ACORD 175 (2012/04)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 175 (2012/04)
Commercial Policy Change
Request
ACORD 175, Commercial Policy Change Request, is used to submit
requested changes in a commercial insurance policy to the carrier.
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
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone No.
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No.
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Insured's Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Address If Changed
Insured's Name and Mailing
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
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 Attention
Enter text: The name of the individual at the insurance company that is the primary
contact.
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 Account Number
Enter identifier: The account number to be used for billing purposes. This is the billing
number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the
insurer assigns. If the account already exists, the agent should provide the previously
assigned number.
IDENTIFICATION SECTION Effective Date of Change
Enter date: The date on which the change should take effect.
IDENTIFICATION SECTION Policy Inception Date
Enter date: The date on which the terms and conditions of the policy commenced.
IDENTIFICATION SECTION Policy Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Property
Check the box (if applicable): Indicates the type of policy is property.
IDENTIFICATION SECTION Inland Marine
Check the box (if applicable): Indicates the type of policy is inland marine.
IDENTIFICATION SECTION Umbrella
Check the box (if applicable): Indicates the type of policy is umbrella.
IDENTIFICATION SECTION General Liability
Check the box (if applicable): Indicates the type of policy is general liability.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Auto
Check the box (if applicable): Indicates the type of policy is automobile.
IDENTIFICATION SECTION Truckers
Check the box (if applicable): Indicates the type of policy is truckers.
IDENTIFICATION SECTION Motor Carriers
Check the box (if applicable): Indicates the type of policy is motor carriers.
IDENTIFICATION SECTION Business Owners
Check the box (if applicable): Indicates the type of policy is business owners.
IDENTIFICATION SECTION Workers Comp
Check the box (if applicable): Indicates the type of policy is workers compensation.
IDENTIFICATION SECTION Other Policy Type One
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
listed.
IDENTIFICATION SECTION Other Policy Type Description One
Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Other Policy Type Two
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
listed.
IDENTIFICATION SECTION Other Policy Type Description Two
Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Other Policy Type Three
Check the box (if applicable): Indicates the type of policy/perils insured is other than those
listed.
IDENTIFICATION SECTION Three
Other Policy Type Description
Enter text: The description of the type of policy issued to the insured.
SHORT DESCRIPTION OF
CHANGES / REMARKS
Short Description of Changes /
Remarks
Enter text: The remarks associated with a policy change. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required. As used here, enter a
short description of the changes.
PREMISES INFORMATION
SECTION
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
PREMISES INFORMATION
SECTION
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
PREMISES INFORMATION
SECTION
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
PREMISES INFORMATION
SECTION
LOC #
Enter number: The location number for the premises.
PREMISES INFORMATION
SECTION
BLD #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
SECTION
Street, City, County, State
Enter text: The first address line of the commercial structure.
PREMISES INFORMATION
SECTION
Enter text: The city of the commercial structure.
PREMISES INFORMATION
SECTION
Enter text: The county of the commercial structure.
PREMISES INFORMATION
SECTION
Enter code: The state of the commercial structure.
PREMISES INFORMATION
SECTION
Enter code: The postal code of the commercial structure.
PREMISES INFORMATION
SECTION
City Limits
Check the box (if applicable): Indicates if the building is within the city limits.
PREMISES INFORMATION
SECTION
City Limits
Check the box (if applicable): Indicates if the building is outside the city limits.
PREMISES INFORMATION
SECTION
Interest
Check the box (if applicable): Indicates the named insured's interest in the building is as
its owner.
PREMISES INFORMATION
SECTION
Interest
Check the box (if applicable): Indicates the named insured's interest is the building is as
its tenant.
PREMISES INFORMATION
SECTION
Yr Built
Enter year: The year the building at each location was originally constructed. Specify in the
Remarks section any significant additions or renovations and the year they were
completed.
PREMISES INFORMATION
SECTION
Part Occupied
Enter percentage: The percentage of the building the named insured occupies.
PREMISES INFORMATION
SECTION
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
PREMISES INFORMATION
SECTION
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
PREMISES INFORMATION
SECTION
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
NATURE OF BUSINESS /
DESCRIPTION OF
OPERATIONS
LOC #
Enter number: The location number for the premises.
NATURE OF BUSINESS /
DESCRIPTION OF
OPERATIONS
BLD #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
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Section Name
Field Name
Field and/or Section Description
NATURE OF BUSINESS /
DESCRIPTION OF
OPERATIONS
Description of Operation by
Premises
Enter text: The description of the nature/type of business.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Policy Limit(s) Changed
Check the box (if applicable): Indicates if there is a change to the policy limits.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
AUTO-VEHICLE
DESCRIPTION / LIMITS
VEH # One
Enter number: The producer assigned vehicle number.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Year One
Enter year: The model year of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Make One
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
AUTO-VEHICLE
DESCRIPTION / LIMITS
Model One
Enter text: The manufacturer's model name for the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Body Type One
Enter code: The body type of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
V.I.N One
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
AUTO-VEHICLE
DESCRIPTION / LIMITS
PP (private passenger) One
Check the box (if applicable): Indicates the predominant type of the vehicle is private
passenger.
