ACORD 155 BM (2014/12) - Boiler and Machinery Section 2002

ACORD 155 BM (2014/12) - Boiler and Machinery Section 2002
ACORD 155 BM, Boiler & Machinery Section 2002, has been designed to address basic underwriting and rating needs for the issuance of Boiler
and Machinery policies under the ISO 2002 rules.
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 portion of the application impedes tracking the full account.
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. (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) 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
Age of Oldest Machinery
and Equipment
Enter number: The age of the oldest piece of machinery / equipment.
PREMISES INFORMATION
Premises #
Enter number: The location number for the premises.
PREMISES INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
PREMISES INFORMATION
Policy Limit - Equipment
Breakdown
Enter limit: The limit for equipment breakdown coverage.
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PREMISES INFORMATION
Deductible - Equipment
Breakdown
Enter deductible: The deductible for equipment breakdown coverage.
PREMISES INFORMATION
Policy Limit - Pressure or
Vacuum Equipment
Property Damage
Enter limit: The property damage limit for pressure or vacuum equipment coverage.
PREMISES INFORMATION
Deductible - Pressure or
Vacuum Equipment
Enter deductible: The property damage deductible for pressure or vacuum equipment coverage.
PREMISES INFORMATION
Policy Limit - Mechanical
and Electrical Equipment
Property Damage
Enter limit: The property damage limit for mechanical and electrical equipment coverage.
PREMISES INFORMATION
Deductible - Mechanical and
Electrical Equipment
Enter deductible: The deductible amount for mechanical and electrical equipment coverage.
PREMISES INFORMATION
Policy Limit - Production
Machinery Property Damage
Enter limit: The property damage limit for production machinery coverage.
PREMISES INFORMATION
Deductible - Production
Machinery
Enter deductible: The deductible amount for production machinery coverage.
PREMISES INFORMATION
Policy Limit - Diagnostic
Equipment Property
Damage
Enter limit: The property damage limit for diagnostic equipment coverage.
PREMISES INFORMATION
Deductible - Diagnostic
Equipment
Enter deductible: The deductible amount for diagnostic equipment coverage.
PREMISES INFORMATION
Policy Limit - Expediting
Expense
Enter limit: The limit for expediting expense coverage.
PREMISES INFORMATION
Deductible - Expediting
Expense
Enter deductible: The deductible amount for expediting expense coverage.
PREMISES INFORMATION
Policy Limit - Business
Income / Extra Expense
Enter limit: The limit for business income / extra expense coverage.
PREMISES INFORMATION
Deductible - Business
Income / Extra Expense
Enter deductible: The deductible amount for business income / extra expense coverage.
PREMISES INFORMATION
Policy Limit Extra Expense
Only - Days
Enter number: The number of days for extra expense coverage.
PREMISES INFORMATION
Deductible - Extra Expense
Only
Enter deductible: The deductible amount for extra expense coverage.
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PREMISES INFORMATION
Policy Limit - Extended
Period of Restoration - Days
Enter number: The number of days for extended period of restoration coverage.
PREMISES INFORMATION
Deductible - Extended
Period of Restoration
Enter deductible: The deductible amount for extended period of restoration coverage.
PREMISES INFORMATION
Policy Limit - Data or Media
Enter limit: The limit for data or media coverage.
PREMISES INFORMATION
Deductible - Data or Media
Enter deductible: The deductible amount for data or media coverage.
PREMISES INFORMATION
Policy Limit - Spoilage /
Perishable Goods
Enter limit: The limit for spoilage / perishable goods coverage.
PREMISES INFORMATION
Deductible - Spoilage /
Perishable Goods
Enter deductible: The deductible amount for spoilage / perishable goods coverage.
PREMISES INFORMATION
Policy Limit - Utility / Service
Interr - Hours
Enter number: The number of hours for utility service interruption coverage.
PREMISES INFORMATION
Deductible - Utility / Service
Interr
Enter deductible: The deductible amount for utility service interruption coverage.
PREMISES INFORMATION
Policy Limit - Newly
Acquired Premises - Days
Enter number: The number of days for newly acquired premises coverage.
PREMISES INFORMATION
Deductible - Newly Acquired
Premises
Enter deductible: The deductible amount for newly acquired premises coverage.
PREMISES INFORMATION
Policy Limit - Ord or Law
Enter limit: The limit for ordinance or law coverage.
