ACORD 407 (2014/12) - Livestock Mortality Section

ACORD 407 (2014/12) - Livestock Mortality Section
ACORD 407, Livestock Mortality Section, is used as an attachment to ACORD 401, Agriculture Application, to apply for insurance coverage on
livestock mortality, livestock theft, major medical, surgery, loss of use, and named and optional perils.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
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 National Association of
Insurance Commissioners (NAIC).
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION
Renewal
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
APPLICANT INFORMATION
Applicant Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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Page 1 of 21
APPLICANT INFORMATION
Individual
Check the box (if applicable): Indicates the legal entity code for the named insured is
Individual.
APPLICANT INFORMATION
Partnership
Check the box (if applicable): Indicates the legal entity code for the named insured is
Partnership.
APPLICANT INFORMATION
Corporation
Check the box (if applicable): Indicates the legal entity code for the named insured is
Corporation.
APPLICANT INFORMATION
Joint Venture
Check the box (if applicable): Indicates the legal entity code for the named insured is Joint
Venture.
APPLICANT INFORMATION
Other
Check the box (if applicable): Indicates the legal entity code for the named insured is other than
those listed on the form.
APPLICANT INFORMATION
Describe other
Enter text: The description of the other legal entity.
APPLICANT INFORMATION
Years in business
Enter number: The number of years the insured has been in business.
APPLICANT INFORMATION
NAICS
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code
assigned to the business activity (if known).
APPLICANT INFORMATION
Federal ID#
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION
Mailing address
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION
Contact Name
Enter text: The full name of the contact.
APPLICANT INFORMATION
Phone (A/C, No, Ext)
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION
E-Mail Address
Enter text: The named insured's primary e-mail address.
ANIMAL INFORMATION
Animal # One
Enter identifier: The producer assigned identifier for the animal.
ANIMAL INFORMATION
LOC # One
Enter number: The producer assigned number of the location.
ANIMAL INFORMATION
Bldg # One
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ANIMAL INFORMATION
Name of Animal One
Enter text: The full name of the animal.
ANIMAL INFORMATION
Sire One
Enter text: The name of the animal's sire (father).
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ANIMAL INFORMATION
Dam One
Enter text: The name of the animal's dam (mother).
ANIMAL INFORMATION
Registration # One
Enter identifier: The registration number of the animal.
ANIMAL INFORMATION
Sex One
Enter code: The gender of the animal.
ANIMAL INFORMATION
Birth Date One
Enter date: The birth date of the animal.
ANIMAL INFORMATION
Breed One
Enter text: The breed of the animal.
ANIMAL INFORMATION
Use & Function One
Enter text: The description of the use / function of the animal.
ANIMAL INFORMATION
Acquired From One
Enter text: The name of the person or organization the animal was acquired from.
ANIMAL INFORMATION
Purchase Price One
Enter amount: The purchase price of the animal.
ANIMAL INFORMATION
Payment Method - Cash
One
Check the box (if applicable): Indicates the animal was purchased with cash.
ANIMAL INFORMATION
Payment Method - Check
One
Check the box (if applicable): Indicates the animal was purchased with a check.
ANIMAL INFORMATION
Payment Method - Other
One
Check the box (if applicable): Indicates the animal was purchased with a method other than
those listed.
ANIMAL INFORMATION
Describe Payment Method -
Other One
Enter text: The payment method used to purchase the animal.
ANIMAL INFORMATION
Acquisition Method -
Auction One
Check the box (if applicable): Indicates the animal was acquired at an auction.
ANIMAL INFORMATION
Acquisition Method - Private
One
Check the box (if applicable): Indicates the animal was acquired through private means.
ANIMAL INFORMATION
Acquisition Method -
Homebred One
Check the box (if applicable): Indicates the animal was homebred.
ANIMAL INFORMATION
Acquisition Method - Other
One
Check the box (if applicable): Indicates the animal was acquired in a method other than those
listed.
ANIMAL INFORMATION
Acquisition Method -
Describe other One
Enter text: The method the animal was acquired.
ANIMAL INFORMATION
Date Acquired One
Enter date: The date the animal was acquired.
ANIMAL INFORMATION
Accommodations - Stall One
Check the box (if applicable): Indicates the animal's accommodations is a stall.
ANIMAL INFORMATION
Accommodations - Corral
One
Check the box (if applicable): Indicates the animal's accommodations is a corral.
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ANIMAL INFORMATION
Accommodations - Open
Pasture One
Check the box (if applicable): Indicates the animal's accommodations is an open pasture.
ANIMAL INFORMATION
Accommodations - Other
Check the box (if applicable): Indicates the animal's accommodations is other than those listed.
