ACORD 149 (2013/09) - DEALERS SECTION
ACORD 149 (2013/09) - DEALERS SECTION
ACORD 149, Dealers Section is used to provide basic information for inland marine coverage involving:
* Camera dealers
* Equipment dealers
* Fine Arts dealers
* Musical Instrument dealers
* Stamp and Coin dealers
This form is designed to be used in conjunction with the ACORD 125, Commercial Insurance Application - Applicant Information Section.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
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. As used here, this is the proposed effective date.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant / First Name
Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Subject of Insurance -
Camera Dealer (Checkbox)
Check the box (if applicable): Indicates the subject of insurance is a camera dealer.
IDENTIFICATION SECTION
Subject of Insurance -
Equipment Dealer
(Checkbox)
Check the box (if applicable): Indicates the subject of insurance is an equipment dealer.
IDENTIFICATION SECTION
Subject of Insurance - Fine
Arts Dealer (Checkbox)
Check the box (if applicable): Indicates the subject of insurance is a fine arts dealer.
ACORD 149 (2013/09) rev. 07-31-2013 P age 1 of 11
IDENTIFICATION SECTION
Subject of Insurance -
Musical Instrument Dealer
(Checkbox)
Check the box (if applicable): Indicates the subject of insurance is a musical instrument dealer.
IDENTIFICATION SECTION
Subject of Insurance -
Stamp And Coin Dealer
(Checkbox)
Check the box (if applicable): Indicates the subject of insurance is a stamp and coin dealer.
IDENTIFICATION SECTION
Subject of Insurance - Other
(Checkbox)
Check the box (if applicable): Indicates the nature of business is other than those listed.
IDENTIFICATION SECTION
Describe Other
Enter text: The description of the nature/type of business.
IDENTIFICATION SECTION
Premises from which
Business is Conducted
Enter text: The first address line of the commercial structure.
IDENTIFICATION SECTION
Enter text: The second address line of the commercial structure.
IDENTIFICATION SECTION
Enter text: The city of the commercial structure.
IDENTIFICATION SECTION
Enter code: The state of the commercial structure.
IDENTIFICATION SECTION
Enter code: The postal code of the commercial structure.
PREMISES PROTECTION
Floor on which Premises is
Located
Enter identifier: The floor/section of the building where the Insured's property is located.
PREMISES PROTECTION
Any Property in Basement?
Yes (Checkbox)
Enter Y for a Yes response. Input N for No response. Indicates there is property in the
basement below grade level.
PREMISES PROTECTION
Describe
Enter text: The description of property in the basement below grade level.
PREMISES PROTECTION
Number of Entrances Open
to the Public
Enter number: The number of entrances open to the public.
PREMISES PROTECTION
Number of Show Windows
Enter number: The number of windows used to display your property.
PREMISES PROTECTION
How are Show Windows
Protected
Enter text: The security measures taken to protect the property in show windows from loss.
PREMISES PROTECTION
Number of Showcases
Enter number: The number of showcases used to display your property.
PREMISES PROTECTION
How are Showcases
Protected
Enter text: The security measures taken to protect the property in showcases from loss.
PREMISES INFORMATION
Burglar Alarm Type
Enter text: The description of any burglar alarm protecting the building or contents. Descriptive
terms such as safe, premises, perimeter, or ultrasonic may be suitable.
PREMISES INFORMATION
Certificate #
Enter identifier: The Underwriters Laboratories or other testing organization Certificate Number,
if applicable. Attach a copy of the certificate to the application.
ACORD 149 (2013/09)
Page 2 of 11
PREMISES INFORMATION
Expiration Date
Enter date: The expiration date of the certificate.
PREMISES INFORMATION
Extent
Enter code: The designated extent of protection as described in the Insurance Services Office
crime rating manual.
PREMISES INFORMATION
Line Security - Yes / No
Enter Y for a Yes response. Input N for No response. Indicates if the alarm lines are
protected.
PREMISES INFORMATION
Local Gong (Checkbox)
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
PREMISES INFORMATION
Central Station (Checkbox)
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
PREMISES INFORMATION
Other Connect (Checkbox)
Check the box (if applicable): Indicates the alarm connection is other than those listed.
