ACORD 410 (2013/09)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 410 (2013/09)
Small Farm / Ranch Application
ACORD 410, Small Farm / Ranch Application, is intended to be used
in lieu of ACORD 401 through 404, for small farm / ranch properties, not over three farm
buildings and two residential buildings, and not over two different types of businesses
(e.g., dairy, crops, livestock, etc.). Do not use if property is to be schedule or blanket
rated.
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 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 (A/C, No, Ext)
Enter number: The fax number of the producer/agency.
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 Company
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.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Company Policy or Program Name
Enter text: The description of an independently filed policy or program that may be
optionally available from the insurance company. It may also be used to name the
subsidiary company in which the line of business will be placed.
IDENTIFICATION SECTION Program Code
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Billing Plan Direct Bill (Checkbox)
Check the box (if applicable): Indicates if the policy is to be direct billed.
IDENTIFICATION SECTION Agency Bill (Checkbox)
Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
IDENTIFICATION SECTION Payment Plan
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -
Quarterly, etc.).
IDENTIFICATION SECTION Quote
Check the box (if applicable): Indicates the response expected from the company is a
quote.
IDENTIFICATION SECTION Bound
Check the box (if applicable): Indicates the coverage has been bound.
IDENTIFICATION SECTION Date
Enter date: The date the policy status becomes effective. This date is used for policy
statuses of bound, change, and cancel.
IDENTIFICATION SECTION Issue Policy
Check the box (if applicable): Indicates the response expected from the company is an
issued policy.
IDENTIFICATION SECTION Policy Type
Enter text: The description of the type of policy issued to the insured.
IDENTIFICATION SECTION Deposit
Enter amount: The amount of the premium received as a deposit.
APPLICANT INFORMATION Other Named Insureds) *
Name (First Named Insured &
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION Relationship
Enter code: The relationship of the named insured to the first named insured. Examples
are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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Section Name
Field Name
Field and/or Section Description
APPLICANT INFORMATION
Enter code: The relationship of the named insured to the first named insured. Examples
are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter code: The relationship of the named insured to the first named insured. Examples
are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
APPLICANT INFORMATION
Enter code: The relationship of the named insured to the first named insured. Examples
are: I - Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
APPLICANT INFORMATION Insured)
Mailing Address (of First Named
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 Phone (A/C, No, Ext)
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION Phone # on Premises
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION E-Mail Address
Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION Individual
Form of Business Organization:
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.
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Section Name
Field Name
Field and/or Section Description
APPLICANT INFORMATION Joint Venture
Check the box (if applicable): Indicates the legal entity code for the named insured is
Joint Venture.
APPLICANT INFORMATION Other Checkbox
Check the box (if applicable): Indicates the legal entity code for the named insured is not
listed on the form.
APPLICANT INFORMATION Other Description
Enter text: The description of the legal entity if not listed on the form.
APPLICANT INFORMATION Date Business Started
Enter date: The date the current owners purchased or started the business.
APPLICANT INFORMATION SIC
Enter code: The Standard Industry Classification code assigned to the business activity (if
known). This is the code which represents the nature of the employer's business which is
contained in the Standard Industrial Classification Manual published by the Federal Office
of Management and Budget.
APPLICANT INFORMATION Federal ID #
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION Contact
Enter text: The full name of the contact.
APPLICANT INFORMATION Phone (A/C, No, Ext)
Enter number: The primary phone number of the contact.
TYPE OF FARM / RANCH
Field Crops
Check the box (if applicable): Indicates the nature of the operation is a field crops farm /
ranch.
TYPE OF FARM / RANCH
Fruits
Check the box (if applicable): Indicates the nature of the operation is a fruit / citrus farm /
ranch.
TYPE OF FARM / RANCH
Vegetables
Check the box (if applicable): Indicates the nature of the operation is a vegetable farm /
ranch.
TYPE OF FARM / RANCH
Dairy
Check the box (if applicable): Indicates the nature of the operation is a dairy farm / ranch.
TYPE OF FARM / RANCH
Mushrooms
Check the box (if applicable): Indicates the nature of the operation is a mushroom farm.
TYPE OF FARM / RANCH
Nuts
Check the box (if applicable): Indicates the nature of the operation is a nut farm / ranch.
TYPE OF FARM / RANCH
Flowers
Check the box (if applicable): Indicates the nature of the operation is a flowers farm /
ranch.
TYPE OF FARM / RANCH
Vineyards
Check the box (if applicable): Indicates the nature of the operation is a vineyard.
TYPE OF FARM / RANCH
Greenhouses
Check the box (if applicable): Indicates the nature of the operation is a greenhouse farm /
ranch.
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Section Name
Field Name
Field and/or Section Description
TYPE OF FARM / RANCH
Nursery Stock
Check the box (if applicable): Indicates the nature of the operation is a nursery stock farm
/ ranch.
TYPE OF FARM / RANCH
Sod
Check the box (if applicable): Indicates the nature of the operation is a sod farm.
TYPE OF FARM / RANCH
Worms
Check the box (if applicable): Indicates the nature of the operation is a worm farm.
TYPE OF FARM / RANCH
Bees
Check the box (if applicable): Indicates the nature of the operation is a bee farm.
TYPE OF FARM / RANCH
Fur Bearing Animals
Check the box (if applicable): Indicates the nature of the operation is a fur bearing animals
farm / ranch.
TYPE OF FARM / RANCH
Livestock
Check the box (if applicable): Indicates the nature of the operation is a livestock farm /
ranch.
TYPE OF FARM / RANCH
Type
Enter text: The description of the livestock on the farm / ranch.
TYPE OF FARM / RANCH
Tobacco
Check the box (if applicable): Indicates the nature of the operation is a tobacco farm /
ranch.
TYPE OF FARM / RANCH
Poultry
Check the box (if applicable): Indicates the nature of the operation is a poultry farm /
ranch.
TYPE OF FARM / RANCH
Other
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Blank Field
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Other
Check the box (if applicable): Indicates the nature of the farm / ranch operation is other
than those listed.
