Amt. of Insurance Seven
Enter limit: The amount of insurance for the class / grouping. This is the total value of all
of the unscheduled items within the class / grouping. Values can be either on a
Replacement Cost or Actual Cash Value basis.
UNSCHEDULED
EQUIPMENT
% Coins Seven
Enter percentage: The coinsurance percentage contemplated by the amount of insurance
required. Most insurers require 100 percent coinsurance.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS ACORD 45 Attached (checkbox)
Check the box (if applicable): Indicates an ACORD 45, Additional Interests Schedule is
attached.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS One
Interest Loss Payee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Lienholder (checkbox) One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest (checkbox) One
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest Description One
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Rank One
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Name and Address One
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address postal code.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Reference # One
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS One
Certificate Required (checkbox)
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Location One
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Building One
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Scheduled Item Number One
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other One
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Item Description One
Enter text: The description of the item of interest if needed to further clarify. For a vehicle,
list the make, model and VIN number. For a scheduled item, list the description, such as
three carat diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Two
Interest Loss Payee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Lienholder (checkbox) Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest (checkbox) Two
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest Description Two
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Rank Two
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Name and Address Two
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Reference # Two
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Two
Certificate Required (checkbox)
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Location Two
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Building Two
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Scheduled Item Number Two
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Two
Enter text: The description of the item which has an additional interest.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Item Description Two
Enter text: The description of the item of interest if needed to further clarify. For a vehicle,
list the make, model and VIN number. For a scheduled item, list the description, such as
three carat diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Three
Interest Loss Payee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Lienholder (checkbox) Three
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest (checkbox) Three
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Interest Description Three
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Rank Three
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Name and Address Three
Enter text: The additional interest's full name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS
Enter code: The additional interest's mailing address postal code.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Reference # Three
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Three
Certificate Required (checkbox)
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Location Three
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Building Three
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Scheduled Item Number Three
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Other Three
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENTS Item Description Three
Enter text: The description of the item of interest if needed to further clarify. For a vehicle,
list the make, model and VIN number. For a scheduled item, list the description, such as
three carat diamond in six point setting.
GENERAL INFORMATION
1. Equipment rented, loaned to or
from others with or without
operators? Y/N
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Equipment rented, loaned to/from others with/without operators?.
GENERAL INFORMATION
Description
Enter text: If the applicant is involved in any sort of rental or loan agreement, explain the
circumstances and the nature of the agreement, including who is carrying the insurance
for the equipment.
GENERAL INFORMATION
2. Is applicant operating
equipment that is not listed here?
Y/N
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is applicant operating equipment not listed here?.
GENERAL INFORMATION
Description
Enter text: An explanation of any applicant operation equipment not listed.
GENERAL INFORMATION
3. Property used underground?
Y/N
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Property used underground?.
GENERAL INFORMATION
Description
Enter text: Indicate if any work is done underground and if equipment is left underground.
Explain all circumstances of underground operations.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
4. Any work done afloat? Y/N
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Any work done afloat?.
GENERAL INFORMATION
Description
Enter text: An explanation of any work done afloat. Indicate if any work is done on bodies
of water and if equipment is left afloat unattended for extended periods. Explain
circumstances and indicate which bodies of water are involved.
SCHEDULED EQUIPMENT
% Coinsurance
Enter percentage: The coinsurance percent at which the rate is published. Also, the
amount of property value insured (as a percent). It can also represent the least amount of
insurance the insured must carry on the property protected by the policy.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
SCHEDULED EQUIPMENT
Number (#) One
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type One
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description One
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. One
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used One
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased One
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer One
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number One
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year One
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity One
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance One
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Two
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Two
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Two
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Two
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Two
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Two
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Two
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Two
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Two
Enter year: The model year of the item.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Capacity Two
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Two
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Three
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Three
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Three
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Three
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Three
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Three
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Three
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Three
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Three
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Three
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Three
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Four
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Four
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Four
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Four
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Four
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Four
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Four
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Four
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Four
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Four
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Four
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Five
Enter identifier: The producer assigned identifier for the item.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Type Five
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Five
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Five
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Five
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Five
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Five
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Five
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Five
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Five
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Five
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Six
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Six
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Six
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Six
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Six
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Six
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Six
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Six
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Six
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Six
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Six
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Seven
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Seven
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Seven
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Seven
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Seven
Enter code: A code indicating if the item was purchased new or used.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Date Purchased Seven
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Seven
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Seven
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Seven
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Seven
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Seven
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Eight
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Eight
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Eight
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Eight
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Eight
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Eight
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Eight
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Eight
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Eight
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Eight
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Eight
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Nine
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Nine
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Nine
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Nine
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Nine
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Nine
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Nine
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Nine
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Nine
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Nine
Enter number: The quantity or volume of the item.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Amount of Insurance Nine
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Ten
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Ten
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Ten
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Ten
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Ten
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Ten
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Ten
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Ten
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Ten
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Ten
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Ten
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Eleven
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Eleven
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Eleven
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Eleven
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Eleven
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Eleven
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Eleven
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Eleven
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Eleven
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Eleven
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Eleven
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Twelve
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Twelve
Enter code: The code identifying the class / grouping of property into which the item falls.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Description Twelve
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Twelve
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Twelve
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Capacity Twelve
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Twelve
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Twelve
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Twelve
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Date Purchased Twelve
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Twelve
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Thirteen
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Thirteen
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Thirteen
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Thirteen
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Thirteen
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Date Purchased Thirteen
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Thirteen
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Thirteen
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Thirteen
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Capacity Thirteen
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Thirteen
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Fourteen
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Fourteen
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Fourteen
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Fourteen
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Fourteen
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Capacity Fourteen
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Fourteen
Enter text: The name of the manufacturer of the item.
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Section Name
Field Name
Field and/or Section Description
SCHEDULED EQUIPMENT
Model Number Fourteen
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Fourteen
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Date Purchased Fourteen
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Fourteen
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
SCHEDULED EQUIPMENT
Number (#) Fifteen
Enter identifier: The producer assigned identifier for the item.
SCHEDULED EQUIPMENT
Type Fifteen
Enter code: The code identifying the class / grouping of property into which the item falls.
SCHEDULED EQUIPMENT
Description Fifteen
Enter text: The description of the item.
SCHEDULED EQUIPMENT
ID#/Serial No. Fifteen
Enter identifier: The identification number, serial number, or any other identifying symbol of
the item.
SCHEDULED EQUIPMENT
New/Used Fifteen
Enter code: A code indicating if the item was purchased new or used.
SCHEDULED EQUIPMENT
Capacity Fifteen
Enter date: The date the item was purchased, (MM/DD/YYYY).
SCHEDULED EQUIPMENT
Manufacturer Fifteen
Enter text: The name of the manufacturer of the item.
SCHEDULED EQUIPMENT
Model Number Fifteen
Enter text: The manufacturer's model name or number for the item.
SCHEDULED EQUIPMENT
Model Year Fifteen
Enter year: The model year of the item.
SCHEDULED EQUIPMENT
Date Purchased Fifteen
Enter number: The quantity or volume of the item.
SCHEDULED EQUIPMENT
Amount of Insurance Fifteen
Enter limit: The amount of insurance representing the liability limit for the particular
described equipment. The limit should reflect the required coinsurance percentage and
the requested basis of valuation (ACV or Replacement Cost).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) of the company(ies) listed on the document. This is required in most
states.
SIGNATURE
Producer's Name (Please Print)
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 FL)
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). Note: The NPN is not the same as the producer
state license number.
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Section Name
Field Name
Field and/or Section Description
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
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