ANIMAL INFORMATION
Accommodations - Other
Description
Enter text: The description of the animal's accommodations.
ANIMAL INFORMATION
Number of Acres One
Enter number: The number of acres the animal has access to.
ANIMAL INFORMATION
Animal # Two
Enter identifier: The producer assigned identifier for the animal.
ANIMAL INFORMATION
LOC # Two
Enter number: The producer assigned number of the location.
ANIMAL INFORMATION
Bldg # Two
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ANIMAL INFORMATION
Name of Animal Two
Enter text: The full name of the animal.
ANIMAL INFORMATION
Sire Two
Enter text: The name of the animal's sire (father).
ANIMAL INFORMATION
Dam Two
Enter text: The name of the animal's dam (mother).
ANIMAL INFORMATION
Registration # Two
Enter identifier: The registration number of the animal.
ANIMAL INFORMATION
Sex Two
Enter code: The gender of the animal.
ANIMAL INFORMATION
Birth Date Two
Enter date: The birth date of the animal.
ANIMAL INFORMATION
Breed Two
Enter text: The breed of the animal.
ANIMAL INFORMATION
Use & Function Two
Enter text: The description of the use / function of the animal.
ANIMAL INFORMATION
Acquired From Two
Enter text: The name of the person or organization the animal was acquired from.
ANIMAL INFORMATION
Purchase Price Two
Enter amount: The purchase price of the animal.
ANIMAL INFORMATION
Payment Method - Cash
Two
Check the box (if applicable): Indicates the animal was purchased with cash.
ANIMAL INFORMATION
Payment Method - Check
Two
Check the box (if applicable): Indicates the animal was purchased with a check.
ANIMAL INFORMATION
Payment Method - Other
Two
Check the box (if applicable): Indicates the animal was purchased with a method other than
those listed.
ANIMAL INFORMATION
Describe Payment Method -
Other Two
Enter text: The payment method used to purchase the animal.
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ANIMAL INFORMATION
Acquisition Method -
Auction Two
Check the box (if applicable): Indicates the animal was acquired at an auction.
ANIMAL INFORMATION
Acquisition Method - Private
Two
Check the box (if applicable): Indicates the animal was acquired through private means.
ANIMAL INFORMATION
Acquisition Method -
Homebred Two
Check the box (if applicable): Indicates the animal was homebred.
ANIMAL INFORMATION
Acquisition Method - Other
Two
Check the box (if applicable): Indicates the animal was acquired in a method other than those
listed.
ANIMAL INFORMATION
Acquisition Method -
Describe other Two
Enter text: The method the animal was acquired.
ANIMAL INFORMATION
Date Acquired Two
Enter date: The date the animal was acquired.
ANIMAL INFORMATION
Accommodations - Stall
Two
Check the box (if applicable): Indicates the animal's accommodations is a stall.
ANIMAL INFORMATION
Accommodations - Corral
Two
Check the box (if applicable): Indicates the animal's accommodations is a corral.
ANIMAL INFORMATION
Accommodations - Open
Pasture Two
Check the box (if applicable): Indicates the animal's accommodations is an open pasture.
ANIMAL INFORMATION
Accommodations - Other
Check the box (if applicable): Indicates the animal's accommodations is other than those listed.
ANIMAL INFORMATION
Accommodations - Other
Description
Enter text: The description of the animal's accommodations.
ANIMAL INFORMATION
Number of Acres Two
Enter number: The number of acres the animal has access to.
ANIMAL INFORMATION
Animal # Three
Enter identifier: The producer assigned identifier for the animal.
ANIMAL INFORMATION
LOC # Three
Enter number: The producer assigned number of the location.
ANIMAL INFORMATION
Bldg # Three
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ANIMAL INFORMATION
Name of Animal Three
Enter text: The full name of the animal.
ANIMAL INFORMATION
Sire Three
Enter text: The name of the animal's sire (father).
ANIMAL INFORMATION
Dam Three
Enter text: The name of the animal's dam (mother).
ANIMAL INFORMATION
Registration # Three
Enter identifier: The registration number of the animal.
ANIMAL INFORMATION
Sex Three
Enter code: The gender of the animal.
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ANIMAL INFORMATION
Birth Date Three
Enter date: The birth date of the animal.
ANIMAL INFORMATION
Breed Three
Enter text: The breed of the animal.
ANIMAL INFORMATION
Use & Function Three
Enter text: The description of the use / function of the animal.
ANIMAL INFORMATION
Acquired From Three
Enter text: The name of the person or organization the animal was acquired from.
ANIMAL INFORMATION
Purchase Price Three
Enter amount: The purchase price of the animal.