TYPE OF FARM / RANCH
Blank Field
Enter text: The description of the nature of the farm / ranch operations.
TYPE OF FARM / RANCH
Describe Farm/Ranch Operations
Enter text: The text description of the operations of this risk or insured.
PREMISES INFORMATION
LOC # One
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
BLD # One
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
PREMISES INFORMATION
Street, City, County, State, Zip One
Enter text: The first address line of the physical location.
PREMISES INFORMATION
Enter text: The county of the location.
PREMISES INFORMATION
Enter text: The city of the physical location.
PREMISES INFORMATION
Enter code: The state or province of the physical location.
PREMISES INFORMATION
Enter code: The postal code of the physical location.
PREMISES INFORMATION
Prot Class One
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.
PREMISES INFORMATION
# Acres Total One
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
# Acres Cultivated One
Enter number: The size of the piece of land that is cultivated in acres.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
# Acres in Pasture One
Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION
Farmed By One
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Gross Receipts One
Enter amount: The gross receipts amount for this location.
PREMISES INFORMATION
LOC # Two
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
BLD # Two
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
PREMISES INFORMATION
Street, City, County, State, Zip Two
Enter text: The first address line of the physical location.
PREMISES INFORMATION
Enter text: The county of the location.
PREMISES INFORMATION
Enter text: The city of the physical location.
PREMISES INFORMATION
Enter code: The state or province of the physical location.
PREMISES INFORMATION
Enter code: The postal code of the physical location.
PREMISES INFORMATION
Prot Class Two
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.
PREMISES INFORMATION
# Acres Total Two
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
# Acres Cultivated Two
Enter number: The size of the piece of land that is cultivated in acres.
PREMISES INFORMATION
# Acres in Pasture Two
Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION
Farmed By Two
Enter text: The description of who the location is farmed by.
PREMISES INFORMATION
Gross Receipts Two
Enter amount: The gross receipts amount for this location.
PREMISES INFORMATION
LOC # Three
Enter number: The producer assigned number of the location.
PREMISES INFORMATION
BLD # Three
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
PREMISES INFORMATION
Street, City, County, State, Zip
Three
Enter text: The first address line of the physical location.
PREMISES INFORMATION
Enter text: The county of the location.
PREMISES INFORMATION
Enter text: The city of the physical location.
PREMISES INFORMATION
Enter code: The state or province of the physical location.
PREMISES INFORMATION
Enter code: The postal code of the physical location.
PREMISES INFORMATION
Prot Class Three
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.
PREMISES INFORMATION
# Acres Total Three
Enter number: The size of the piece of land in acres.
PREMISES INFORMATION
# Acres Cultivated Three
Enter number: The size of the piece of land that is cultivated in acres.
PREMISES INFORMATION
# Acres in Pasture Three
Enter number: The size of the piece of land that is pasture land in acres.
PREMISES INFORMATION
Farmed By Three
Enter text: The description of who the location is farmed by.
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Section Name
Field Name
Field and/or Section Description
PREMISES INFORMATION
Gross Receipts Three
Enter amount: The gross receipts amount for this location.
PREMISES INFORMATION
Does applicant have other
businesses? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
have any other business?.
PREMISES INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has any other businesses.
PREMISES INFORMATION
Does applicant have other
businesses? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
have any other business?.
PREMISES INFORMATION
Is business new to agency? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is the business
new to the agency?.
PREMISES INFORMATION
Is business new to agency? No
Check the box (if applicable): Indicates a No response to the question, Is the business
new to the agency?.
PREMISES INFORMATION
Date of last inspection
Enter date: The date of the last inspection.
LOSS HISTORY
Date of Occurrence One
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss One
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description One
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid One
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date of Occurrence Two
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Two
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description Two
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Two
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date of Occurrence Three
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Three
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description Three
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Three
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Date of Occurrence Four
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Four
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description Four
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Four
Enter amount: The amount that has been paid on this claim to date.
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Section Name
Field Name
Field and/or Section Description
LOSS HISTORY
Date of Occurrence Five
Enter date: The date when the accident or incident occurred that resulted in the filing of a
claim.
LOSS HISTORY
Type of Loss Five
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property,
General Liability).
LOSS HISTORY
Description Five
Enter text: A brief description of the loss.
LOSS HISTORY
Amount Paid Five
Enter amount: The amount that has been paid on this claim to date.
PRIOR INSURANCE
INFORMATION
Prior Carrier One
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance One
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # One
Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION
Amount of Coverage One
Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION
Prior Carrier Two
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance Two
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # Two
Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION
Amount of Coverage Two
Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION
Prior Carrier Three
Enter text: The name of the previous insurer.
PRIOR INSURANCE
INFORMATION
Type of Insurance Three
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage
liability.
PRIOR INSURANCE
INFORMATION
Policy # Three
Enter identifier: The policy number of the previous coverage.
PRIOR INSURANCE
INFORMATION
Amount of Coverage Three
Enter limit: The limit amount of the prior coverage.
PRIOR INSURANCE
INFORMATION
Has any policy been cancelled or
non-renewed in the past five (5)
years? (Missouri Applicants - Do
not answer this question) Yes
Check the box (if applicable): Indicates a 'Yes response to the question, Has any policy
been cancelled or non-renewed in the past mandated number of years?.
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Section Name
Field Name
Field and/or Section Description
PRIOR INSURANCE
INFORMATION
Explain if Yes
Enter text: An explanation as to whether any policy has been cancelled or nonrenewed in
the past 5 years.
PRIOR INSURANCE
INFORMATION
Has any policy been cancelled or
non-renewed in the past five (5)
years? No
Check the box (if applicable): Indicates a 'No response to the question, Has any policy
been cancelled or non-renewed in the past mandated number of years?.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
ADDITIONAL INTEREST
PROPERTY
Premises Number One
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST
PROPERTY
Building Number One
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST
PROPERTY
Name and Address One
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
PROPERTY
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
PROPERTY
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
PROPERTY
Interest One
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
PROPERTY
Evidence: Certificate One
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
PROPERTY
Policy One
Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST
PROPERTY
Other checkbox One
Check the box (if applicable): Indicates the additional interest requires evidence other than
those types listed.