AUTO-VEHICLE
DESCRIPTION / LIMITS
SPEC (special) One
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
AUTO-VEHICLE
DESCRIPTION / LIMITS
COML (commercial) One
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
AUTO-VEHICLE
DESCRIPTION / LIMITS
SYM \ AGE One
Enter code: The symbol required for physical damage coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP / OTC SYM One
Enter code: The symbol required for comprehensive / other than collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COLL SYM One
Enter code: The symbol required for collision coverage.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Street (Required in KY) One
Enter text: The vehicle's physical address line one.
AUTO-VEHICLE
DESCRIPTION / LIMITS
City One
Enter text: The vehicle's physical address city name.
AUTO-VEHICLE
DESCRIPTION / LIMITS
County One
Enter text: The vehicle's physical address county name.
AUTO-VEHICLE
DESCRIPTION / LIMITS
State One
Enter code: The vehicle's physical address state or province code.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Zip One
Enter code: The vehicle's physical address postal code.
AUTO-VEHICLE
DESCRIPTION / LIMITS
LIC State One
Enter code: The state or province in which the vehicle is registered.
AUTO-VEHICLE
DESCRIPTION / LIMITS
TERR One
Enter code: The rating territory code where the vehicle is principally garaged.
AUTO-VEHICLE
DESCRIPTION / LIMITS
GVW / GCW One
Enter number: The actual weight of the vehicle or the combined weight of tractor and
trailer in pounds.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Class One
Enter code: The rate class of the vehicle. If two rate classes are required, this element
should be used to enter the liability code.
AUTO-VEHICLE
DESCRIPTION / LIMITS
SIC One
Enter code: The secondary Special Industry Class code which applies to commercial
vehicles as determined by industry rating manuals.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Factor One
Enter rate: The primary liability rating factor contains the number which is used, along with
the secondary rating factor, in determining the liability premium. The primary rating factor
which is always positive is based on the primary class.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Seat CP One
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Radius One
Enter number: The radius in whole numbers within which this vehicle is operated.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Farthest Terminal One
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation
in which the vehicle is operated. The source of this code is the Insurance Services Office
Zone code list.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Cost New One
Enter amount: The original cost of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Pleasure One
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Farm One
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Commercial One
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Retail One
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail
industry.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Service One
Check the box (if applicable): Indicates the primary use for the vehicle is for the service
industry.
AUTO-VEHICLE
DESCRIPTION / LIMITS
For Hire One
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Use One
Check the box (if applicable): Indicates the primary use for the vehicle is for other
purposes.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Use Description
Enter text: The description of the other vehicle usage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Liab One
Check the box (if applicable): Indicates the vehicle has liability coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
No-fault One
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add'l No-fault One
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Med Pay One
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Unins Motor One
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Undrins Motor One
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Towing & Labor One
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Spec C of L One
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
F One
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FT One
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this
vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FTW One
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of
loss on this vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
LSP One
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss
on this vehicle.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP/OTC One
Check the box (if applicable): Indicates the vehicle has comprehensive or other than
collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Coll One
Check the box (if applicable): Indicates the vehicle has collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Rent Reimb One
Check the box (if applicable): Indicates the vehicle has rental reimbursement or
transportation expense coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FG One
Check the box (if applicable): Indicates the vehicle has full glass coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Coverage One
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically
listed.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Coverage Description One
Enter text: The description of the other type of coverage on the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
ACV One
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the actual cash value or market value.
