ACORD 70 (2012/03) - PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO)

ACORD 70 (2012/03) - PERSONAL POLICY CHANGE REQUEST (EXCEPT AUTO)

ACORD 70, Personal Policy Change Request (Except Auto), is used to request mid-term changes to any personal lines policy, except auto. For

auto changes, see ACORD 71, Personal Auto Policy Change Request. This form should be used instead of individual turnaround endorsement

requests. A copy of the request may be sent to the insured to confirm that the change is submitted to the company. The form provides for property,

mobile home, inland marine, watercraft and umbrella changes.

Form Page 1

Section Name

Field Name

Description

IDENTIFICATION SECTION

Loc #

Enter number: The producer assigned number of the location.

IDENTIFICATION SECTION

Date

Enter date: The date on which the form is completed. (MM/DD/YYYY)

IDENTIFICATION SECTION

Agency

Enter text: The full name of the producer / agency.

IDENTIFICATION SECTION

Enter text: The mailing address line one of the producer / agency.

IDENTIFICATION SECTION

Enter text: The mailing address line two of the producer / agency.

IDENTIFICATION SECTION

Enter text: The mailing address city name of the producer / agency.

IDENTIFICATION SECTION

Enter code: The mailing address state or province code of the producer / agency.

IDENTIFICATION SECTION

Enter code: The mailing address postal code of the producer / agency.

IDENTIFICATION SECTION

Contact Name

Enter text: The name of the individual at the producer's establishment that is the primary

contact.

IDENTIFICATION SECTION

Phone (A/C, No, Ext)

Enter number: The producer's contact person's phone number. If applicable, include the area

code and extension.

IDENTIFICATION SECTION

FAX

Enter number: The fax number of the producer / agency.

IDENTIFICATION SECTION

E-Mail Address

Enter text: The producer's contact person's e-mail address.

IDENTIFICATION SECTION

Code

Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by

the insurer.

IDENTIFICATION SECTION

Subcode

Enter code: The identification code assigned by the insurer to the sub-producer (e.g., individual)

within a producer's office (e.g., agency or brokerage).

IDENTIFICATION SECTION

Agency Customer ID

Enter identifier: The customer's identification number assigned by the producer (e.g., agency or

brokerage).

IDENTIFICATION SECTION

Insured's Name and Mailing

Address if changed

Enter text: The named insured(s) as it / they will appear on the policy declarations page.

IDENTIFICATION SECTION

Enter text: The named insured's mailing address line one.

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IDENTIFICATION SECTION

Enter text: The named insured's mailing address line two.

IDENTIFICATION SECTION

Enter text: The named insured's mailing address city name.

IDENTIFICATION SECTION

Enter code: The named insured's mailing address state or province code.

IDENTIFICATION SECTION

Enter code: The named insured's mailing address postal code.

IDENTIFICATION SECTION

Policy Type - Homeowner

Check the box (if applicable): Indicates the type of policy is homeowners.

IDENTIFICATION SECTION

Policy Type - Mobile Home

Check the box (if applicable): Indicates the type of policy is mobile home.

IDENTIFICATION SECTION

Policy Type - Inland Marine

Check the box (if applicable): Indicates the type of policy is inland marine.

IDENTIFICATION SECTION

Policy Type - Dwelling Fire

Check the box (if applicable): Indicates the type of policy is dwelling fire.

IDENTIFICATION SECTION

Policy Type - Watercraft

Check the box (if applicable): Indicates the type of policy is watercraft.

IDENTIFICATION SECTION

Policy Type - Umbrella

Check the box (if applicable): Indicates the type of policy is umbrella.

IDENTIFICATION SECTION

Effective Date of Change

Enter date: The date on which the change should take effect.

IDENTIFICATION SECTION

Inception Date of Policy

Enter date: The effective date of the policy. The date that the terms and conditions of the policy

commence. (MM/DD/YYYY)

IDENTIFICATION SECTION

Expiration Date

Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)

IDENTIFICATION SECTION

Carrier

Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use

the actual name of the company within the group to which the policy has been issued. This is

not the insurer's group name or trade name.

IDENTIFICATION SECTION

NAIC #

Enter code: The identification code assigned to the insurer by the National Association of

Insurance Commissioners (NAIC).

IDENTIFICATION SECTION

Named Insured

Enter text: The named insured(s) as it / they will appear on the policy declarations page.

IDENTIFICATION SECTION

Policy Number

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being

referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for

self-insurance, the self-insured license or contract number.

IDENTIFICATION SECTION

Attention

Enter text: The name of the individual at the insurance company that is the primary contact.

IDENTIFICATION SECTION

Account Number

Enter identifier: The account number to be used for billing purposes. This is the billing number

assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns.

If the account already exists, the agent should provide the previously assigned number.

IDENTIFICATION SECTION

Direct Bill Policy

Check the box (if applicable): Indicates if the policy is to be direct billed.

IDENTIFICATION SECTION

Direct Bill Acct

Check the box (if applicable): Indicates if the account is to be direct billed.

IDENTIFICATION SECTION

Agency Bill

Check the box (if applicable): Indicates if the policy is to be producer / agency billed.

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IDENTIFICATION SECTION

Payment Plan - Full Pay

Check the box (if applicable): Indicates a full payment will be made on the policy.