ADDITIONAL INTEREST
PROPERTY
Other Description One
Enter text: The description of the type of evidence required by the additional insured.
ADDITIONAL INTEREST
PROPERTY
Send Bill One
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
PROPERTY
Building Number Two
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST
PROPERTY
Name and Address Two
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
PROPERTY
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
PROPERTY
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
PROPERTY
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
PROPERTY
Interest Two
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
PROPERTY
Evidence: Certificate Two
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
PROPERTY
Policy Two
Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST
PROPERTY
Other checkbox Two
Check the box (if applicable): Indicates the additional interest requires evidence other than
those types listed.
ADDITIONAL INTEREST
PROPERTY
Other Description Two
Enter text: The description of the type of evidence required by the additional insured.
ADDITIONAL INTEREST
PROPERTY
Send Bill Two
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST
PROPERTY
Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
PROPERTY
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
PROPERTY
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
PROPERTY
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
PROPERTY
Employee As Lessor
Check the box (if applicable): Indicates the additional interest type is an employee as
lessor.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
PROPERTY
Other
Check the box (if applicable): Indicates the additional interest is not any of the types listed
on the form.
ADDITIONAL INTEREST
PROPERTY
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
LIABILITY
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests
are associated with the same item.
ADDITIONAL INTEREST
LIABILITY
Name and Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
LIABILITY
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
LIABILITY
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
LIABILITY
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
LIABILITY
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
LIABILITY
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
LIABILITY
Reference Number
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
LIABILITY
Certificate Required
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
LIABILITY
Interest in Item Number: Location
Enter number: The producer assigned number of the location which has an additional
interest.
ADDITIONAL INTEREST
LIABILITY
Building
Enter number: The producer assigned number of the building which has an additional
interest.
ADDITIONAL INTEREST
LIABILITY
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional
interest.
ADDITIONAL INTEREST
LIABILITY
Boat
Enter number: The producer assigned number of the boat which has an additional
interest.
ADDITIONAL INTEREST
LIABILITY
Scheduled Item Number
Enter number: The producer assigned number of the scheduled item which has an
additional interest.
ADDITIONAL INTEREST
LIABILITY
Other
Enter text: The description of the item which has an additional interest.
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Section Name
Field Name
Field and/or Section Description
ADDITIONAL INTEREST
LIABILITY
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.
PROPERTY COVERAGE
Location #
Enter number: The producer assigned number of the location.
PROPERTY COVERAGE
Fire District Name
Enter text: The property's fire district name.
PROPERTY COVERAGE
Distance to Hydrant
Enter number: The distance in feet from the nearest hydrant that supports the protection
class used.
PROPERTY COVERAGE
Distance to Fire Station
Enter number: The distance in miles from the nearest fire station that supports the
protection class used.
PROPERTY COVERAGE
Principal Dwelling Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Principal Dwelling Construction
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 COVERAGE
Principal Dwelling Type of Heat
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Principal Dwelling Age of Bldg
Enter number: The age of the building in years.
PROPERTY COVERAGE
Principal Dwelling Age of Roof
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Principal Dwelling Square Feet
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
PROPERTY COVERAGE
Principal Dwelling RC/ACV
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 COVERAGE
Principal Dwelling Coinsurance %
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.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Principal Dwelling Prot Class
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 COVERAGE
Principal Dwelling Cause 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 COVERAGE
Principal Dwelling Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Principal Dwelling Value
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Principal Dwelling Limit of
Insurance
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Principal Dwelling Premium
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Household PP Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Household PP RC/ACV
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 COVERAGE
Household PP Coinsurance %
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 COVERAGE
Household PP Prot Class
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 COVERAGE
Household PP Cause 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 COVERAGE
Household PP Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Household PP Value
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Household PP Limit of Insurance
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Household PP Premium
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Other Dwelling Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Other Dwelling Construction
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 COVERAGE
Other Dwelling Type of Heat
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Other Dwelling Age of Bldg
Enter number: The age of the building in years.
PROPERTY COVERAGE
Other Dwelling Age of Roof
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Other Dwelling Square Feet
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
PROPERTY COVERAGE
Other Dwelling RC/ACV
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 COVERAGE
Other Dwelling Coinsurance %
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 COVERAGE
Other Dwelling Prot Class
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.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other Dwelling Cause 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 COVERAGE
Other Dwelling Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Other Dwelling Value
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Other Dwelling Limit of Insurance
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Other Dwelling Premium
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Household PP Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Household PP RC/ACV
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 COVERAGE
Household PP Coinsurance %
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 COVERAGE
Household PP Prot Class
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 COVERAGE
Household PP Cause 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 COVERAGE
Household PP Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Household PP Value
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Household PP Limit of Insurance
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Household PP Premium
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Snowmobiles Bldg Type
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Snowmobiles RC/ACV
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 COVERAGE
Snowmobiles Coinsurance %
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 COVERAGE
Snowmobiles Prot Class
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 COVERAGE
Snowmobiles Cause 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 COVERAGE
Snowmobiles Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Snowmobiles Value
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Snowmobiles Limit of Insurance
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Snowmobiles Premium
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Other One
Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE
Other Bldg Type One
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other Construction One
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 COVERAGE
Other Type of Heat One
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Other Age of Bldg One
Enter number: The age of the building in years.
PROPERTY COVERAGE
Other Age of Roof One
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Other Square Feet One
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
PROPERTY COVERAGE
Other RC/ACV 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 COVERAGE
Other Coinsurance % 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 COVERAGE
Other Prot Class One
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 COVERAGE
Other Cause 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 COVERAGE
Other Deductible One
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Other Value One
Enter amount: The value of the premises or item.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other Limit of Insurance One
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Other Premium One
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Other Two
Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE
Other Bldg Type Two
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Other Construction Two
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 COVERAGE
Other Type of Heat Two
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Other Age of Bldg Two
Enter number: The age of the building in years.