PREMISES INFORMATION
Deductible - Ord or Law
Enter deductible: The deductible amount for ordinance or law coverage.
PREMISES INFORMATION
Policy Limit - Errors and
Omissions
Enter limit: The limit for errors and omissions coverage.
PREMISES INFORMATION
Deductible - Errors and
Omissions
Enter deductible: The deductible amount for errors and omissions coverage.
PREMISES INFORMATION
Policy Limit - Brands and
Labels
Enter limit: The limit for brands and labels coverage.
PREMISES INFORMATION
Deductible - Brands and
Labels
Enter deductible: The deductible amount for brands and labels coverage.
PREMISES INFORMATION
Policy Limit - Contingent
Bus Inc / Extra Expense
Enter limit: The limit for contingent business income / extra expense coverage.
PREMISES INFORMATION
Deductible - Contingent Bus
Inc / Extra Expense
Enter deductible: The deductible amount for contingent business income / extra expense
coverage.
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PREMISES INFORMATION
Policy Limit - Covered
Premises
Enter limit: The limit for covered premises coverage.
PREMISES INFORMATION
Deductible - Covered
Premises
Enter deductible: The deductible amount for covered premises coverage.
PREMISES INFORMATION
Policy Limit - Sale, Services,
Materials
Enter limit: The limit for sales, service, materials coverage.
PREMISES INFORMATION
Deductible - Sale, Services,
Materials
Enter deductible: The deductible amount for sales, service, materials coverage.
PREMISES INFORMATION
Policy Limit - Demolition
Enter limit: The limit for demolition coverage.
PREMISES INFORMATION
Deductible - Demolition
Enter deductible: The deductible amount for demolition coverage.
PREMISES INFORMATION
Policy Limit - Off Premises
Property Damage
Enter limit: The limit for off premises property damage coverage.
PREMISES INFORMATION
Deductible - Off Premises
Property Damage
Enter deductible: The deductible amount for off premises property damage coverage.
PREMISES INFORMATION
Other Coverage Description
Enter text: The description of the coverage.
PREMISES INFORMATION
Policy Limit - Other
Enter limit: The limit amount for the coverage.
PREMISES INFORMATION
Deductible - Other
Enter limit: The deductible amount for the coverage.
COVERAGE LIMITATIONS
Limit - Ammonia
Contamination
Enter limit: The limit for ammonia contamination coverage.
COVERAGE LIMITATIONS
Limit - Consequential Loss
Enter limit: The limit for consequential loss coverage.
COVERAGE LIMITATIONS
Limit - Hazardous
Substance
Enter limit: The limit for hazardous substance coverage.
COVERAGE LIMITATIONS
Limit - Water Damage
Enter limit: The limit for water damage coverage.
COVERAGE LIMITATIONS
Other Coverage Limitations
Enter text: The description of the coverage.
COVERAGE LIMITATIONS
Limit - Other Limit
Enter limit: The limit amount for the coverage.
CONDITIONS OR OPTIONAL Limit - Business Income
COVERAGES
Report Date
Enter date: The report date for business income coverage. As used here, complete this section
if coverage for business income is selected.
CONDITIONS OR OPTIONAL Limit - Business Income
COVERAGES
Annual Value
Enter amount: The annual value for business income coverage.
CONDITIONS OR OPTIONAL Limit - Business Income
COVERAGES
Coinsurance Percentage
Enter percentage: The coinsurance percentage for business income coverage.
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CONDITIONS OR OPTIONAL
COVERAGES
Limit - Diagnostic
Equipment Included Or
Excluded
Enter code: Indicates if the coverage is included or excluded.
CONDITIONS OR OPTIONAL
COVERAGES
Other Coverage Limitations
Enter text: The description of the coverage.
CONDITIONS OR OPTIONAL
COVERAGES
Limit - Other Limit
Enter limit: The limit amount for the coverage.