PREMISES INFORMATION
Other Connect Description
Enter text: The description of the alarm connection.
PREMISES INFORMATION
Burglar Alarm Installed and
Serviced By
Enter text: The name of the alarm company that installed and services the alarm. Alarm
companies often install, maintain, and service the system in addition to providing Central Station
facilities.
PREMISES INFORMATION
Response Time
Enter time: The response time established by the manufacturer.
PREMISES INFORMATION
Clock Hourly (Checkbox)
Check the box (if applicable): Indicates the guard/watchman is required to make hourly rounds
using a special time recording device or in connection with the central station service. If other
than hourly, indicate the time interval in the Other box.
PREMISES INFORMATION
Other (Checkbox)
Check the box (if applicable): Indicates the guard/watchman is required to make some other
type of rounds.
PREMISES INFORMATION
Other Description
Enter text: The description of the rounds the guards/watchmen are required to make.
PREMISES INFORMATION
Premises Fire Protection
Enter text: The description of the type of fire protection for the premises (e.g. sprinklers,
standpipes, chemical systems). As used here, if the premises is sprinklered, indicate the
percentage of the area covered by the system, whether wet/dry system, if valve monitors are
included and if connected to central station. Other devices would include smoke detectors.
PREMISES INFORMATION
Fire Alarm Manufacturer
Enter text: The name of the manufacturer of the alarm, and if it is UL listed.
PREMISES INFORMATION
Certificate #
Enter identifier: The Underwriters Laboratory or other testing organization Certificate Number, if
applicable. Attach a copy of the certificate to the application.
PREMISES INFORMATION
Local Gong (Checkbox)
Check the box (if applicable): Indicates the fire alarm rings on an audible gong located outside
of the building.
PREMISES INFORMATION
Central Station (Checkbox)
Check the box (if applicable): Indicates the fire alarm rings at an alarm company, police
department or fire department.
PREMISES INFORMATION
Other Connect (Checkbox)
Check the box (if applicable): Indicates the fire alarm connection is other than those listed.
PREMISES INFORMATION
Other Connect Description
Enter text: The description of the alarm connection.
ACORD 149 (2013/09)
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PREMISES INFORMATION
Total Gross Sales
Enter amount: The total gross sales for the prior twelve (12) months.
PREMISES INFORMATION
The Highest Merchandise
Inventory during the Past
Twelve Months was taken
on what date?
Enter date: The date you performed a physical inventory that resulted in the highest inventory of
the year.
PREMISES INFORMATION
The Highest Merchandise
Inventory during the Past
Twelve Months was exactly
Enter amount: The highest value of the physical inventory for the prior twelve (12) months.
PREMISES INFORMATION
The Average Value of
Property of Others During
the Past Twelve Months in
your Custody at Any One
Time and Including Average
Accrued Charges
Outstanding was.
Enter amount: The average value of merchandise of others which is in your care, custody and
control for the previous year.
PREMISES INFORMATION
Describe your Stock
Enter text: The specific description of the property to be insured. Describe any specific items
which are unique in size or value as respects the rest of the stock.
PREMISES INFORMATION
Do you Rent your Property
to Others? Yes (Checkbox)
Enter Y for a Yes response. Input N for No response. Indicates if you rent property to others.
PREMISES INFORMATION
Do you Rent your Property
to Others? Describe if Yes
Enter text: The description of how often you lease/rent merchandise to others, the insurance
arrangements and the percentage of your gross sales that are generated from the lease/rental
operations. Provide a complete copy of any written rental or lease agreement used for this
activity.
PREMISES INFORMATION
Do you have Property on
Consignment? Yes
(Checkbox)
Enter Y for a Yes response. Input N for No response. Indicates If the dealer accepts property
from others for sale or display.
PREMISES INFORMATION
Do you have Property on
Consignment? Describe if
Yes
Enter text: The description of property on consignment and how often it is done. Provide a
complete copy of any written agreement used for this activity.