PROPERTY COVERAGE
Other Age of Roof Two
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Other Square Feet Two
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
PROPERTY COVERAGE
Other RC/ACV 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 COVERAGE
Other Coinsurance % 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 COVERAGE
Other Prot Class Two
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.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other Cause of Loss Two
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PROPERTY COVERAGE
Other Deductible Two
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Other Value Two
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Other Limit of Insurance Two
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Other Premium Two
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Other Three
Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE
Other Bldg Type Three
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Other Construction Three
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 COVERAGE
Other Type of Heat Three
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Other Age of Bldg Three
Enter number: The age of the building in years.
PROPERTY COVERAGE
Other Age of Roof Three
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Other Square Feet Three
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
PROPERTY COVERAGE
Other RC/ACV Three
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
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other Coinsurance % Three
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 COVERAGE
Other Prot Class Three
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 COVERAGE
Other Cause of Loss Three
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PROPERTY COVERAGE
Other Deductible Three
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Other Value Three
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Other Limit of Insurance Three
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Other Premium Three
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Other Four
Enter code: The code designating the subject of insurance or premium bearing option.
PROPERTY COVERAGE
Other Bldg Type Four
Enter text: The type of structure (e.g. animal shelter, grain bin, silo, etc.).
PROPERTY COVERAGE
Other Construction Four
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 COVERAGE
Other Type of Heat Four
Enter text: The description of the type of fuel used by the heating unit.
PROPERTY COVERAGE
Other Age of Bldg Four
Enter number: The age of the building in years.
PROPERTY COVERAGE
Other Age of Roof Four
Enter number: The age of the roof in years.
PROPERTY COVERAGE
Other Square Feet Four
Enter number: The number of square feet of the building or area occupied at this location
for which insurance is being requested.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
PROPERTY COVERAGE
Other RC/ACV Four
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 COVERAGE
Other Coinsurance % Four
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 COVERAGE
Other Prot Class Four
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 COVERAGE
Other Cause of Loss Four
Enter code: The causes of loss the subject of insurance is to be covered for. Examples:
* Basic
* Broad
* Special excluding theft
* Earthquake
PROPERTY COVERAGE
Other Deductible Four
Enter deductible: The deductible amount that is to apply to this subject of insurance.
PROPERTY COVERAGE
Other Value Four
Enter amount: The value of the premises or item.
PROPERTY COVERAGE
Other Limit of Insurance Four
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
PROPERTY COVERAGE
Other Premium Four
Enter amount: The premium amount for this subject of insurance.
PROPERTY COVERAGE
Additional Coverages,
Restrictions, Endorsements and
Rating Information
Enter text: The remarks associated with a specific location or sublocation.
LIABILITY COVERAGE
Bodily Injury and Property Damage
Liability: Each Occurrence
Amount
Enter limit: The each occurrence limit amount for bodily injury and property damage
coverage.
LIABILITY COVERAGE
General Aggregate Limit
Enter limit: The general aggregate limit amount for bodily injury and property damage
coverage.
LIABILITY COVERAGE
Personal and Advertising Injury
Liability
Enter limit: The each occurrence limit amount for personal and advertising injury
coverage.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
General Aggregate Limit
Enter limit: The general aggregate limit amount for personal and advertising injury
coverage.
LIABILITY COVERAGE
Medical Payments
Enter limit: The each person limit amount for medical payments coverage.
LIABILITY COVERAGE
General Aggregate Limit
Enter limit: The each occurrence limit amount for medical payments coverage.
LIABILITY COVERAGE
Property Damage Liability Fire
Damage Limit
Enter limit: The any one fire limit amount for fire damage coverage.
LIABILITY COVERAGE
Additional Coverage- Damage to
Property of Others
Enter limit: The limit amount for damage to property of others coverage.
LIABILITY COVERAGE
AAIS Personal Liability Coverage
Name of Insured (s)
Enter text: The additional interest's full name. As used here, this is a named insured
covered by personal liability coverage.
LIABILITY COVERAGE
Enter text: The additional interest's full name. As used here, this is a named insured
covered by personal liability coverage.
LIABILITY COVERAGE
Other Coverage
Enter code: The code for the coverage.
LIABILITY COVERAGE
Enter text: The description of the coverage.
LIABILITY COVERAGE
Amount
Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE
Other Coverage
Enter code: The code for the coverage.
LIABILITY COVERAGE
Enter text: The description of the coverage.
LIABILITY COVERAGE
Amount
Enter limit: The limit amount for the coverage.
LIABILITY COVERAGE
Commercial General Liability Yes
Check the box (if applicable): Indicates commercial general liability coverage is requested.
LIABILITY COVERAGE
Commercial General Liability No
Check the box (if applicable): Indicates commercial general liability coverage is not
requested.
LIABILITY COVERAGE
Farm Personal Liability Yes
Check the box (if applicable): Indicates farm personal liability coverage is requested.
LIABILITY COVERAGE
Farm Personal Liability No
Check the box (if applicable): Indicates farm personal liability coverage is not requested.
LIABILITY COVERAGE
Farm Commercial Liability AAIS
Yes
Check the box (if applicable): Indicates farm commercial liability coverage is requested.
LIABILITY COVERAGE
Farm Commercial Liability AAIS
No
Check the box (if applicable): Indicates farm commercial liability coverage is not
requested.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
LIABILITY COVERAGE
(Continued)
Initial Farm Premises Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Not More Than _ Acres
Enter number: The maximum number of acres for the initial farm premises coverage.
ACORD 410 (2013/09) rev. 06-28-2013
22 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Loc #
Enter identifier: The producer assigned location identifier for the additional farm premises
maintained by the named insured.
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the initial farm premises.
LIABILITY COVERAGE
(Continued)
Additional Farm Premises
Maintained by Named Insured:
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Seasonal
Check the box (if applicable): Indicates the additional non-farm premises occupied by the
insured is seasonal.
LIABILITY COVERAGE
(Continued)
Permanent
Check the box (if applicable): Indicates if the additional non-farm premises occupied by
the insured is permanent.