ANIMAL INFORMATION
Payment Method - Cash
Three
Check the box (if applicable): Indicates the animal was purchased with cash.
ANIMAL INFORMATION
Payment Method - Check
Three
Check the box (if applicable): Indicates the animal was purchased with a check.
ANIMAL INFORMATION
Payment Method - Other
Three
Check the box (if applicable): Indicates the animal was purchased with a method other than
those listed.
ANIMAL INFORMATION
Describe Payment Method -
Other Three
Enter text: The payment method used to purchase the animal.
ANIMAL INFORMATION
Acquisition Method -
Auction Three
Check the box (if applicable): Indicates the animal was acquired at an auction.
ANIMAL INFORMATION
Acquisition Method - Private
Three
Check the box (if applicable): Indicates the animal was acquired through private means.
ANIMAL INFORMATION
Acquisition Method -
Homebred Three
Check the box (if applicable): Indicates the animal was homebred.
ANIMAL INFORMATION
Acquisition Method - Other
Three
Check the box (if applicable): Indicates the animal was acquired in a method other than those
listed.
ANIMAL INFORMATION
Acquisition Method -
Describe other Three
Enter text: The method the animal was acquired.
ANIMAL INFORMATION
Date Acquired Three
Enter date: The date the animal was acquired.
ANIMAL INFORMATION
Accommodations - Stall
Three
Check the box (if applicable): Indicates the animal's accommodations is a stall.
ANIMAL INFORMATION
Accommodations - Corral
Three
Check the box (if applicable): Indicates the animal's accommodations is a corral.
ANIMAL INFORMATION
Accommodations - Open
Pasture Three
Check the box (if applicable): Indicates the animal's accommodations is an open pasture.
ANIMAL INFORMATION
Accommodations - Other
Check the box (if applicable): Indicates the animal's accommodations is other than those listed.
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ANIMAL INFORMATION
Accommodations - Other
Description
Enter text: The description of the animal's accommodations.
ANIMAL INFORMATION
Number of Acres Three
Enter number: The number of acres the animal has access to.
ANIMAL INFORMATION
Animal # Four
Enter identifier: The producer assigned identifier for the animal.
ANIMAL INFORMATION
LOC # Four
Enter number: The producer assigned number of the location.
ANIMAL INFORMATION
Bldg # Four
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ANIMAL INFORMATION
Name of Animal Four
Enter text: The full name of the animal.
ANIMAL INFORMATION
Sire Four
Enter text: The name of the animal's sire (father).
ANIMAL INFORMATION
Dam Four
Enter text: The name of the animal's dam (mother).
ANIMAL INFORMATION
Registration # Four
Enter identifier: The registration number of the animal.
ANIMAL INFORMATION
Sex Four
Enter code: The gender of the animal.
ANIMAL INFORMATION
Birth Date Four
Enter date: The birth date of the animal.
ANIMAL INFORMATION
Breed Four
Enter text: The breed of the animal.
ANIMAL INFORMATION
Use & Function Four
Enter text: The description of the use / function of the animal.
ANIMAL INFORMATION
Acquired From Four
Enter text: The name of the person or organization the animal was acquired from.
ANIMAL INFORMATION
Purchase Price Four
Enter amount: The purchase price of the animal.
ANIMAL INFORMATION
Payment Method - Cash
Four
Check the box (if applicable): Indicates the animal was purchased with cash.
ANIMAL INFORMATION
Payment Method - Check
Four
Check the box (if applicable): Indicates the animal was purchased with a check.
ANIMAL INFORMATION
Payment Method - Other
Four
Check the box (if applicable): Indicates the animal was purchased with a method other than
those listed.
ANIMAL INFORMATION
Describe Payment Method -
Other Four
Enter text: The payment method used to purchase the animal.
ANIMAL INFORMATION
Acquisition Method -
Auction Four
Check the box (if applicable): Indicates the animal was acquired at an auction.
ANIMAL INFORMATION
Acquisition Method - Private
Four
Check the box (if applicable): Indicates the animal was acquired through private means.
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ANIMAL INFORMATION
Acquisition Method -
Homebred Four
Check the box (if applicable): Indicates the animal was homebred.
ANIMAL INFORMATION
Acquisition Method - Other
Four
Check the box (if applicable): Indicates the animal was acquired in a method other than those
listed.
ANIMAL INFORMATION
Acquisition Method -
Describe other Four
Enter text: The method the animal was acquired.
ANIMAL INFORMATION
Date Acquired Four
Enter date: The date the animal was acquired.
ANIMAL INFORMATION
Accommodations - Stall
Four
Check the box (if applicable): Indicates the animal's accommodations is a stall.
ANIMAL INFORMATION
Accommodations - Corral
Four
Check the box (if applicable): Indicates the animal's accommodations is a corral.