AUTO-VEHICLE
DESCRIPTION / LIMITS
AA One
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the agreed amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
ST AMT One
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the stated amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Applicable Limit One
Enter amount: The agreed or stated amount used in determining the value of the vehicle
at the time of loss.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP/OTC One
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Spec C of L One
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
AUTO-VEHICLE
DESCRIPTION / LIMITS
Applicable Deductible One
Enter amount: The comprehensive or specified cause of loss deductible amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Collision Deductible One
Enter deductible: The collision deductible amount.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Drive to Work or School under 15
miles one way One
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
work or school, and is driven to work or school under 15 miles one way.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Drive to Work or School 15 miles
or over one way One
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
work or school, and is driven to work or school 15 miles or over one way.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Net Veh CR/CR One
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits
that apply on a policy level. Provide under remarks a description of each debit or credit
used in the calculation of the net rating factor.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Total Premium One
Enter amount: The total amount for the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Liability One
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
AUTO-VEHICLE
DESCRIPTION / LIMITS
No-fault One
Enter limit: The personal injury protection (PIP) limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add'l No-fault One
Enter limit: The additional personal injury protection (APIP) limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Medical Payments One
Enter limit: The medical payments per person limit.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Uninsured Motorists One
Enter limit: The uninsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Underinsured Motorists One
Enter limit: The underinsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Policy Limit(s) Changed
Check the box (if applicable): Indicates if there is a change to the policy limits.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
AUTO-VEHICLE
DESCRIPTION / LIMITS
VEH # Two
Enter number: The producer assigned vehicle number.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Year Two
Enter year: The model year of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Make Two
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Model Two
Enter text: The manufacturer's model name for the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Body Type Two
Enter code: The body type of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
V.I.N Two
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
AUTO-VEHICLE
DESCRIPTION / LIMITS
PP (private passenger) Two
Check the box (if applicable): Indicates the predominant type of the vehicle is private
passenger.
AUTO-VEHICLE
DESCRIPTION / LIMITS
SPEC (special) Two
Check the box (if applicable): Indicates the predominant type of the vehicle is special (e.g.
classic, antique automobile).
AUTO-VEHICLE
DESCRIPTION / LIMITS
COML (commercial) Two
Check the box (if applicable): Indicates the predominant type of the vehicle is commercial.
AUTO-VEHICLE
DESCRIPTION / LIMITS
SYM \ AGE Two
Enter code: The symbol required for physical damage coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP / OTC SYM One
Enter code: The symbol required for comprehensive / other than collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COLL SYM One
Enter code: The symbol required for collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Street (Required in KY) Two
Enter text: The vehicle's physical address line one.
AUTO-VEHICLE
DESCRIPTION / LIMITS
City Two
Enter text: The vehicle's physical address city name.
AUTO-VEHICLE
DESCRIPTION / LIMITS
County Two
Enter text: The vehicle's physical address county name.
AUTO-VEHICLE
DESCRIPTION / LIMITS
State Two
Enter code: The vehicle's physical address state or province code.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Zip Two
Enter code: The vehicle's physical address postal code.
AUTO-VEHICLE
DESCRIPTION / LIMITS
LIC State Two
Enter code: The state or province in which the vehicle is registered.
AUTO-VEHICLE
DESCRIPTION / LIMITS
TERR Two
Enter code: The rating territory code where the vehicle is principally garaged.
AUTO-VEHICLE
DESCRIPTION / LIMITS
GVW / GCW Two
Enter number: The actual weight of the vehicle or the combined weight of tractor and
trailer in pounds.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Class Two
Enter code: The rate class of the vehicle. If two rate classes are required, this element
should be used to enter the liability code.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
SIC Two
Enter code: The secondary Special Industry Class code which applies to commercial
vehicles as determined by industry rating manuals.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Factor Two
Enter rate: The primary liability rating factor contains the number which is used, along with
the secondary rating factor, in determining the liability premium. The primary rating factor
which is always positive is based on the primary class.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Seat CP Two
Enter number: The seating capacity of the vehicle. Required for rating public passenger
vehicles.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Radius Two
Enter number: The radius in whole numbers within which this vehicle is operated.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Farthest Terminal Two
Enter code: Identifies the location of the farthest zone from the vehicle's base of operation
in which the vehicle is operated. The source of this code is the Insurance Services Office
Zone code list.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Cost New Two
Enter amount: The original cost of the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Pleasure Two
Check the box (if applicable): Indicates the primary use for the vehicle is for pleasure.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Farm Two
Check the box (if applicable): Indicates the primary use for the vehicle is for farming.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Commercial Two
Check the box (if applicable): Indicates the primary use for the vehicle is for commercial
purposes.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Retail Two
Check the box (if applicable): Indicates the primary use for the vehicle is for the retail
industry.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Service Two
Check the box (if applicable): Indicates the primary use for the vehicle is for the service
industry.
AUTO-VEHICLE
DESCRIPTION / LIMITS
For Hire One
Check the box (if applicable): Indicates the primary use for the vehicle is for hire.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Use One
Check the box (if applicable): Indicates the primary use for the vehicle is for other
purposes.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Use Description
Enter text: The description of the other vehicle usage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Liab Two
Check the box (if applicable): Indicates the vehicle has liability coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
No-fault Two
Check the box (if applicable): Indicates the vehicle has no-fault coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add'l No-fault Two
Check the box (if applicable): Indicates the vehicle has additional no-fault coverage.