LIABILITY COVERAGE
(Continued)
Loc #
Enter identifier: The producer assigned location identifier for the additional non-farm
premises occupied by the insured.
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for additional non-farm premises occupied by the
insured.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for additional non-farm premises occupied by the insured.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for additional non-farm premises occupied by the
insured.
LIABILITY COVERAGE
(Continued)
Additional Residence Rented To
Others Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Number of Families
Enter number: The number of families in the additional residence rented to others.
LIABILITY COVERAGE
(Continued)
Loc #
Enter identifier: The producer assigned location identifier for the additional residence
rented to others.
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the additional residence rented to others.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the additional residence rented to others.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for additional residence rented to others.
LIABILITY COVERAGE
(Continued)
Custom Farming Receipts (Rate
Per $1,000)
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Receipts Amount
Enter amount: The receipts amount for custom farming.
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for custom farming.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for custom farming.
ACORD 410 (2013/09) rev. 06-28-2013
24 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for custom farming.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Sales
Enter amount: The receipts amount for the incidental business activity.
LIABILITY COVERAGE
(Continued)
Coverage
Enter text: The description of any other information required by the insurer for the
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the incidental business activity.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the incidental business activity.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the incidental business activity.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor 1-3 Persons
Enter percentage: The increased limits factor for the coverage. As used here, this is for a
day care with 1 to 3 persons.
LIABILITY COVERAGE
(Continued)
Basis/Rate 1-3 Persons
Enter code: The premium basis code for day care coverage. As used here, this is for a
day care with 1 to 3 persons.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for day care coverage. As used here, this is for a day care with 1 to 3
persons.
LIABILITY COVERAGE
(Continued)
Premium 1-3 Persons
Enter amount: The premium amount for day care coverage. As used here, this is for a day
care with 1 to 3 persons.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor 1-6 Persons
Enter percentage: The increased limits factor for the coverage. As used here, this is for a
day care with 1 to 6 persons.
LIABILITY COVERAGE
(Continued)
Basis/Rate 1-6 Persons
Enter code: The premium basis code for day care coverage. As used here, this is for a
day care with 1 to 6 persons.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for day care coverage. As used here, this is for a day care with 1 to 6
persons.
LIABILITY COVERAGE
(Continued)
Premium 1-6 Persons
Enter amount: The premium amount for day care coverage. As used here, this is for a day
care with 1 to 6 persons.
LIABILITY COVERAGE
(Continued)
Limited Farm Pollution Liability
(Refer To Company): Code
Enter code: The code for the coverage.
ACORD 410 (2013/09) rev. 06-28-2013
25 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for limited farm pollution liability.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for limited farm pollution liability.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for limited farm pollution liability.
LIABILITY COVERAGE
(Continued)
Contingent Liability For Crop
Dusting By Independent Aircraft
(Rate Per $1,000 Cost): Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Cost
Enter amount: The cost for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE
(Continued)
Limit
Enter limit: The limit amount for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for contingent liability for crop dusting by
independent aircraft.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for contingent liability for crop dusting by independent aircraft.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for contingent liability for crop dusting by independent
aircraft.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Inservant
Check the box (if applicable): Indicates coverage is requested for inservants.
LIABILITY COVERAGE
(Continued)
Outservant
Check the box (if applicable): Indicates coverage is requested for outservants.
LIABILITY COVERAGE
(Continued)
# of Residential Employees
Enter number: The number of residential employees for domestic workers compensation
coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for domestic workers compensation coverage.
ACORD 410 (2013/09) rev. 06-28-2013
26 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for domestic workers compensation coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for domestic workers compensation coverage.
LIABILITY COVERAGE
(Continued)
Animal Collision: Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Limit per Head
Enter limit: The per head limit for animal collision coverage.
LIABILITY COVERAGE
(Continued)
# of Head
Enter number: The head count for animal collision coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for animal collision coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for animal collision coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for animal collision coverage.
LIABILITY COVERAGE
(Continued)
Employers Liability Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
# Full Time Employees
Enter number: The number of full time employees for employers liability coverage.
LIABILITY COVERAGE
(Continued)
# Part Time Employees
Enter number: The number of part time employees for employers liability coverage.
LIABILITY COVERAGE
(Continued)
Total Payroll
Enter amount: The total payroll amount for employers liability coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for employers liability coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for employers liability coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for employers liability coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
ACORD 410 (2013/09) rev. 06-28-2013
27 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
ACORD 410 (2013/09) rev. 06-28-2013
28 of 38
Section Name
Field Name
Field and/or Section Description
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
LIABILITY COVERAGE
(Continued)
Code
Enter code: The code for the coverage.
LIABILITY COVERAGE
(Continued)
Blank Field
Enter text: The description of the coverage.
LIABILITY COVERAGE
(Continued)
Incr Limits Factor
Enter percentage: The increased limits factor for the coverage.
LIABILITY COVERAGE
(Continued)
Basis/Rate
Enter code: The premium basis code for the coverage.
LIABILITY COVERAGE
(Continued)
Enter rate: The rate for the coverage.
LIABILITY COVERAGE
(Continued)
Premium
Enter amount: The premium amount for the coverage.
ACORD 410 (2013/09) rev. 06-28-2013
29 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Is there is a year-round water
source available for fire
protection? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there a year-
round water supply usable for fire protection?,
GENERAL INFORMATION
Is there is a year-round water
source available for fire
protection? No
Check the box (if applicable): Indicates a No response to the question, Is there a year-
round water supply usable for fire protection?,
GENERAL INFORMATION
Source: Well
Check the box (if applicable): Indicates the source of water is a well.
GENERAL INFORMATION
Pond/Lake
Check the box (if applicable): Indicates the source of water is a pond or lake.
GENERAL INFORMATION
Hydrant Within 1000 Ft
Check the box (if applicable): Indicates the source of water is a fire hydrant within 1,000
feet.
GENERAL INFORMATION
Other checkbox
Check the box (if applicable): Indicates the source of water is other than those listed.
GENERAL INFORMATION
Other Description
Enter text: The source of water for fire protection.