ANIMAL INFORMATION
Accommodations - Open
Pasture Four
Check the box (if applicable): Indicates the animal's accommodations is an open pasture.
ANIMAL INFORMATION
Accommodations - Other
Check the box (if applicable): Indicates the animal's accommodations is other than those listed.
ANIMAL INFORMATION
Accommodations - Other
Description
Enter text: The description of the animal's accommodations.
ANIMAL INFORMATION
Number of Acres Four
Enter number: The number of acres the animal has access to.
COVERAGES / LIMITS
Animal # One
Enter identifier: The producer assigned identifier for the animal.
COVERAGES / LIMITS
Mortality One
Enter limit: The limit amount for mortality coverage.
COVERAGES / LIMITS
Options - Full Mortality One
Enter Y for a Yes response. Input N for No response. Indicates if the full mortality option has
been selected.
COVERAGES / LIMITS
Options - Theft One
Enter Y for a Yes response. Input N for No response. Indicates if the theft option has been
selected.
COVERAGES / LIMITS
Options - Named Perils One
Enter Y for a Yes response. Input N for No response. Indicates if the named perils option has
been selected.
COVERAGES / LIMITS
Options - Optional Perils
One
Enter Y for a Yes response. Input N for No response. Indicates if the option perils option has
been selected.
COVERAGES / LIMITS
Major Medical One
Enter limit: The limit amount for major medical coverage.
COVERAGES / LIMITS
Surgery One
Enter limit: The limit amount for surgery coverage.
COVERAGES / LIMITS
Loss of Use One
Enter limit: The limit amount for loss of use coverage.
COVERAGES / LIMITS
Premium One
Enter amount: The premium amount for the animal.
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COVERAGES / LIMITS
Animal # Two
Enter identifier: The producer assigned identifier for the animal.
COVERAGES / LIMITS
Mortality Two
Enter limit: The limit amount for mortality coverage.
COVERAGES / LIMITS
Options - Full Mortality Two
Enter Y for a Yes response. Input N for No response. Indicates if the full mortality option has
been selected.
COVERAGES / LIMITS
Options - Theft Two
Enter Y for a Yes response. Input N for No response. Indicates if the theft option has been
selected.
COVERAGES / LIMITS
Options - Named Perils Two
Enter Y for a Yes response. Input N for No response. Indicates if the named perils option has
been selected.
COVERAGES / LIMITS
Options - Optional Perils
Two
Enter Y for a Yes response. Input N for No response. Indicates if the option perils option has
been selected.
COVERAGES / LIMITS
Major Medical Two
Enter limit: The limit amount for major medical coverage.
COVERAGES / LIMITS
Surgery Two
Enter limit: The limit amount for surgery coverage.
COVERAGES / LIMITS
Loss of Use Two
Enter limit: The limit amount for loss of use coverage.
COVERAGES / LIMITS
Premium Two
Enter amount: The premium amount for the animal.
COVERAGES / LIMITS
Animal # Three
Enter identifier: The producer assigned identifier for the animal.
COVERAGES / LIMITS
Mortality Three
Enter limit: The limit amount for mortality coverage.
COVERAGES / LIMITS
Options - Full Mortality
Three
Enter Y for a Yes response. Input N for No response. Indicates if the full mortality option has
been selected.
COVERAGES / LIMITS
Options - Theft Three
Enter Y for a Yes response. Input N for No response. Indicates if the theft option has been
selected.
COVERAGES / LIMITS
Options - Named Perils
Three
Enter Y for a Yes response. Input N for No response. Indicates if the named perils option has
been selected.
COVERAGES / LIMITS
Options - Optional Perils
Three
Enter Y for a Yes response. Input N for No response. Indicates if the option perils option has
been selected.
COVERAGES / LIMITS
Major Medical Three
Enter limit: The limit amount for major medical coverage.
COVERAGES / LIMITS
Surgery Three
Enter limit: The limit amount for surgery coverage.
COVERAGES / LIMITS
Loss of Use Three
Enter limit: The limit amount for loss of use coverage.
COVERAGES / LIMITS
Premium Three
Enter amount: The premium amount for the animal.
COVERAGES / LIMITS
Animal # Four
Enter identifier: The producer assigned identifier for the animal.
COVERAGES / LIMITS
Mortality Four
Enter limit: The limit amount for mortality coverage.
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COVERAGES / LIMITS
Options - Full Mortality Four
Enter Y for a Yes response. Input N for No response. Indicates if the full mortality option has
been selected.
COVERAGES / LIMITS
Options - Theft Four
Enter Y for a Yes response. Input N for No response. Indicates if the theft option has been
selected.