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Med Pay Two
Check the box (if applicable): Indicates the vehicle has medical payments coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Unins Motor Two
Check the box (if applicable): Indicates the vehicle has uninsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Undrins Motor Two
Check the box (if applicable): Indicates the vehicle has underinsured motorists coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Towing & Labor Two
Check the box (if applicable): Indicates the vehicle has towing and labor coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Spec C of L Two
Check the box (if applicable): Indicates the vehicle has specified cause of loss coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
F Two
Check the box (if applicable): Indicates fire is a specified cause of loss on this vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FT Two
Check the box (if applicable): Indicates fire and theft is a specified cause of loss on this
vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FTW Two
Check the box (if applicable): Indicates fire, theft and windstorm is a specified cause of
loss on this vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
LSP Two
Check the box (if applicable): Indicates limited specified perils is a specified cause of loss
on this vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP/OTC Two
Check the box (if applicable): Indicates the vehicle has comprehensive or other than
collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Coll Two
Check the box (if applicable): Indicates the vehicle has collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Rent Reimb Two
Check the box (if applicable): Indicates the vehicle has rental reimbursement or
transportation expense coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
FG Two
Check the box (if applicable): Indicates the vehicle has full glass coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Coverage Two
Check the box (if applicable): Indicates the vehicle has a type of coverage not specifically
listed.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Other Coverage Description Two
Enter text: The description of the other type of coverage on the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
ACV Two
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the actual cash value or market value.
AUTO-VEHICLE
DESCRIPTION / LIMITS
AA Two
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the agreed amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
ST AMT Two
Check the box (if applicable): Indicates the valuation method used in determining the
value of the vehicle at the time of loss is the stated amount.
ACORD 175 (2012/04) rev. 04-30-2012
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Applicable Limit Two
Enter amount: The agreed or stated amount used in determining the value of the vehicle
at the time of loss.
AUTO-VEHICLE
DESCRIPTION / LIMITS
COMP/OTC Two
Check the box (if applicable): Indicates the deductible is for comprehensive or other than
collision coverage.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Spec C of L Two
Check the box (if applicable): Indicates the deductible is for specified causes of loss. The
Specified Cause of Loss Codes are:
SCL Specified Cause of Loss
F Fire
F&T Fire and Theft
F,T&W Fire, Theft and Wind
LSP Limited Specified Perils
SP Specified Perils
AUTO-VEHICLE
DESCRIPTION / LIMITS
Applicable Deductible Two
Enter amount: The comprehensive or specified cause of loss deductible amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Collision Deductible Two
Enter deductible: The collision deductible amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Drive to Work or School under 15
miles one way Two
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
work or school, and is driven to work or school under 15 miles one way.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Drive to Work or School 15 miles
or over one way Two
Check the box (if applicable): Indicates the vehicle is used for commuting purposes to
work or school, and is driven to work or school 15 miles or over one way.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Net Veh CR/CR Two
Enter rate: The net rating factor that applies to this vehicle. Do not include debits or credits
that apply on a policy level. Provide under remarks a description of each debit or credit
used in the calculation of the net rating factor.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Total Premium Two
Enter amount: The total amount for the vehicle.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Liability Two
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
AUTO-VEHICLE
DESCRIPTION / LIMITS
No-fault Two
Enter limit: The personal injury protection (PIP) limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Add'l No-fault Two
Enter limit: The additional personal injury protection (APIP) limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Medical Payments Two
Enter limit: The medical payments per person limit.
ACORD 175 (2012/04) rev. 04-30-2012
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Section Name
Field Name
Field and/or Section Description
AUTO-VEHICLE
DESCRIPTION / LIMITS
Uninsured Motorists Two
Enter limit: The uninsured motorists combined single limit per accident limit amount.
AUTO-VEHICLE
DESCRIPTION / LIMITS
Underinsured Motorists Two
Enter limit: The underinsured motorists combined single limit per accident limit amount.
DRIVER INFORMATION
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
DRIVER INFORMATION
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
DRIVER INFORMATION
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
DRIVER INFORMATION
Driver # One
Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION
Name One
Enter text: The driver's first name (given name). As used here, if the company requires an
address enter it in remarks.
DRIVER INFORMATION
Enter text: The driver's middle name or initial (other given name).
DRIVER INFORMATION
Enter text: The driver's last name (surname).
DRIVER INFORMATION
City
Enter text: The city of the driver.
DRIVER INFORMATION
State
Enter code: The state or province of the driver.
DRIVER INFORMATION
Zip
Enter code: The postal code of the driver.
DRIVER INFORMATION
Sex One
Enter code: The gender of the driver.
DRIVER INFORMATION
Mar Stat One
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -
Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil
Union/Registered Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
DRIVER INFORMATION
Date of Birth One
Enter date: The birth date of the driver.