GENERAL INFORMATION
Quantity: Less Than 1000 Gallons
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is under 1,000 gallons.
GENERAL INFORMATION
1000 - 3000 Gallons
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is 1,000 - 3,000 gallons.
GENERAL INFORMATION
Over 3000 Gallons
Check the box (if applicable): Indicates the quantity of the water supply for fire protection
is over 3,000 gallons.
GENERAL INFORMATION
Are any wood or coal fired stoves
are used in any buildings? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any wood
or coal fired stoves used?.
GENERAL INFORMATION
Are any wood or coal fired stoves
are used in any buildings? NO
Check the box (if applicable): Indicates a No response to the question, Are any wood or
coal fired stoves used?.
GENERAL INFORMATION
Explain if Yes
Enter text: An explanation as to whether the applicant uses any wood or coal fired stoves
on the premises.
GENERAL INFORMATION
Are there are any burglary and/or
fire alarms on the premises? Yes
This question cannot be asked in
Missouri.
Check the box (if applicable): Indicates a Yes response to the question, Are there any
burglar and / or fire alarms?.
GENERAL INFORMATION
Are there are any burglary and/or
fire alarms on the premises? No
This question cannot be asked in
Missouri.
Check the box (if applicable): Indicates a No response to the question, Are there any
burglar and / or fire alarms?.
GENERAL INFORMATION
If Yes Type of Alarm
Enter text: The description of the type of alarm.
ACORD 410 (2013/09) rev. 06-28-2013
30 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
Diagram #
Enter identifier: The producer assigned identifier for the diagram of the location.
GENERAL INFORMATION
Does applicant perform
maintenance on equipment? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
perform maintenance on equipment?.
GENERAL INFORMATION
Does applicant perform
maintenance on equipment? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
perform maintenance on equipment?.
GENERAL INFORMATION
If no, please indicate type of
repairs done, where done and by
whom
Enter text: An explanation as to whether the applicant performs any maintenance of
equipment on the premises.
GENERAL INFORMATION
Is entire premises occupied year
round? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is entire
premises occupied year round?.
GENERAL INFORMATION
Is entire premises occupied year
round? No
Check the box (if applicable): Indicates a No response to the question, Is entire
premises occupied year round?.
GENERAL INFORMATION
During the last ten years has any
applicant been convicted of any
degree of the crime of arson? Yes
Check the box (if applicable): Indicates a Yes response to the question, During the last
mandated number of year, has any applicant been convicted of any degree of the crime of
arson?.
GENERAL INFORMATION
During the last ten years has any
applicant been convicted of any
degree of the crime of arson? No
Check the box (if applicable): Indicates a No response to the question, During the last
mandated number of year, has any applicant been convicted of any degree of the crime of
arson?.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
GENERAL INFORMATION
(Continued)
Are independent contractors hired
to perform any farming
operations? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are
independent contractors hired to perform any farming operations?.
GENERAL INFORMATION
(Continued)
Are independent contractors hired
to perform any farming
operations? No
Check the box (if applicable): Indicates a No response to the question, Are independent
contractors hired to perform any farming operations?.
GENERAL INFORMATION
(Continued)
Is any part of farm used or leased
for organized recreational use?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Any part of farm
used or leased for organized recreational use?.
GENERAL INFORMATION
(Continued)
Is any part of farm used or leased
for organized recreational use? No
Check the box (if applicable): Indicates a No response to the question, Any part of farm
used or leased for organized recreational use?.
ACORD 410 (2013/09) rev. 06-28-2013
31 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Does applicant build, repair or
design machinery equipment or
systems for anyone at a charge or
fee? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
build, repair or design machinery, equipment or systems for anyone at a charge or fee?.
GENERAL INFORMATION
(Continued)
Does applicant build, repair or
design machinery equipment or
systems for anyone at a charge or
fee? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
build, repair or design machinery, equipment or systems for anyone at a charge or fee?.
GENERAL INFORMATION
(Continued)
Does applicant mix, process,
slaughter, butcher or otherwise
prepare for any end consumer
his or any other grower's product?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
mix, process, slaughter, butcher or otherwise prepare for any end consumer his or any
other grower's product?.
GENERAL INFORMATION
(Continued)
Does applicant mix, process,
slaughter, butcher or otherwise
prepare for any end consumer
his or any other grower's product?
No
Check the box (if applicable): Indicates a No response to the question, Does applicant
mix, process, slaughter, butcher or otherwise prepare for any end consumer his or any
other grower's product?.
GENERAL INFORMATION
(Continued)
Does applicant handle any
product, such as seed, fertilizer,
sprays etc for resale? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
handle any product, such as seed, fertilizer, sprays, etc. for resale?.
GENERAL INFORMATION
(Continued)
Does applicant handle any
product, such as seed, fertilizer,
sprays etc for resale? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
handle any product, such as seed, fertilizer, sprays, etc. for resale?.
GENERAL INFORMATION
(Continued)
Are any contract or service
operations performed for others,
such as snow removal, tilling,
excavating or ditching? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
contract or service operations performed for others such as snow removal, tilling,
excavating, or ditching?.
GENERAL INFORMATION
(Continued)
Are any contract or service
operations performed for others,
such as snow removal, tilling,
excavating or ditching? No
Check the box (if applicable): Indicates a No response to the question, Are any contract
or service operations performed for others such as snow removal, tilling, excavating, or
ditching?.
ACORD 410 (2013/09) rev. 06-28-2013
32 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Are the farm premises open to the
public for activities such as
roadside stands? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are the farm
premises open to the public for activities such as, road side stands, U-Pick, recreational,
Rent-a-Garden, auction, sales, show, food, or beverage service, hay rides, fishing,
kennels, animal boarding, or Christmas tree sales uses?.
GENERAL INFORMATION
(Continued)
Are the farm premises open to the
public for activities such as
roadside stands? No
Check the box (if applicable): Indicates a No response to the question, Are the farm
premises open to the public for activities such as, road side stands, U-Pick, recreational,
Rent-a-Garden, auction, sales, show, food, or beverage service, hay rides, fishing,
kennels, animal boarding, or Christmas tree sales uses?.