COVERAGES / LIMITS
Options - Named Perils Four
Enter Y for a Yes response. Input N for No response. Indicates if the named perils option has
been selected.
COVERAGES / LIMITS
Options - Optional Perils
Four
Enter Y for a Yes response. Input N for No response. Indicates if the option perils option has
been selected.
COVERAGES / LIMITS
Major Medical Four
Enter limit: The limit amount for major medical coverage.
COVERAGES / LIMITS
Surgery Four
Enter limit: The limit amount for surgery coverage.
COVERAGES / LIMITS
Loss of Use Four
Enter limit: The limit amount for loss of use coverage.
COVERAGES / LIMITS
Premium Four
Enter amount: The premium amount for the animal.
COVERAGES / LIMITS
Animal # Five
Enter identifier: The producer assigned identifier for the animal.
COVERAGES / LIMITS
Mortality Five
Enter limit: The limit amount for mortality coverage.
COVERAGES / LIMITS
Options - Full Mortality Five
Enter Y for a Yes response. Input N for No response. Indicates if the full mortality option has
been selected.
COVERAGES / LIMITS
Options - Theft Five
Enter Y for a Yes response. Input N for No response. Indicates if the theft option has been
selected.
COVERAGES / LIMITS
Options - Named Perils Five
Enter Y for a Yes response. Input N for No response. Indicates if the named perils option has
been selected.
COVERAGES / LIMITS
Options - Optional Perils
Five
Enter Y for a Yes response. Input N for No response. Indicates if the option perils option has
been selected.
COVERAGES / LIMITS
Major Medical Five
Enter limit: The limit amount for major medical coverage.
COVERAGES / LIMITS
Surgery Five
Enter limit: The limit amount for surgery coverage.
COVERAGES / LIMITS
Loss of Use Five
Enter limit: The limit amount for loss of use coverage.
COVERAGES / LIMITS
Premium Five
Enter amount: The premium amount for the animal.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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ADDITIONAL COVERAGES
Animal # One
Enter identifier: The producer assigned identifier for the animal.
ADDITIONAL COVERAGES
Coverage Code One
Enter code: The code for the coverage.
ADDITIONAL COVERAGES
Coverage Description One
Enter text: The description of the coverage being requested.
ADDITIONAL COVERAGES
Limit 1 One
Enter limit: The limit amount for the coverage.
ADDITIONAL COVERAGES
Deductible One
Enter deductible: The deductible amount for the coverage.
ADDITIONAL COVERAGES
Additional Options 1 - Code
One
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 1-
Description One
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Additional Options - 1 Code
Two
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 1 -
Description Two
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Premium One
Enter amount: The premium amount for the coverage.
ADDITIONAL COVERAGES
Animal # Two
Enter identifier: The producer assigned identifier for the animal.
ADDITIONAL COVERAGES
Coverage Code Two
Enter code: The code for the coverage.
ADDITIONAL COVERAGES
Coverage Description Two
Enter text: The description of the coverage being requested.
ADDITIONAL COVERAGES
Limit 1 Two
Enter limit: The limit amount for the coverage.
ADDITIONAL COVERAGES
Deductible Two
Enter deductible: The deductible amount for the coverage.
ADDITIONAL COVERAGES
Additional Options 2 - Code
One
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 2 -
Description One
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Additional Options 2 - Code
Two
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 2 -
Description Two
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Premium Two
Enter amount: The premium amount for the coverage.
ADDITIONAL COVERAGES
Animal # Three
Enter identifier: The producer assigned identifier for the animal.
ADDITIONAL COVERAGES
Coverage Code Three
Enter code: The code for the coverage.
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ADDITIONAL COVERAGES
Coverage Description Three
Enter text: The description of the coverage being requested.
ADDITIONAL COVERAGES
Limit 1 Three
Enter limit: The limit amount for the coverage.
ADDITIONAL COVERAGES
Deductible Three
Enter deductible: The deductible amount for the coverage.
ADDITIONAL COVERAGES
Additional Options 3 - Code
One
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 3 -
Description One
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Additional Options 3 - Code
Two
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 3 -
Description Two
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Premium Three
Enter amount: The premium amount for the coverage.
ADDITIONAL COVERAGES
Animal # Four
Enter identifier: The producer assigned identifier for the animal.
ADDITIONAL COVERAGES
Coverage Code Four
Enter code: The code for the coverage.
ADDITIONAL COVERAGES
Coverage Description Four
Enter text: The description of the coverage being requested.
ADDITIONAL COVERAGES
Limit 1 Four
Enter limit: The limit amount for the coverage.
ADDITIONAL COVERAGES
Deductible Four
Enter deductible: The deductible amount for the coverage.
