ACORD 3 (2011/07)

ACORD 3 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 3 (2011/07)
General Liability Notice of
Occurrence / Claim
ACORD 3, General Liability Notice of Occurrence / Claim, is used to
report both commercial and personal liability losses. The third page of the form contains
required state specific fraud warnings.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Address 1
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Address 2
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION City
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION State
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Zip
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 (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION FAX
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).
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Insured Location Code
Enter code: The code the policyholder defines that is used to allocate loss experience to
cost centers. For example, if a grocery store chain is insured and the entire chain was
under one policy, the grocery store chain might choose to allocate the losses for each
store. To do this they would provide a store number or store code (something the insured
defines) when they report a claim. The insured would include that store number in the
Insured Location Code field so that the carrier can record the code in their claim system
and then the right store is assessed the loss experience.
IDENTIFICATION SECTION Date of Loss
Enter date: The date that the loss occurred.
IDENTIFICATION SECTION Time of Loss
Enter time: The approximate time that the loss occurred.
IDENTIFICATION SECTION AM
Check the box (if applicable): Indicates the loss occurred in the morning.
IDENTIFICATION SECTION PM
Check the box (if applicable): Indicates the loss occurred in the afternoon or evening.
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 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.
INSURED
Name of Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INSURED
Date of Birth
Enter date: The date of birth of the insured.
INSURED
FEIN
Enter identifier: The tax identifier of the named insured. As used here, this is the Federal
Employer Identification Number.
INSURED
Primary Phone
Enter number: The named insured's primary phone number.
INSURED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INSURED
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
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Section Name
Field Name
Field and/or Section Description
INSURED
Secondary Phone
Enter number: The named insured's secondary phone number.
INSURED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INSURED
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
INSURED
Insured's Mailing Address
Enter text: The named insured's mailing address line one.
INSURED
Address 2
Enter text: The named insured's mailing address line two.
INSURED
City
Enter text: The named insured's mailing address city name.
INSURED
State
Enter code: The named insured's mailing address state or province code.
INSURED
Zip
Enter code: The named insured's mailing address postal code.
INSURED
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
INSURED
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
CONTACT
Contact Insured
Check the box (if applicable): Indicates If the individual to contact is the same as the
insured, check this box and leave blank the areas for contact name, address and phone
numbers.
CONTACT
Name of Contact
Enter text: The full name (First, Middle, Last) of the individual to be contacted as a
representative of the insured on all subsequent business relating to this incident. No entry
is needed if the 'Contact Insured' option is checked.
CONTACT
Primary Phone
Enter number: The loss contact's primary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
CONTACT
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
CONTACT
Secondary Phone
Enter number: The loss contact's secondary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
CONTACT
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
CONTACT
When to Contact
Enter text: The best time of the day to contact this individual (e.g., evenings, days, noon to
3:00 P.M.).
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Section Name
Field Name
Field and/or Section Description
CONTACT
Contact's Mailing Address
Enter text: The loss contact's first address line.
CONTACT
Address 2
Enter text: The loss contact's second address line.
CONTACT
City
Enter text: The loss contact's city.
CONTACT
State
Enter code: The loss contact's state.
CONTACT
Zip
Enter code: The loss contact's postal code.
CONTACT
Primary E-Mail Address
Enter text: The loss contact's primary e-mail address.
CONTACT
Secondary E-Mail Address
Enter text: The loss contact's secondary e-mail address.
OCCURRENCE
Location of Occurrence Street
Enter text: The loss location's physical street address.
OCCURRENCE
Location of Occurrence City,
State, Zip
Enter text: The loss location's city.
OCCURRENCE
State
Enter code: The loss location's state or province code.
OCCURRENCE
Zip
Enter code: The loss location's postal code.
OCCURRENCE
Location of Occurrence Country
Enter code: The loss location's country code.
OCCURRENCE
Describe Location of Occurrence if
not at Specific Street Address
Enter text: The description of the location of loss if not at a specific street address.