PREMISES INFORMATION
Deductible Amount
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PREMISES INFORMATION
Coinsurance Percentage -
80% (Checkbox)
Check the box (if applicable): Indicates that 80% of the total value of the subject of insurance is
being insured. As used here, the coinsurance percentage is the percentage of the total value of
the subject of insurance being insured. If the amount of insurance falls below this percentage,
the insured must share in the amount of the loss. This field should be completed even when
writing agreed amount coverage.
PREMISES INFORMATION
Coinsurance Percentage -
90% (Checkbox)
Check the box (if applicable): Indicates that 90% of the total value of the subject of insurance is
being insured.
ACORD 149 (2013/09)
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PREMISES INFORMATION
Coinsurance Percentage -
100% (Checkbox)
Check the box (if applicable): Indicates that 100% of the total value of the subject of insurance is
being insured.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - ($)
Enter limit: The limit for stock/inventory located at the premises. As used here, if separate limits
are required for different types of stock, provide the limits and describe each type of stock.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - Other
Enter text: The description of stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - ($)
Enter limit: The limit for stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - Other
Enter text: The description of stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - ($)
Enter limit: The limit for stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - Other
Enter text: The description of stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - ($)
Enter limit: The limit for stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
a. Stock / Inventory Located
at - Other
Enter text: The description of stock/inventory located at the premises.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit by Registered Mail
or Armored Car
Services ($)
Enter limit: The limit for stock/inventory shipped by registered mail or armored car services
during the year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit by Registered Mail
or Armored Car
Services - Annual Values
Shipped ($)
Enter amount: The total dollar amount of stock/inventory shipped by registered mail or armored
car services.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit by Registered Mail
or Armored Car
Services - Average Value
Per Shipment ($)
Enter amount: The average dollar amount of stock/inventory by registered mail or armored car
services.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in of
Transit By Parcel Delivery
Service ($)
Enter limit: The limit for stock/inventory shipped by parcel delivery service during the year.
ACORD 149 (2013/09)
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LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in of
Transit By Parcel Delivery
Service - Annual Values
Shipped ($)
Enter amount: The total dollar amount of stock/inventory shipped by parcel delivery service
during the year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in of
Transit By Parcel Delivery
Service - Average Value Per
Shipment ($)
Enter amount: The average dollar amount of stock/inventory by parcel delivery service.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in of
Transit By Common Carrier
Or Contract Carrier ($)
Enter limit: The limit for stock/inventory shipped by common carrier or contract carrier during the
year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit By Common Carrier
Or Contract Carrier - Annual
Values Shipped ($)
Enter amount: The total dollar amount of stock/inventory shipped by common carrier or contract
carrier during the year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit By Common Carrier
Or Contract Carrier -
Average Value Per Shipment
($)
Enter amount: The average dollar amount of stock/inventory by common carrier or contract
carrier.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit on Your Vehicle ($)
Enter limit: The limit for stock/inventory shipped on your vehicles during the year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit on Your Vehicle -
Annual Values Shipped ($)
Enter amount: The total dollar amount of stock/inventory shipped on your vehicles during the
year.
LIMITS OF INSURANCE
REQUIRED
b. Stock / Inventory in
Transit on Your Vehicle -
Average Value Per Shipment
($)
Enter amount: The average dollar amount of stock/inventory on your vehicles.
LIMITS OF INSURANCE
REQUIRED
c. Stock / Inventory in the
Custody/Control of the
Insured or Their Employees
while away from the
Premises
Enter limit: The limit for stock/inventory in the custody/control of the insured or their employees
while away from the premises.
LIMITS OF INSURANCE
REQUIRED
d. Property in Show
Windows at Premises
Described in a above, but
not to exceed
Enter limit: The limit for property in show windows at premises listed in this application.
ACORD 149 (2013/09)
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LIMITS OF INSURANCE
REQUIRED
d. Property in Show
Windows at Premises
Described in a above, but
not to exceed
Enter limit: The maximum limit for property in show windows at premises listed in this
application.
LIMITS OF INSURANCE
REQUIRED
1. Maximum Amount in any
One Show Window when
Open for Business
Enter limit: The maximum limit for property in any one show window when open for business at
premises listed in this application.