ADDITIONAL COVERAGES
Additional Options 4 - Code
One
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 4 -
Description One
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Additional Options 4 - Code
Two
Enter code: The code for an option applicable to the coverage.
ADDITIONAL COVERAGES
Additional Options 4 -
Description Two
Enter text: The description of the option being requested.
ADDITIONAL COVERAGES
Premium Four
Enter amount: The premium amount for the coverage.
GENERAL INFORMATION
1. Does the amount of
insurance applied for, on
any specific animal, exceed
the purchase price of that
animal?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the amount of insurance applied for, on any specific animal, exceed the purchase price of
that animal?.
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GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the amount of insurance applied for on any specific
animal exceeds the purchase price of that animal.
GENERAL INFORMATION
2. Does anyone other than
you have an insurable
interest in any animals
listed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does anyone other than you have an insurable interest in any animals listed?.
GENERAL INFORMATION
Name One
Enter text: The additional interest's full name.
GENERAL INFORMATION
Address One
Enter text: The additional interest's mailing address line one.
GENERAL INFORMATION
Enter text: The additional interest's mailing address city name.
GENERAL INFORMATION
Enter code: The additional interest's mailing address state or province code.
GENERAL INFORMATION
Enter code: The additional interest's mailing address postal code.
GENERAL INFORMATION
Percent One
Enter percentage: The percentage of ownership the additional interest has in the item.
GENERAL INFORMATION
Name Two
Enter text: The additional interest's full name.
GENERAL INFORMATION
Address Two
Enter text: The additional interest's mailing address line one.
GENERAL INFORMATION
Enter text: The additional interest's mailing address city name.
GENERAL INFORMATION
Enter code: The additional interest's mailing address state or province code.
GENERAL INFORMATION
Enter code: The additional interest's mailing address postal code.
GENERAL INFORMATION
Percent Two
Enter percentage: The percentage of ownership the additional interest has in the item.
GENERAL INFORMATION
3. Is any animal leased to
others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is any animal leased to others?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any animal is leased to others.
GENERAL INFORMATION
4. Has any animal had any
insurance not listed in the
prior insurance section?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any animal had any insurance not listed in the prior insurance section?.
GENERAL INFORMATION
Company One
Enter text: The name of the previous insurer.
GENERAL INFORMATION
Policy Number One
Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION
Expiration Date One
Enter date: The expiration date of the previous coverage.
GENERAL INFORMATION
Company Two
Enter text: The name of the previous insurer.
GENERAL INFORMATION
Policy Number Two
Enter identifier: The policy number of the previous coverage.
GENERAL INFORMATION
Expiration Date Two
Enter date: The expiration date of the previous coverage.
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GENERAL INFORMATION
5. Is there any other
insurance on any animal
included in this application?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there any other insurance on any animal included in this application?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is any other insurance on any animal included in
this application.
GENERAL INFORMATION
6. Has any animal suffered
any accident, disease or
sickness, had colic/bloat or
indigestion, or experienced
birthing difficulties?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any animal suffered any accident, disease or sickness, had colic/bloat or indigestion, or
experienced birthing difficulties?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any animal suffered any accident disease or sickness,
had colic/bloat or indigestion, or experienced birthing difficulties.
GENERAL INFORMATION
7. Are there any animals not
wormed on a regular basis?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any animals that are not wormed on a regular schedule?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there are any animals not wormed on a regular
schedule.
GENERAL INFORMATION
8. Have all animals received
all appropriate inoculations
within the last year?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Have all animals received all appropriate inoculations within the last year?.
GENERAL INFORMATION
Inoculation One
Enter text: The description of the inoculation given to the animals.
GENERAL INFORMATION
Date One
Enter date: The date the inoculation was given to the animals.
GENERAL INFORMATION
Inoculation Two
Enter text: The description of the inoculation given to the animals.
GENERAL INFORMATION
Date Two
Enter date: The date the inoculation was given to the animals.
GENERAL INFORMATION
Inoculation Three
Enter text: The description of the inoculation given to the animals.
GENERAL INFORMATION
Date Three
Enter date: The date the inoculation was given to the animals.
GENERAL INFORMATION
Inoculation Four
Enter text: The description of the inoculation given to the animals.
GENERAL INFORMATION
Date Four
Enter date: The date the inoculation was given to the animals.
GENERAL INFORMATION
9. Do you have a
veterinarian or veterinary
group that you use
consistently?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do you have a veterinarian group or veterinary group that you use consistently?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is a veterinarian or veterinary group that is used
consistently.
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GENERAL INFORMATION
10. Has any animal been
examined or treated by a
veterinarian for other than
routine care?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any animal been examined or treated by a veterinarian for other than routine care?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any animal as been examined or treated by a
veterinarian for other than routine care.