DRIVER INFORMATION
Yrs Exp One
Enter number: The number of years of driving experience for the driver.
DRIVER INFORMATION
Year LIC One
Enter year: The original year in which a driver's license was issued to this driver.
DRIVER INFORMATION
Drivers License Number/Social
Security Number One
Enter identifier: The driver's license number. As used here, if the driver's license number
is not available, enter the social security number.
DRIVER INFORMATION
Social Security Number
Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION
State LIC One
Enter code: The state in which the driver is licensed.
DRIVER INFORMATION
Date Hire One
Enter date: The date the driver was hired.
DRIVER INFORMATION
Broaden No-Fault One
Enter Y for a Yes response. Input N for No response. Indicates that broadened no fault
coverage applies to the driver (not applicable in all states).
DRIVER INFORMATION
DOC One
Enter Y for a Yes response. Input N for No response. Indicates the driver is covered by
Drive Other Car coverage.
DRIVER INFORMATION
Use Veh # One
Enter number: The producer assigned vehicle number that this driver primarily uses.
ACORD 175 (2012/04) rev. 04-30-2012
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Section Name
Field Name
Field and/or Section Description
DRIVER INFORMATION
% Use One
Enter percentage: Indicates the percentage of driving done by this driver in the primary
vehicle that this driver uses.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
WORKERS'
COMPENSATION RATING
INFORMATION
Type of Change One
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
WORKERS'
COMPENSATION RATING
INFORMATION
State One
Enter text: The name of the state to which the rating information is applicable.
WORKERS'
COMPENSATION RATING
INFORMATION
LOC One
Enter number: The producer assigned number of the location.
WORKERS'
COMPENSATION RATING
INFORMATION
Class Code One
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
from the National Counsel on Compensation Insurance (NCCI) Workers Compensation
and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
may be used.
WORKERS'
COMPENSATION RATING
INFORMATION
Descr Code One
Enter code: The company description code for this type of risk (if applicable).
WORKERS'
COMPENSATION RATING
INFORMATION
Categories, Duties, Classifications
One
Enter text: The descriptions of activities and operations. One class code may include
several descriptions. It is extremely important to enter the specific classification
description or, at least, a brief statement regarding the duties of the employees. Enter as
much information as necessary to avoid misclassifying the operations.
WORKERS'
COMPENSATION RATING
INFORMATION
# of Employees One
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year.
Underwriters use this number to determine if the payroll estimates appear adequate.
ACORD 175 (2012/04) rev. 04-30-2012
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Section Name
Field Name
Field and/or Section Description
WORKERS'
COMPENSATION RATING
INFORMATION
# of Employees One
Enter number: The number of part time employees to whom the classification applies.
The average number is sufficient when the total number fluctuates during the year.
Underwriters use this number to determine if the payroll estimates appear adequate
WORKERS'
COMPENSATION RATING
INFORMATION
Estimated Annual Remuneration
One
Enter amount: The estimated total annual remuneration/payroll for the class.
Remuneration/Payroll means money or substitutes for money, such as the value of meals
or lodging if provided. Accurate payroll estimates help avoid additional premium
requirements being discovered during an audit. Do not include overtime premium.
WORKERS'
COMPENSATION RATING
INFORMATION
Type of Change Two
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
WORKERS'
COMPENSATION RATING
INFORMATION
State Two
Enter text: The name of the state to which the rating information is applicable.
WORKERS'
COMPENSATION RATING
INFORMATION
LOC Two
Enter number: The producer assigned number of the location.
WORKERS'
COMPENSATION RATING
INFORMATION
Class Code Two
Enter code: The Rating Classification Code is a six-digit alpha-numeric code obtained
from the National Counsel on Compensation Insurance (NCCI) Workers Compensation
and Employers' Liability Insurance Manual. Only suffixes specifically shown on rate pages
may be used.
WORKERS'
COMPENSATION RATING
INFORMATION
Descr Code Two
Enter code: The company description code for this type of risk (if applicable).
ACORD 175 (2012/04) rev. 04-30-2012
16 of 30
Section Name
Field Name
Field and/or Section Description
WORKERS'
COMPENSATION RATING
INFORMATION
Categories, Duties, Classifications
Two
Enter text: The descriptions of activities and operations. One class code may include
several descriptions. It is extremely important to enter the specific classification
description or, at least, a brief statement regarding the duties of the employees. Enter as
much information as necessary to avoid misclassifying the operations.
WORKERS'
COMPENSATION RATING
INFORMATION
# of Employees Two
Enter number: The number of full time employees to whom the classification applies. The
average number is sufficient when the total number fluctuates during the year.
Underwriters use this number to determine if the payroll estimates appear adequate.