LIMITS OF INSURANCE
REQUIRED
All Windows when Open for
Business
Enter limit: The maximum limit for property in all windows when open for business at premises
listed in this application.
LIMITS OF INSURANCE
REQUIRED
2. Maximum Amount in any
One Show Window when
Closed for Business
Enter limit: The maximum limit for property in any one window when closed for business at
premises listed in this application.
LIMITS OF INSURANCE
REQUIRED
Maximum Amount in all
Windows when Closed for
Business
Enter limit: The maximum limit for property in all windows when closed for business at premises
listed in this application.
LIMITS OF INSURANCE
REQUIRED
3. Maximum Amount of
Inventory on the Floor at
Close of Business (outside
of safe / vault)
Enter limit: The maximum limit for inventory on the floor at close of business (outside of
safe/vault).
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).
LIMITS OF INSURANCE
REQUIRED
e. Equipment and
Accessories Inside the
Building (Applicable to
Equipment Dealers only)
Enter limit: The limit for equipment and accessories located inside the building at the premises
listed in this application.
LIMITS OF INSURANCE
REQUIRED
Equipment and Accessories
Outside the Building
(Applicable to Equipment
Dealers only)
Enter limit: The limit for equipment and accessories located outside the building at the premises
listed in this application.
LIMITS OF INSURANCE
REQUIRED
f. Property While on Exhibit
($)
Enter limit: The limit for property while on exhibit away from the premises listed in this
application.
LIMITS OF INSURANCE
REQUIRED
How often is Property on
Exhibit
Enter text: The description of the frequency property is on exhibit.
ACORD 149 (2013/09)
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LIMITS OF INSURANCE
REQUIRED
g. In any One Loss,
Disaster, Or Occurrence ($)
Enter limit: The maximum limit on property in any one loss, disaster or occurrence.
LIMITS OF INSURANCE
REQUIRED
h. The Aggregate ($)
Enter limit: The aggregate limit to apply to all places where coverage is afforded except for
property in transit.
SAFE / VAULT
INFORMATION
Is any Stock kept in a Safe
/Vault - Safe (Checkbox)
Check the box (if applicable): Indicates the information provided applies to a safe. As used here,
indicates there is property kept in a safe. This section provides underwriting and rating
information. If you cannot classify the type of safe/vault, enter the exact information on any
labels on the containers in the Remarks area.
SAFE / VAULT
INFORMATION
Is any Stock kept in a Safe
/Vault - Vault (Checkbox)
Check the box (if applicable): Indicates the information provided applies to a vault. As used
here, indicates there is property kept in a vault.
SAFE / VAULT
INFORMATION
Is any Stock kept in a Safe
/Vault - Describe
Enter text: The description of the stock kept in the safe or vault.
SAFE / VAULT
INFORMATION
Manufacturer - Safe
(Checkbox)
Check the box (if applicable): Indicates the information provided applies to a safe. As used here,
this section provides underwriting and rating information. If you cannot classify the type of
safe/vault, enter the exact information on any labels on the containers in the Remarks area.
SAFE / VAULT
INFORMATION
Manufacturer - Vault
(Checkbox)
Check the box (if applicable): Indicates the information provided applies to a vault.
SAFE / VAULT
INFORMATION
Manufacturer
Enter text: The safe or vault manufacturer's name.
SAFE / VAULT
INFORMATION
Labeling Information - UL
(Checkbox)
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories, Inc.
(UL).
SAFE / VAULT
INFORMATION
Labeling Information - Other
(Checkbox)
Check the box (if applicable): Indicates the rating is based on a rating organization other than
Underwriters Laboratories, Inc. (UL).
SAFE / VAULT
INFORMATION
Labeling Information -
Describe
Enter text: The description of the rating and labeling information or any other pertinent
information.
SAFE / VAULT
INFORMATION
Type - Burglary (Checkbox)
Check the box (if applicable): Indicates the safe/vault is burglar resistive.