OCCURRENCE
Police or Fire Department
Contacted
Enter text: The name of the municipal, county or other police department, fire department
or other authority to which the accident was reported, including any precinct or station
number, if available.
OCCURRENCE
Report Number
Enter identifier: The report number assigned by the authority contacted. For example, the
number of the vehicle incident report filed by the police after an automobile accident.
OCCURRENCE
Description of Occurrence
Enter text: The description of the incident resulting in a potential loss to the insured. As
used here, attach ACORD 101, Additional Remarks Schedule, if more space is required.
TYPE OF LIABILITY
Premises: Insured is Owner
Check the box (if applicable): Indicates the named insured's interest in the property is as
its owner.
TYPE OF LIABILITY
Premises: Insured is Tenant
Check the box (if applicable): Indicates the named insured's interest in the property is as
its tenant.
TYPE OF LIABILITY
Premises: Insured is Other
Check the box (if applicable): Indicates the named insured's interest in the property is
other than those listed.
TYPE OF LIABILITY
Premises: Insured is Other
Description
Enter text: The named insured's interest in the property.
TYPE OF LIABILITY
Owners Name & Address
Enter text: The full name of the individual or business that is the owner of the vehicle or
property.
TYPE OF LIABILITY
Address 1
Enter text: The first address line of the owner of the vehicle or property.
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Section Name
Field Name
Field and/or Section Description
TYPE OF LIABILITY
Address 2
Enter text: The second address line of the owner of the vehicle or property.
TYPE OF LIABILITY
City
Enter text: The city of the owner of the vehicle or property.
TYPE OF LIABILITY
State
Enter code: The state or province code of the owner of the vehicle or property.
TYPE OF LIABILITY
Zip
Enter code: The postal code of the owner of the vehicle or property.
TYPE OF LIABILITY
Type of Premises
Enter text: The description of the premises (e.g., mercantile with apartments).
TYPE OF LIABILITY
Primary Phone
Enter number: The primary phone number for the owner of the vehicle or property.
TYPE OF LIABILITY
Home
Check the box (if applicable): Indicates the primary phone number for the owner is a home
phone.
TYPE OF LIABILITY
Bus
Check the box (if applicable): Indicates the primary phone number for the owner is a
business phone.
TYPE OF LIABILITY
Cell
Check the box (if applicable): Indicates the primary phone number for the owner is a cell
phone.
TYPE OF LIABILITY
Secondary Phone
Enter number: The secondary phone number for the owner of the vehicle or property.
TYPE OF LIABILITY
Home
Check the box (if applicable): Indicates the secondary phone number for the owner is a
home phone.
TYPE OF LIABILITY
Bus
Check the box (if applicable): Indicates the secondary phone number for the owner is a
business phone.
TYPE OF LIABILITY
Cell
Check the box (if applicable): Indicates the secondary phone number for the owner is a
cell phone.
TYPE OF LIABILITY
Primary E-Mail Address
Enter text: The primary e-mail address of the owner of the vehicle or property.
TYPE OF LIABILITY
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
TYPE OF LIABILITY
Products: Insured Is Manufacturer
Check the box (if applicable): Indicates the named insured's interest in the product is as its
manufacturer.
TYPE OF LIABILITY
Products: Insured Is Vendor
Check the box (if applicable): Indicates the named insured's interest in the product is as its
vendor.
TYPE OF LIABILITY
Products: Insured is Other
Check the box (if applicable): Indicates the named insured's interest in the product is other
than those listed.
TYPE OF LIABILITY
Products: Insured is Other
Description
Enter text: The named insured's interest in the product.
TYPE OF LIABILITY
Manufacturers Name & Address
Enter text: The full name of the product manufacturer.
TYPE OF LIABILITY
Address 1
Enter text: The product manufacturer's first address line.
TYPE OF LIABILITY
Address 2
Enter text: The product manufacturer's second address line.
TYPE OF LIABILITY
City
Enter text: The product manufacturer's city.
TYPE OF LIABILITY
State
Enter code: The product manufacturer's state or province.