WORKERS'
COMPENSATION RATING
INFORMATION
# of Employees Two
Enter number: The number of part time employees to whom the classification applies.
The average number is sufficient when the total number fluctuates during the year.
Underwriters use this number to determine if the payroll estimates appear adequate
WORKERS'
COMPENSATION RATING
INFORMATION
Estimated Annual Remuneration
Two
Enter amount: The estimated total annual remuneration/payroll for the class.
Remuneration/Payroll means money or substitutes for money, such as the value of meals
or lodging if provided. Accurate payroll estimates help avoid additional premium
requirements being discovered during an audit. Do not include overtime premium.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Premises #
Enter number: The location number for the premises.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Building #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Subject of Insurance One
Enter code: The code designating the subject of insurance or premium bearing option.
ACORD 175 (2012/04) rev. 04-30-2012
17 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Amount One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Coins % One
Enter percentage: 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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Valuation One
Enter code: Indicate the method which will be used to determine the amount paid on a
claim. Valuation methods are:
ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value
RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost
AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount
MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Causes of Loss One
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Inflation Guards % One
Enter percentage: The inflation guard percentage gives an automatic increase in the
amount of coverage based on a percentage over time. List both the percentage amount
and the period of time during which it applies (e.g., 4% per year).
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Forms and Conditions to Apply
One
Enter text: The form numbers and special conditions that apply to this subject of
insurance. Also indicate here if coverage is blanket or average rated.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Subject of Insurance Two
Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Amount Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
ACORD 175 (2012/04) rev. 04-30-2012
18 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Coins % Two
Enter percentage: 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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Valuation Two
Enter code: Indicate the method which will be used to determine the amount paid on a
claim. Valuation methods are:
ACV . . . . . . . . . . . . . . . . . . . . . . . . . Actual Cash Value
RC. . . . . . . . . . . . . . . . . . . . . . . . . . .Replacement Cost
AA . . . . . . . . . . . . . . . . . . . . . . . . . . Agreed Amount
MV . . . . . . . . . . . . . . . . . . . . . . . . . . Market Value
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Causes of Loss
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Inflation Guards % Two
Enter percentage: The inflation guard percentage gives an automatic increase in the
amount of coverage based on a percentage over time. List both the percentage amount
and the period of time during which it applies (e.g., 4% per year).
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Forms and Conditions to Apply
Two
Enter text: The form numbers and special conditions that apply to this subject of
insurance. Also indicate here if coverage is blanket or average rated.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Additional Coverages, Options,
Endorsements, and Rating
Information
Enter text: The remarks associated with a specific location or sublocation.
ACORD 175 (2012/04) rev. 04-30-2012
19 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Construction Type
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
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Distance to Hydrant
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Distance to Fire Stat
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Fire District / Code Number
Enter text: The property's fire district name.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Enter code: The property's fire district code number which can be found in the individual
states manual pages.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Prot CL
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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
# Stories
Enter number: The number of stories for this building not including any basement.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
# Basements
Enter number: The number of basements for this building.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Yr Built
Enter year: The year the building at each location was originally constructed. Specify in the
Remarks section any significant additions or renovations and the year they were
completed.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Total Area
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
ACORD 175 (2012/04) rev. 04-30-2012
20 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Wiring
Check the box (if applicable): Indicates if any wiring improvements have been made since
the original construction.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Year
Enter year: The year the wiring improvements took place.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Roofing
Check the box (if applicable): Indicates if any roofing improvements have been made
since the original construction.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Year
Enter year: The year the roofing improvements took place.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Plumbing
Check the box (if applicable): Indicates if any plumbing improvements have been made
since the original construction.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Year
Enter year: The year the plumbing improvements took place.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Heating
Check the box (if applicable): Indicates if any heating improvements have been made
since the original construction.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Year
Enter year: The year the heating improvements took place.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Other Improvements
Check the box (if applicable): Indicates if any other improvements have been made since
the original construction.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Year
Enter text: The description of other improvements that have been made to the structure.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
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.
ACORD 175 (2012/04) rev. 04-30-2012
21 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Roof Type
Enter code: The material used to construct the roof. Examples:
* Composition (fiberglass, asphalt, etc.)
* Metal
* Poured
* Slate
* Tile
* Wood Shake/ (pleas this list is not all inclusive)
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Tax Code
Enter code: The city, county or state tax code, if applicable.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Other Occupancies
Enter text: The description of any other occupancies located in the building not operated
by the insured and not listed in the Description of Operations section on the ACORD 125.