GENERAL INFORMATION
(Continued)
Are any portions of the farm
rented or leased or used by any
other individual or corporation or
interest for other than farming?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
portions of the farm rented or leased or used by any other individual, corporation or
interest for other than farming?.
GENERAL INFORMATION
(Continued)
Are any portions of the farm
rented or leased or used by any
other individual or corporation or
interest for other than farming? No
Check the box (if applicable): Indicates a No response to the question, Are any portions
of the farm rented or leased or used by any other individual, corporation or interest for
other than farming?.
GENERAL INFORMATION
(Continued)
Is there any unusual hazard such
as open dump pits, silage pits,
sump holes, ponds, lakes or
reservoirs? Yes
Check the box (if applicable): Indicates a Yes response to the question, Any unusual
hazards such as (but not limited to) dump pits, silage pits, gravel pits, rock quarries, sump
holes, ponds, lakes or reservoirs?.
GENERAL INFORMATION
(Continued)
Is there any unusual hazard such
as open dump pits, silage pits,
sump holes, ponds, lakes or
reservoirs? No
Check the box (if applicable): Indicates a No response to the question, Any unusual
hazards such as (but not limited to) dump pits, silage pits, gravel pits, rock quarries, sump
holes, ponds, lakes or reservoirs?.
GENERAL INFORMATION
(Continued)
Is there an airstrip on the
premises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there an
airstrip on the premises?.
GENERAL INFORMATION
(Continued)
Is there an airstrip on the
premises? No
Check the box (if applicable): Indicates a No response to the question, Is there an
airstrip on the premises?.
GENERAL INFORMATION
(Continued)
Are any hold harmless or
indemnifying agreements in
effect? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any Hold
Harmless or Indemnifying agreements in effect?.
GENERAL INFORMATION
(Continued)
Are any hold harmless or
indemnifying agreements in
effect? No
Check the box (if applicable): Indicates a No response to the question, Are any Hold
Harmless or Indemnifying agreements in effect?.
ACORD 410 (2013/09) rev. 06-28-2013
33 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
If livestock is kept, are all areas
adequately fenced and are fences
in a good state of repair? Yes
Check the box (if applicable): Indicates a Yes response to the question, If livestock is
kept, are all areas adequately fenced and are fences in a good state of repair?.
GENERAL INFORMATION
(Continued)
If livestock is kept, are all areas
adequately fenced and are fences
in a good state of repair? No
Check the box (if applicable): Indicates a No response to the question, If livestock is
kept, are all areas adequately fenced and are fences in a good state of repair?.
GENERAL INFORMATION
(Continued)
Open range area
Check the box (if applicable): Indicates the premises is in an open range area.
GENERAL INFORMATION
(Continued)
Closed range area
Check the box (if applicable): Indicates the premises is in a closed range area.
GENERAL INFORMATION
(Continued)
Are the described premises the
only premises which the applicant
or spouse owns, rents or operates
as a farm or ranch, or maintains as
a residence, other than business
property? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are the
described insured premises the only premises which the applicant or spouse owns, rents
or operates as a farm or ranch, or maintains as a residence, other than business
property?.
GENERAL INFORMATION
(Continued)
Are the described premises the
only premises which the applicant
or spouse owns, rents or operates
as a farm or ranch, or maintains as
a residence, other than business
property? No
Check the box (if applicable): Indicates a No response to the question, Are the
described insured premises the only premises which the applicant or spouse owns, rents
or operates as a farm or ranch, or maintains as a residence, other than business
property?.
GENERAL INFORMATION
(Continued)
Any non-owned horses on any
insured premises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Any non-owned
horses on any insured premises?.
GENERAL INFORMATION
(Continued)
Any non-owned horses on any
insured premises? No
Check the box (if applicable): Indicates a No response to the question, Any non-owned
horses on any insured premises?.
GENERAL INFORMATION
(Continued)
Does insured board, race breed or
rent horses? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does insured
own, board, race, breed or rent horses?.
GENERAL INFORMATION
(Continued)
Does insured board, race breed or
rent horses? No
Check the box (if applicable): Indicates a No response to the question, Does insured
own, board, race, breed or rent horses?.
ACORD 410 (2013/09) rev. 06-28-2013
34 of 38
Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Is any land held for real estate
development or speculation? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is any land held
for real estate development or speculation?.
GENERAL INFORMATION
(Continued)
Is any land held for real estate
development or speculation? No
Check the box (if applicable): Indicates a No response to the question, Is any land held
for real estate development or speculation?.
GENERAL INFORMATION
(Continued)
Does applicant maintain any
vacation or seasonal premises?
Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
maintain any vacation or seasonal premises?.
GENERAL INFORMATION
(Continued)
Does applicant maintain any
vacation or seasonal premises?
No
Check the box (if applicable): Indicates a No response to the question, Does applicant
maintain any vacation or seasonal premises?.
GENERAL INFORMATION
(Continued)
If dairy farm, is there any
processing of milk? Yes
Check the box (if applicable): Indicates a Yes response to the question, If dairy farm, is
there any processing of milk?.
GENERAL INFORMATION
(Continued)
If dairy farm, is there any
processing of milk? No
Check the box (if applicable): Indicates a No response to the question, If dairy farm, is
there any processing of milk?.
GENERAL INFORMATION
(Continued)
If dairy farm, is there any retail
sales of milk products to public?
Yes
Check the box (if applicable): Indicates a Yes response to the question, If dairy farm, is
there any retail sales of milk products to public?.
GENERAL INFORMATION
(Continued)
If dairy farm, is there any retail
sales of milk products to public?
No
Check the box (if applicable): Indicates a No response to the question, If dairy farm, is
there any retail sales of milk products to public?.
GENERAL INFORMATION
(Continued)
Receipts Amount
Enter amount: The total amount of receipts gained from the sale of milk products.
GENERAL INFORMATION
(Continued)
Number of Cows Milked
Enter number: The number of animals milked. As used here, this is the number of cows
milked.