TYPE OF LIABILITY
Zip
Enter code: The product manufacturer's postal code.
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Section Name
Field Name
Field and/or Section Description
TYPE OF LIABILITY
Type of Product
Enter text: The description of the insureds product (e.g., automobile parts, sales,
appliances repair).
TYPE OF LIABILITY
Primary Phone
Enter number: The primary phone number for the product manufacturer.
TYPE OF LIABILITY
Home
Check the box (if applicable): Indicates the primary phone number for the product
manufacturer is a home phone.
TYPE OF LIABILITY
Bus
Check the box (if applicable): Indicates the primary phone number for the product
manufacturer is a business phone.
TYPE OF LIABILITY
Cell
Check the box (if applicable): Indicates the primary phone number for the product
manufacturer is a cell phone.
TYPE OF LIABILITY
Secondary Phone
Enter number: The secondary phone number for the product manufacturer.
TYPE OF LIABILITY
Home
Check the box (if applicable): Indicates the secondary phone number for the product
manufacturer is a home phone.
TYPE OF LIABILITY
Bus
Check the box (if applicable): Indicates the secondary phone number for the product
manufacturer is a business phone.
TYPE OF LIABILITY
Cell
Check the box (if applicable): Indicates the secondary phone number for the product
manufacturer is a cell phone.
TYPE OF LIABILITY
Primary E-Mail Address
Enter text: The primary email address for the product manufacturer.
TYPE OF LIABILITY
Secondary E-Mail Address
Enter text: The secondary email address for the product manufacturer.
TYPE OF LIABILITY
Where Can Product Be Seen?
Enter text: The location where the product can be inspected by the adjuster. If other than
the insureds address, include the address.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
INJURED / PROPERTY
DAMAGED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED / PROPERTY
DAMAGED
Enter text: The first address line of the injured party.
INJURED / PROPERTY
DAMAGED
Enter text: The second address line of the injured party.
INJURED / PROPERTY
DAMAGED
Enter text: The city of the injured party.
INJURED / PROPERTY
DAMAGED
Enter code: The state or province of the injured party.
INJURED / PROPERTY
DAMAGED
Enter code: The postal code of the injured party.
INJURED / PROPERTY
DAMAGED
Primary Phone
Enter number: The primary phone number of the injured party.
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Section Name
Field Name
Field and/or Section Description
INJURED / PROPERTY
DAMAGED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INJURED / PROPERTY
DAMAGED
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
INJURED / PROPERTY
DAMAGED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
INJURED / PROPERTY
DAMAGED
Secondary Phone
Enter number: The secondary phone number of the injured party.
INJURED / PROPERTY
DAMAGED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INJURED / PROPERTY
DAMAGED
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INJURED / PROPERTY
DAMAGED
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
INJURED / PROPERTY
DAMAGED
Primary E-Mail Address
Enter text: The primary email address for the injured party.
INJURED / PROPERTY
DAMAGED
Secondary E-Mail Address
Enter text: The secondary email address for the injured party.
INJURED / PROPERTY
DAMAGED
Employers Name & Address
Enter text: The employer name (business name if self-employed).
INJURED / PROPERTY
DAMAGED
Enter text: The first address line of the employer's physical address.
INJURED / PROPERTY
DAMAGED
Enter text: The second address line of the employer's physical address.
INJURED / PROPERTY
DAMAGED
Enter text: The city of the employer's physical address.
INJURED / PROPERTY
DAMAGED
Enter code: The state code of the employer's physical address.
INJURED / PROPERTY
DAMAGED
Enter code: The postal code of the employer's physical address.
INJURED / PROPERTY
DAMAGED
Primary Phone
Enter number: The primary phone number of the employer.
INJURED / PROPERTY
DAMAGED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INJURED / PROPERTY
DAMAGED
Bus
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
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Section Name
Field Name
Field and/or Section Description
INJURED / PROPERTY
DAMAGED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
INJURED / PROPERTY
DAMAGED
Secondary Phone
Enter number: The secondary phone number of the employer.