ADDITIONAL INTEREST
Prem # - One
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Bldg # - One
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Certificate Required Yes -
One
Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST
Certificate Required No -
One
Check the box (if applicable): Indicates the additional interest does not require a Certificate of
Insurance,
ADDITIONAL INTEREST
Name and Address - One
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Interest - One
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Prem # - Two
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Bldg # - Two
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Certificate Required Yes -
Two
Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST
Certificate Required No -
Two
Check the box (if applicable): Indicates the additional interest does not require a Certificate of
Insurance,
ADDITIONAL INTEREST
Name and Address - Two
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
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ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Interest - Two
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Prem # - Three
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Bldg # - Three
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Certificate Required Yes -
Three
Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST
Certificate Required No -
Three
Check the box (if applicable): Indicates the additional interest does not require a Certificate of
Insurance,
ADDITIONAL INTEREST
Name and Address - Three
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Interest - Three
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Prem # - Four
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Bldg # - Four
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Certificate Required Yes -
Four
Check the box (if applicable): Indicates the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST
Certificate Required No -
Four
Check the box (if applicable): Indicates the additional interest does not require a Certificate of
Insurance,
ADDITIONAL INTEREST
Name and Address - Four
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
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ADDITIONAL INTEREST
Interest - Four
Enter text: The description of the other type of additional interest.
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).
GENERAL INFORMATION
1. Are equipment
maintenance, overhaul,
monitoring, disassembly
and repair conducted
according to manufacturers'
instructions? - Yes
Check the box (if applicable): Indicates a Yes response to the question, Are equipment
maintenance, overhaul, monitoring, disassembly and repair conducted according to
manufacturers' instructions?.
GENERAL INFORMATION
1. Are equipment
maintenance, overhaul,
monitoring, disassembly
and repair conducted
according to manufacturers'
instructions? - No
Check the box (if applicable): Indicates a No response to the question, Are equipment
maintenance, overhaul, monitoring, disassembly and repair conducted according to
manufacturers' instructions?. As used here, if No, explain.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether equipment maintenance, overhaul, monitoring,
disassembly and repair are not conducted according to manufacturers instructions.
GENERAL INFORMATION
2. Is all equipment
accessible with respect to
repair or replacement? - Yes
Check the box (if applicable): Indicates a Yes response to the question, Is all equipment
accessible with respect to repair or replacement?.
GENERAL INFORMATION
2. Is all equipment
accessible with respect to
repair or replacement? - No
Check the box (if applicable): Indicates a No response to the question, Is all equipment
accessible with respect to repair or replacement?. As used here, if No, explain.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether all equipment is not accessible with respect to repair or
replacement.
GENERAL INFORMATION
3. Are all equipment
instrumentation and
controls in accordance with
manufacturers'
specifications? - Yes
Check the box (if applicable): Indicates a Yes response to the question, Are all equipment
instrumentation and controls in accordance with manufacturers specifications?.
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GENERAL INFORMATION
3. Are all equipment
instrumentation and
controls in accordance with
manufacturers'
specifications? - No
Check the box (if applicable): Indicates a Yes response to the question, Are all equipment
instrumentation and controls in accordance with manufacturers specifications?. As used here, if
No, explain.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether all equipment instrumentation and controls are not in
accordance with manufacturers' specifications.
GENERAL INFORMATION
4. Are chlorofluorocarbon
(CFC) refrigerants used in
the machinery to cool any
part of the premises or
process? - Yes
Check the box (if applicable): Indicates a Yes response to the question, Are
chlorofluorocarbon (CFC) refrigerants used in the machinery to cool any part of the premises or
process?. As used here, if Yes, explain.
GENERAL INFORMATION
4. Are chlorofluorocarbon
(CFC) refrigerants used in
the machinery to cool any
part of the premises or
process? - No
Check the box (if applicable): Indicates a No response to the question, Are chlorofluorocarbon
(CFC) refrigerants used in the machinery to cool any part of the premises or process?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any chlorofluorocarbon refrigerants are used in the
machinery to cool any part of the premises or process.
GENERAL INFORMATION
5. Is all machinery and
equipment in good
condition? - Yes
Check the box (if applicable): Indicates a Yes response to the question, Is all machinery and
equipment in good condition?.
GENERAL INFORMATION
5. Is all machinery and
equipment in good
condition? - No
Check the box (if applicable): Indicates a No response to the question, Is all machinery and
equipment in good condition?. As used here, if No, explain.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether all machinery and equipment are not in good condition.
REMARKS
Remarks
Enter text: The remarks associated with the boiler and machinery line of business. Enter any
additional information required for underwriting or rating.
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
Producers Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License
Number
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. (MM/DD/YYYY)
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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.
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