GENERAL INFORMATION
(Continued)
Are any premises used for hunting
purposes? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are any
premises used for hunting purposes?.
GENERAL INFORMATION
(Continued)
Are any premises used for hunting
purposes? No
Check the box (if applicable): Indicates a No response to the question, Are any
premises used for hunting purposes?.
GENERAL INFORMATION
(Continued)
By Owners
Check the box (if applicable): Indicates the premises is used for hunting by the owners.
GENERAL INFORMATION
(Continued)
No Charge
Check the box (if applicable): Indicates the premises is used for hunting for no charge.
GENERAL INFORMATION
(Continued)
Fee
Check the box (if applicable): Indicates the premises is used for hunting for a fee.
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Rented to Others
Check the box (if applicable): Indicates the premises is rented to others for hunting.
GENERAL INFORMATION
(Continued)
Receipts Amount
Enter amount: The receipts amount for hunting on the premises.
GENERAL INFORMATION
(Continued)
Does applicant maintain a non-
farm office or private school in an
insured building? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
maintain a non-farm office or private school in an insured building?.
GENERAL INFORMATION
(Continued)
Does applicant maintain a non-
farm office or private school in an
insured building? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
maintain a non-farm office or private school in an insured building?.
GENERAL INFORMATION
(Continued)
Is there a swimming pool on
premises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there a
swimming pool on the premises?.
GENERAL INFORMATION
(Continued)
Is there a swimming pool on
premises? No
Check the box (if applicable): Indicates a No response to the question, Is there a
swimming pool on the premises?.
GENERAL INFORMATION
(Continued)
Is it fenced? Yes
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is
an approved height.
GENERAL INFORMATION
(Continued)
Is it fenced? No
Check the box (if applicable): Indicates the swimming pool is not surrounded by a fence
that is an approved height.
GENERAL INFORMATION
(Continued)
Is there a diving board? Yes
Check the box (if applicable): Indicates the swimming pool has a diving board.
GENERAL INFORMATION
(Continued)
Is there a diving board? No
Check the box (if applicable): Indicates the swimming pool does not have a diving board.
GENERAL INFORMATION
(Continued)
Does applicant serve on any
boards of remuneration? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
serve on any boards for remuneration?.
GENERAL INFORMATION
(Continued)
Does applicant serve on any
boards of remuneration? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
serve on any boards for remuneration?.
GENERAL INFORMATION
(Continued)
Is the applicant a subsidiary of
another or does the applicant have
subsidiary? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is the applicant
a subsidiary of another or does the applicant have subsidiaries?.
GENERAL INFORMATION
(Continued)
Is the applicant a subsidiary of
another or does the applicant have
subsidiary? No
Check the box (if applicable): Indicates a No response to the question, Is the applicant a
subsidiary of another or does the applicant have subsidiaries?.
GENERAL INFORMATION
(Continued)
Is a formal safety program in
existence? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there a
formal safety program in existence?.
GENERAL INFORMATION
(Continued)
Is a formal safety program in
existence? No
Check the box (if applicable): Indicates a No response to the question, Is there a formal
safety program in existence?.
ACORD 410 (2013/09) rev. 06-28-2013
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Section Name
Field Name
Field and/or Section Description
GENERAL INFORMATION
(Continued)
Does the applicant have any
potentially dangerous animals or
exotic pets? Yes
Check the box (if applicable): Indicates a Yes response to the question, Does applicant
have any potentially dangerous animals or exotic pets?.
GENERAL INFORMATION
(Continued)
Does the applicant have any
potentially dangerous animals or
exotic pets? No
Check the box (if applicable): Indicates a No response to the question, Does applicant
have any potentially dangerous animals or exotic pets?.
GENERAL INFORMATION
(Continued)
Is there any watercraft
snowmobile exposure? Yes
Check the box (if applicable): Indicates a Yes response to the question, Is there any
watercraft or snowmobile exposure?.
GENERAL INFORMATION
(Continued)
Is there any watercraft
snowmobile exposure? No
Check the box (if applicable): Indicates a No response to the question, Is there any
watercraft or snowmobile exposure?.
GENERAL INFORMATION
(Continued)
Are there any elevators on the
premises? Yes
Check the box (if applicable): Indicates a Yes response to the question, Are there any
elevators on the premises?.
GENERAL INFORMATION
(Continued)
Are there any elevators on the
premises? NO
Check the box (if applicable): Indicates a No response to the question, Are there any
elevators on the premises?.
REMARKS /
ATTACHMENTS
Remarks
Enter text: The general remarks associated with the farm policy. Use this section to
provide any additional information required for underwriting or rating. Attach additional
sheets if more space is required.
REMARKS /
ATTACHMENTS
State Supplements
Check the box (if applicable): Indicates a state supplement is attached to the policy.
REMARKS /
ATTACHMENTS
Photos
Check the box (if applicable): Indicates a photograph is attached to the policy.
REMARKS /
ATTACHMENTS
Bill of Sale
Check the box (if applicable): Indicates a bill of sale is attached to the policy.
REMARKS /
ATTACHMENTS
Appraisals
Check the box (if applicable): Indicates an appraisal is attached to the policy.
REMARKS /
ATTACHMENTS
Inventories
Check the box (if applicable): Indicates an inventory is attached to the policy.
REMARKS /
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
REMARKS /
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
REMARKS /
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
REMARKS /
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
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Section Name
Field Name
Field and/or Section Description
ATTACHMENTS
Other
Check the box (if applicable): Indicates there are attachments to the policy other than
those listed.
ATTACHMENTS
Other Description
Enter text: The description of an attachment to the policy.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
REMARKS
Remarks
Enter text: The general remarks associated with the farm policy. Use this section to
provide any additional information required for underwriting or rating. Attach additional
sheets if more space is required.
SIGNATURE
Applicant Initials
Initial here: The named insured's initials.
SIGNATURE
Copy of the Notice of Information
Practices (checkbox)
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific
38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In
addition, ACORD 38 contains CA and MA state specific language.
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
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.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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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