INJURED / PROPERTY
DAMAGED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INJURED / PROPERTY
DAMAGED
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INJURED / PROPERTY
DAMAGED
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
INJURED / PROPERTY
DAMAGED
Primary E-Mail Address
Enter text: The primary email address for the employer.
INJURED / PROPERTY
DAMAGED
Secondary E-Mail Address
Enter text: The secondary email address for the employer.
INJURED / PROPERTY
DAMAGED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED / PROPERTY
DAMAGED
Sex
Enter code: The gender of the injured party.
INJURED / PROPERTY
DAMAGED
Occupation
Enter text: The occupation of the injured party.
INJURED / PROPERTY
DAMAGED
Describe Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED / PROPERTY
DAMAGED
Where Taken
Enter text: The description of where the injured party was taken.
INJURED / PROPERTY
DAMAGED
What Was Injured Doing?
Enter text: The description of what the injured party was doing when the accident
occurred.
INJURED / PROPERTY
DAMAGED
Describe Property
Enter text: The description of the damaged property (e.g. printer # 31).
INJURED / PROPERTY
DAMAGED
Estimate Amount
Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property.
INJURED / PROPERTY
DAMAGED
Where Can Property Be Seen?
Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If
other than at the insureds address, include the address.
WITNESSES
Name & Address One
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES
Enter text: The city of a person that was a witness to the incident.
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Section Name
Field Name
Field and/or Section Description
WITNESSES
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES
Primary Phone One
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES
Home One
Check the box (if applicable): Indicates the primary phone number is for a home phone.
WITNESSES
Bus One
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
WITNESSES
Cell One
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
WITNESSES
Secondary Phone One
Enter number: The secondary phone number of the witness.
WITNESSES
Home One
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
WITNESSES
Bus One
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
WITNESSES
Cell One
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
WITNESSES
Primary E-Mail Address One
Enter text: The primary email address for the witness.
WITNESSES
Secondary E-Mail Address One
Enter text: The secondary email address for the witness.
WITNESSES
Name & Address Two
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES
Enter text: The city of a person that was a witness to the incident.
WITNESSES
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES
Primary Phone Two
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES
Home Two
Check the box (if applicable): Indicates the primary phone number is for a home phone.
WITNESSES
Bus Two
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
WITNESSES
Cell Two
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
WITNESSES
Secondary Phone Two
Enter number: The secondary phone number of the witness.
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Section Name
Field Name
Field and/or Section Description
WITNESSES
Home Two
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
WITNESSES
Bus Two
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
WITNESSES
Cell Two
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
WITNESSES
Primary E-Mail Address Two
Enter text: The primary email address for the witness.
WITNESSES
Secondary E-Mail Address Two
Enter text: The secondary email address for the witness.
WITNESSES
Name & Address Three
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES
Enter text: The city of a person that was a witness to the incident.
WITNESSES
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES
Primary Phone Three
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES
Home Three
Check the box (if applicable): Indicates the primary phone number is for a home phone.
WITNESSES
Bus Three
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
WITNESSES
Cell Three
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
WITNESSES
Secondary Phone Three
Enter number: The secondary phone number of the witness.
WITNESSES
Home Three
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
WITNESSES
Bus Three
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
WITNESSES
Cell Three
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
WITNESSES
Primary E-Mail Address Three
Enter text: The primary email address for the witness.
WITNESSES
Secondary E-Mail Address Three
Enter text: The secondary email address for the witness.
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Section Name
Field Name
Field and/or Section Description
REMARKS
Remarks (Attach ACORD 101,
Additional Remarks Section, if
more space is required)
Enter text: The general liability notice of occurrence / claim general remarks. Describe
any other additional information that will assist in properly reporting and settling this claim.
Attach ACORD 101, Additional Remarks Section, if more space is required.
REMARKS
Reported By
Enter text: The name of the individual that reported the loss.
REMARKS
Reported To
Enter text: The name of the individual within the agency or company to whom this loss
was reported.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (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).
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).