GENERAL INFORMATION
11. Is there now any
contagious or infectious
disease on any premises, or
has there been during the
last twelve (12) months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there now any contagious or infectious disease on any premises, or has there been during
the last twelve (12) months?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there is or has been any contagious or infectious
disease on any premises during the last twelve (12) months.
GENERAL INFORMATION
12. Have you lost any
animals to death in the last
three years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Have you lost any animals to death in the last three years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any animals were lost to death in the last three (3)
years.
GENERAL INFORMATION
13. Is any animal on
medication or supplements?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is any animal on regular medication or supplements?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether any animal is on regular medication or supplements.
GENERAL INFORMATION
14. Are any animals not
observed or cared for on a
daily basis?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are any animals not observed and cared for on a daily basis?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether thee are any animals not observed and cared for on a
daily basis.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
EQUINE INFORMATION
1. Is any horse not healthy
or sound for its intended
use?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is any horse not healthy or sound the use intended?.
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EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether there is any horse not healthy or sound for the use
intended.
EQUINE INFORMATION
2. For all quarter horses,
appaloosas or paint horses,
does any horse have an
ancestor known to carry
HYPP?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
For all quarter horses, appaloosas or paint horses, does any horse have an ancestor known to
carry HYPP?.
EQUINE INFORMATION
Name of Horse One
Enter text: The full name of the animal.
EQUINE INFORMATION
HYPP One
Enter Y for a Yes response. Input N for No response. Indicates if the animal has an ancestor
known to carry Hyperkalemic Periodic Paralysis (HYPP).
EQUINE INFORMATION
Status One
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis
(HYPP).
EQUINE INFORMATION
Name of Horse Two
Enter text: The full name of the animal.
EQUINE INFORMATION
HYPP Two
Enter Y for a Yes response. Input N for No response. Indicates if the animal has an ancestor
known to carry Hyperkalemic Periodic Paralysis (HYPP).
EQUINE INFORMATION
Status Two
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis
(HYPP).
EQUINE INFORMATION
Name of Horse Three
Enter text: The full name of the animal.
EQUINE INFORMATION
HYPP Three
Enter Y for a Yes response. Input N for No response. Indicates if the animal has an ancestor
known to carry Hyperkalemic Periodic Paralysis (HYPP).
EQUINE INFORMATION
Status Three
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis
(HYPP).
EQUINE INFORMATION
Name of Horse Four
Enter text: The full name of the animal.
EQUINE INFORMATION
HYPP Four
Enter Y for a Yes response. Input N for No response. Indicates if the animal has an ancestor
known to carry Hyperkalemic Periodic Paralysis (HYPP).
EQUINE INFORMATION
Status Four
Enter code: Indicates the status of the animal known to carry Hyperkalemic Periodic Paralysis
(HYPP).
EQUINE INFORMATION
3. Do any animals, past or
present, have conformation
problems, defects or
ailments, illness or disease,
lameness, injury or physical
disability, including but not
limited to: OCD,
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do any animals, past or present, have conformation problems, defects or ailments, illness or
disease, lameness, injury or physical disability, including but not limited to: OCD, neurological
disorders, navicular disease and/or degenerative joint disease?
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EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any animal, past or present, has conformation
problems, defects or ailments, illness or disease, lameness, injury or a physical disability. As
used here, provide full particulars of any past or present conformation problems, defects or
ailments, illness or disease, lameness, injury or physical disability, including but not limited to:
OCD, neurological disorders, navicular disease and / or degenerative joint disease.
EQUINE INFORMATION
4. Has any horse been
nerved or received any
surgical treatment for
lameness?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any horse been nerved or received any surgical treatment for lameness?.
EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any horse has been nerved or received surgical
treatment for lameness.
EQUINE INFORMATION
5. Has any horse
undergone diagnostic
ultrasounds, x-rays or bone
scans?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any horse undergone diagnostic ultrasounds, X-rays or bone scans?.
EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any horse has undergone diagnostic ultrasounds,
x-rays o bone scans.
EQUINE INFORMATION
6. Has any horse received
any joint injections, any type
of medication, long or short
term, or any preventative
treatments in the last twelve
(12) months?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any horse received any joint injections, any type of medication, long or short term, or any
preventative treatments in the last twelve (12) months?.
EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any horse has received joint injections, any type or
medication, or any preventative treatments in the last twelve (12) months.
EQUINE INFORMATION
7. Has any horse been
treated for hoof problems,
founder/laminitis, or rotation
of the coffin bone?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any horse been treated for hoof problems, founder/laminitis, or rotation of the coffin
bone?.
EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any horse has been treated for hoof problems,
founder/laminitis, or rotation of the coffin bone.
EQUINE INFORMATION
8. Is any mare in foal?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is any mare in foal?.
EQUINE INFORMATION
Animal # One
Enter identifier: The producer assigned identifier for the animal.
EQUINE INFORMATION
Name of Covering Stallion
One
Enter text: The name of the animal to which the insured animal is being mated (Covering
Stallion).
EQUINE INFORMATION
Stud Fee Paid One
Enter amount: The fee paid for the stud.
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EQUINE INFORMATION
Animal # Two
Enter identifier: The producer assigned identifier for the animal.
EQUINE INFORMATION
Name of Covering Stallion
Two
Enter text: The name of the animal to which the insured animal is being mated (Covering
Stallion).
EQUINE INFORMATION
Stud Fee Paid Two
Enter amount: The fee paid for the stud.
EQUINE INFORMATION
Animal # Three
Enter identifier: The producer assigned identifier for the animal.
EQUINE INFORMATION
Name of Covering Stallion
Three
Enter text: The name of the animal to which the insured animal is being mated (Covering
Stallion).
EQUINE INFORMATION
Stud Fee Paid Three
Enter amount: The fee paid for the stud.
EQUINE INFORMATION
Animal # Four
Enter identifier: The producer assigned identifier for the animal.
EQUINE INFORMATION
Name of Covering Stallion
Four
Enter text: The name of the animal to which the insured animal is being mated (Covering
Stallion).
EQUINE INFORMATION
Stud Fee Paid Four
Enter amount: The fee paid for the stud.
EQUINE INFORMATION
9. Has any animal been
used as a hunter, jumper or
eventer, or for racing?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any animal been used as a hunter, jumper or eventer, or for racing?.
EQUINE INFORMATION
Remarks
Enter text: An explanation as to whether any animal is used as a hunter, jumper or for racing
activities.
ADDITIONAL INTEREST
Additional Interest One
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST
Loss Payee One
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee One
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Lienholder One
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Employee as Lessor One
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST
Other Interest One
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST
Describe Other Interest One
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Rank One
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Name and Address One
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
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Page 18 of 21
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
Reference # One
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Certificate Required One
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST
Location One
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building One
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle One
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat One
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Scheduled Item Number
One
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST
Other Field One
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST
Item Description One
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST
Additional Interest Two
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST
Loss Payee Two
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee Two
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Lienholder Two
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Employee as Lessor Two
Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST
Other Interest Two
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST
Describe Other Interest Two
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Rank Two
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Name and Address Two
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
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Page 19 of 21
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
Reference # Two
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Certificate Required Two
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST
Location Two
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building Two
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle Two
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat Two
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Scheduled Item Number
Two
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST
Other Field Two
Enter text: The description of the item which has an additional interest.
ADDITIONAL INTEREST
Item Description Two
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
TOTAL PREMIUM
Total Amount of Coverage
Enter limit: The total limit amount for the livestock mortality line of business.
TOTAL PREMIUM
Rate
Enter rate: The rate used to determine the premium for the livestock mortality line of business.
TOTAL PREMIUM
Premium
Enter amount: The premium amount before taxes and surcharges for the livestock mortality line
of business.
TOTAL PREMIUM
Taxes/Surcharges
Enter amount: The amount of taxes and / or surcharges for the livestock mortality line of
business.
TOTAL PREMIUM
Total Premium
Enter amount: The total premium amount, including taxes and surcharges, for the mortality line
of business.
TOTAL PREMIUM
Minimum Premium
Enter amount: The minimum premium amount for the livestock mortality line of business.
ATTACHMENTS
Racing Record
Check the box (if applicable): Indicates that a racing record is attached to the policy.
ATTACHMENTS
Show Record
Check the box (if applicable): Indicates that a show record is attached to the policy.
ATTACHMENTS
Vet Certificate
Check the box (if applicable): Indicates that a vet certificate is attached to the policy.
ATTACHMENTS
Substantiation of Value
Check the box (if applicable): Indicates that a substantiation of value is attached to the policy.
ATTACHMENTS
Other One
Check the box (if applicable): Indicates there is an attachment to the policy other than those
listed.
ACORD 407 (2014/12) rev. 10-15-2014
Page 20 of 21
ATTACHMENTS
Describe Other One
Enter text: The description of the attachment to the policy.
ATTACHMENTS
Other Two
Check the box (if applicable): Indicates there is an attachment to the policy other than those
listed.
ATTACHMENTS
Describe other Two
Enter text: The description of the attachment to the policy.
ATTACHMENTS
Remarks
Enter text: The general remarks associated with the livestock mortality line of business.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
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