If no other occupancy, enter None.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Right Exposure & Distance
Enter text: The description of the buildings, structures, activities conducted, or use of the
adjacent property to the right of the insured premises.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Enter number: The distance to the adjacent exposure on the right of the insured premises
in linear feet.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Left Exposure & Distance
Enter text: The description of the buildings, structures, activities conducted, or use of the
adjacent property to the left of the insured premises.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Enter number: The distance to the adjacent exposure on the left of the insured premises
in linear feet.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Rear Exposure & Distance
Enter text: The description of the buildings, structures, activities conducted, or use of the
adjacent property to the rear of the insured premises.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Enter number: The distance to the adjacent exposure on the rear of the insured premises
in linear feet.
PROPERTY / INLAND
MARINE - 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.
ACORD 175 (2012/04) rev. 04-30-2012
22 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - 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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Expiration Date
Enter date: The expiration date of the certificate.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Extent
Enter code: The designated extent of protection as described in the Insurance Services
Office crime rating manual.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Grade
Enter code: The alarm grade as described in the Insurance Services Office crime rating
manual (e.g., AA, A, B, C) which indicates the time required to respond to a signal from
the alarm system.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Central Station
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
With Keys
Check the box (if applicable): Indicates the alarm company, located off the insured's
premises, has keys to the applicant's property.
PROPERTY / INLAND
MARINE - 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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
# Guards/Watchmen
Enter number: The number of guards and or watchmen employed or contracted for by the
insured.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Clock Hourly
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.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Other than Hourly
Check the box (if applicable): Indicates the guard/watchman is required to make some
other type of rounds.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Other than Hourly
Enter text: The description of the rounds the guards/watchmen are required to make.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Premises Fire Protection
Enter text: The description of the type of fire protection for the premises (e.g. sprinklers,
standpipes, chemical systems).
ACORD 175 (2012/04) rev. 04-30-2012
23 of 30
Section Name
Field Name
Field and/or Section Description
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Fire Alarm Manufacturer
Enter text: The name of the manufacturer of the alarm, and if it is UL listed.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Central Station
Check the box (if applicable): Indicates the fire alarm rings at an alarm company, police
department or fire department.
PROPERTY / INLAND
MARINE - PREMISES
INFORMATION
Local Gong
Check the box (if applicable): Indicates the fire alarm rings on an audible gong located
outside of the building.
INLAND MARINE-
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.
INLAND MARINE-
SCHEDULED EQUIPMENT
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
INLAND MARINE-
SCHEDULED EQUIPMENT
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
INLAND MARINE-
SCHEDULED EQUIPMENT
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
INLAND MARINE-
SCHEDULED EQUIPMENT
Number (#) One
Enter identifier: The producer assigned identifier for the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
Model Year One
Enter year: The model year of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
Description One
Enter text: The description of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
ID #/Serial # One
Enter identifier: The identification number, serial number, or any other identifying symbol
of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
Date Purchased One
Enter date: The date the item was purchased, (MM/DD/YYYY).
INLAND MARINE-
SCHEDULED EQUIPMENT
New/Used One
Enter code: A code indicating if the item was purchased new or used.
INLAND MARINE-
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).
INLAND MARINE-
SCHEDULED EQUIPMENT
Number (#) Two
Enter identifier: The producer assigned identifier for the item.
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Section Name
Field Name
Field and/or Section Description
INLAND MARINE-
SCHEDULED EQUIPMENT
Model Year Two
Enter year: The model year of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
Description Two
Enter text: The description of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
ID #/Serial # Two
Enter identifier: The identification number, serial number, or any other identifying symbol
of the item.
INLAND MARINE-
SCHEDULED EQUIPMENT
Date Purchased Two
Enter date: The date the item was purchased, (MM/DD/YYYY).
INLAND MARINE-
SCHEDULED EQUIPMENT
New/Used Two
Enter code: A code indicating if the item was purchased new or used.
INLAND MARINE-
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).
GENERAL LIABILITY -
LIMITS
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
GENERAL LIABILITY -
LIMITS
General Aggregate
Enter limit: The general liability, general aggregate limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
GENERAL LIABILITY -
LIMITS
Products & Completed Operations
Aggregate
Enter limit: The general liability, products and completed operations aggregate limit
amount. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
GENERAL LIABILITY -
LIMITS
Personal & Advertising Injury
Enter limit: The general liability, personal and advertising injury limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by
the issuing insurer(s).
GENERAL LIABILITY -
LIMITS
Each Occurrence
Enter limit: The general liability, each occurrence limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
GENERAL LIABILITY -
LIMITS
Damage to Rented Premises
Enter limit: The general liability, damage to rented premises each occurrence limit
amount. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
GENERAL LIABILITY -
LIMITS
Medical Expense
Enter limit: The general liability, medical expense each person limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
GENERAL LIABILITY -
LIMITS
Employee Benefits
Enter limit: The general liability employee benefits limit amount.