SAFE / VAULT
INFORMATION
Type - Fire (Checkbox)
Check the box (if applicable): Indicates the safe/vault is fire resistive.
SAFE / VAULT
INFORMATION
Relocking Device - Yes
(Checkbox)
Enter Y for a Yes response. Input N for No response. Indicates if there is a relocking device
on the safe/vault.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Group 1 (Checkbox)
Check the box (if applicable): Indicates the presence of UL Group 1 - High Security combination
locks.
ACORD 149 (2013/09)
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SAFE / VAULT
INFORMATION
Combination Locks - UL
Group 2 (Checkbox)
Check the box (if applicable): Indicates the presence of UL Group 2 - Standard combination
locks.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Other (Checkbox)
Check the box (if applicable): Indicates the presence of combination lock other than those listed.
As used here, indicates there is a non-rated combination lock.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Other Describe
Enter text: The description of the combination lock.
SAFE / VAULT
INFORMATION
Door Type (Excluding Bolt
Work)
Enter text: The description of the door type (e.g. round, square, etc.).
SAFE / VAULT
INFORMATION
Wall Thickness
Enter number: The wall thickness in inches.
SAFE / VAULT
INFORMATION
% of Inventory Kept in the
Safe/Vault when the
Premises is Closed for
Business
Enter percentage: The percent of inventory kept in the safe/vault when the premises are closed
for business.
SAFE / VAULT
INFORMATION
Describe Property
Enter text: The description of property kept in the safe/vault.
SAFE / VAULT
INFORMATION
Manufacturer - Safe
(Checkbox)
Check the box (if applicable): Indicates the information provided applies to a safe.
SAFE / VAULT
INFORMATION
Manufacturer - Vault
(Checkbox)
Check the box (if applicable): Indicates the information provided applies to a vault.
SAFE / VAULT
INFORMATION
Manufacturer
Enter text: The safe or vault manufacturer's name.
SAFE / VAULT
INFORMATION
Label - UL (Checkbox)
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories, Inc.
(UL).
SAFE / VAULT
INFORMATION
Label - Other (Checkbox)
Check the box (if applicable): Indicates the rating is based on a rating organization other than
Underwriters Laboratories, Inc. (UL).
SAFE / VAULT
INFORMATION
Label - Describe
Enter text: The description of the rating and labeling information or any other pertinent
information.
SAFE / VAULT
INFORMATION
Type - Burglary (Checkbox)
Check the box (if applicable): Indicates the safe/vault is burglar resistive.
SAFE / VAULT
INFORMATION
Type - Fire (Checkbox)
Check the box (if applicable): Indicates the safe/vault is fire resistive.
SAFE / VAULT
INFORMATION
Relocking Device - Yes
(Checkbox)
Enter Y for a Yes response. Input N for No response. Indicates if there is a relocking device
on the safe/vault.
ACORD 149 (2013/09)
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SAFE / VAULT
INFORMATION
Combination Locks - UL
Group 1 (Checkbox)
Check the box (if applicable): Indicates the presence of UL Group 1 - High Security combination
locks.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Group 2 (Checkbox)
Check the box (if applicable): Indicates the presence of UL Group 2 - Standard combination
locks.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Other (Checkbox)
Check the box (if applicable): Indicates the presence of combination lock other than those listed.
SAFE / VAULT
INFORMATION
Combination Locks - UL
Other Describe
Enter text: The description of the combination lock.
SAFE / VAULT
INFORMATION
Door Type (Excluding Bolt
Work)
Enter text: The description of the door type (e.g. round, square, etc.).
SAFE / VAULT
INFORMATION
Wall Thickness
Enter number: The wall thickness in inches.
SAFE / VAULT
INFORMATION
% of Inventory Kept in the
Safe/Vault when the
Premises is Closed for
Business
Enter percentage: The percent of inventory kept in the safe/vault when the premises are closed
for business.
SAFE / VAULT
INFORMATION
Describe Property
Enter text: The description of property kept in the safe/vault.
REMARKS
Enter text: The dealers section general remarks. Provide any additional information required for
underwriting or rating.
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).
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.
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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 149 (2013/09)
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