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Section Name
Field Name
Field and/or Section Description
GENERAL LIABILITY -
LIMITS
Other
Enter text: The description of other coverage (not the limit). Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
GENERAL LIABILITY -
LIMITS
Other Benefits
Enter limit: The general liability, other coverage limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Type of Change One
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Location # One
Enter number: The producer assigned identifier for the location number of the risk's
location as it appears on the Applicant Information Section of ACORD 125. All
classifications should be grouped by location number.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Haz # One
Enter number: A unique (within location) number distinguishing this unit-at-risk from the
others.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Classification One
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class
description from the table in this field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Class Code One
Enter code: The general liability class code that corresponds to the classification
description shown in the previous field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Premium Basis One
Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Exposure One
Enter amount: The amount of the exposure used for this class code in calculating the
premium. The contents of this data element depends on the rating basis used. The full
amount of exposure is contained.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Terr One
Enter code: The rating territory code based on location from the appropriate state
exception page.
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Section Name
Field Name
Field and/or Section Description
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Type of Change Two
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Location # Two
Enter number: The producer assigned identifier for the location number of the risk's
location as it appears on the Applicant Information Section of ACORD 125. All
classifications should be grouped by location number.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Haz # Two
Enter number: A unique (within location) number distinguishing this unit-at-risk from the
others.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Classification Two
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class
description from the table in this field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Class Code Two
Enter code: The general liability class code that corresponds to the classification
description shown in the previous field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Premium Basis Two
Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Exposure Two
Enter amount: The amount of the exposure used for this class code in calculating the
premium. The contents of this data element depends on the rating basis used. The full
amount of exposure is contained.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Terr Two
Enter code: The rating territory code based on location from the appropriate state
exception page.
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Section Name
Field Name
Field and/or Section Description
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Type of Change Three
Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-
Delete or I - Informational Only No Change. Various combinations of changes are
permitted in one submission. Use A to add an item that was not previously in the policy
(e.g., add a vehicle, add a coverage). Use D to delete an item (e.g., delete a vehicle,
delete a driver). Use C to change an item in the policy (e.g., change a deductible,
change coverage limits). Use I to identify a risk or other item that is not being changed
but is related to another change on the form. Example: When adding collision coverage to
a vehicle, enter A in the type of change for Collision. Enter I in the type of change for
the Vehicle. Enter enough information to identify the vehicle that is having coverage
changed (e.g. year, make, model, body, VIN).
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Location # Three
Enter number: The producer assigned identifier for the location number of the risk's
location as it appears on the Applicant Information Section of ACORD 125. All
classifications should be grouped by location number.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Haz # Three
Enter number: A unique (within location) number distinguishing this unit-at-risk from the
others.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Classification Three
Enter text: The classification the applicant's liability exposures by location, using the ISO
Classification Table or other industry organization rules. Enter the appropriate class
description from the table in this field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Class Code Three
Enter code: The general liability class code that corresponds to the classification
description shown in the previous field.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Premium Basis Three
Enter code: An industry code designating the rating basis of the exposure amount.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Exposure Three
Enter amount: The amount of the exposure used for this class code in calculating the
premium. The contents of this data element depends on the rating basis used. The full
amount of exposure is contained.
GENERAL LIABILITY -
SCHEDULE OF HAZARDS
Terr Three
Enter code: The rating territory code based on location from the appropriate state
exception page.
UMBRELLA CHANGES
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
UMBRELLA CHANGES
Limit of Liability
Enter limit: The excess umbrella liability limit each occurrence limit.
UMBRELLA CHANGES
Retained Limit
Enter deductible: The excess or umbrella liability deductible or retention amount.
UMBRELLA CHANGES
Other
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
ADDITIONAL INTEREST
Add
Check the box (if applicable): Indicates if the type of change being requested is an add.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
Change
Check the box (if applicable): Indicates if the type of change being requested is a change
to an existing piece of data.
ADDITIONAL INTEREST
Delete
Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST
Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
Employee as Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as
lessor.
ADDITIONAL INTEREST
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Owner
Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST
Registrant
Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST
Name and Address
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
Enter code: The additional interest's country code.
ADDITIONAL INTEREST
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests
are associated with the same item.
ADDITIONAL INTEREST
Evidence: Certificate
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Location
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST
Building
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional
interest.
ADDITIONAL INTEREST
Boat
Enter number: The producer assigned number of the boat which has an additional
interest.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
Airport
Enter identifier: The Federal Aviation Administration's designator for the airport (e.g. ORD -
O'Hare International Airport).
ADDITIONAL INTEREST
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST
Item
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST
Item Description
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.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer. As used here, this information
is required in Florida.
SIGNATURE
Insured'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.
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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