IDENTIFICATION SECTION

Payment Plan - Annual

Check the box (if applicable): Indicates the policy will be paid annually.

IDENTIFICATION SECTION

Payment Plan - Semi-Annual

Check the box (if applicable): Indicates the policy will be paid semi-annually.

IDENTIFICATION SECTION

Payment Plan - Other

Check the box (if applicable): Indicates the policy will be paid in a frequency other than those

listed.

IDENTIFICATION SECTION

Payment Plan - Description

Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,

etc.). As used here, only enter the description when other is selected.

IDENTIFICATION SECTION

Payment Plan - Quarterly

Check the box (if applicable): Indicates the policy will be paid quarterly.

IDENTIFICATION SECTION

Payment Plan - Bi-Monthly

Check the box (if applicable): Indicates the policy will be paid bi-monthly.

IDENTIFICATION SECTION

Payment Plan - Monthly

Check the box (if applicable): Indicates the policy will be paid monthly.

IDENTIFICATION SECTION

Payor - Insured

Check the box (if applicable): Indicates the payor of the policy is the insured.

IDENTIFICATION SECTION

Payor - Mortgagee

Check the box (if applicable): Indicates the payor of the policy is the mortgagee.

IDENTIFICATION SECTION

Payor - Other

Check the box (if applicable): Indicates the payor of the policy is other than those listed.

IDENTIFICATION SECTION

Payor - Description

Enter text: The description of the payor of the policy. As used here, only enter the description

when other is selected.

IDENTIFICATION SECTION

Premium Financed ?

Enter Y for a Yes response. Input N for No response. Indicates if the premium has been

financed.

IDENTIFICATION SECTION

Finance Company

Enter text: The name of the company financing the premium, if applicable.

IDENTIFICATION SECTION

Payment Method - Cash

Check the box (if applicable): Indicates the invoice will be paid in cash.

IDENTIFICATION SECTION

Payment Method - Check

Check the box (if applicable): Indicates the invoice will be paid by check.

IDENTIFICATION SECTION

Payment Method - Credit

Card

Check the box (if applicable): Indicates the invoice will be paid by credit card.

IDENTIFICATION SECTION

Payment Method - EFT

Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer

(EFT).

IDENTIFICATION SECTION

Payment Method - Payroll

Deduction

Check the box (if applicable): Indicates the invoice will be paid by payroll deduction.

IDENTIFICATION SECTION

Payment Method -

Pre-Authorized Draft/Check

(PAC)

Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or

draft.

IDENTIFICATION SECTION

Payment Method - Other

Check the box (if applicable): Indicates the invoice will be paid by a means other than those

listed.

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IDENTIFICATION SECTION

Payment Method - Describe

Enter text: The method the invoice will be paid. As used here, only enter the description when

other is selected.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Dwelling Limit

Enter limit: The limit associated with dwelling coverage.

COVERAGES / LIMITS OF

LIABILITY

Dwelling Premium

Enter amount: The premium associated with dwelling coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Other Structures Limit

Enter limit: The limit associated with other structures coverage.

COVERAGES / LIMITS OF

LIABILITY

Other Structures Premium

Enter amount: The premium associated with other structures coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Personal Property Limit

Enter limit: The limit associated with personal property coverage.

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COVERAGES / LIMITS OF

LIABILITY

Personal Property

Premiums

Enter amount: The premium associated with personal property coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Actual Loss Sustained

(checkbox)

Check the box (if applicable): Indicates the loss of use coverage is on an actual loss sustained

basis.

COVERAGES / LIMITS OF

LIABILITY

Loss of Use Limit

Enter limit: The limit associated with loss of use coverage.

COVERAGES / LIMITS OF

LIABILITY

Loss of Use Premiums

Enter amount: The premium associated with loss of use coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Blanket Limit

Enter limit: The limit associated with blanket coverage which includes dwelling, other structures,

personal property, and loss of use).

COVERAGES / LIMITS OF

LIABILITY

Blanket Premium

Enter amount: The premium associated with blanket coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

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COVERAGES / LIMITS OF

LIABILITY

Actual Loss Sustained

(checkbox)

Check the box (if applicable): Indicates the rental value coverage is on an actual loss sustained

basis.

COVERAGES / LIMITS OF

LIABILITY

Rental Value Limit

Enter limit: The limit associated with rental value (dwelling fire only) coverage.

COVERAGES / LIMITS OF

LIABILITY

Rental Value Premium

Enter amount: The premium associated with rental value (dwelling fire only) coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Additional Expense Limit

Enter limit: The limit associated with additional expense coverage.

COVERAGES / LIMITS OF

LIABILITY

Additional Expense

Premium

Enter amount: The premium associated with additional expense coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Personal Liability Each

Occurrence Limit

Enter limit: The limit associated with personal liability each occurrence coverage.

COVERAGES / LIMITS OF

LIABILITY

Personal Liability Each

Occurrence Premium

Enter amount: The premium associated with personal liability coverage.

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COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

COVERAGES / LIMITS OF

LIABILITY

Medical Payments Each

Person Limit

Enter limit: The limit associated with medical payments each person coverage.

COVERAGES / LIMITS OF

LIABILITY

Medical Payments Each

Person Premium

Enter amount: The premium associated with medical payments coverage.

COVERAGES / LIMITS OF

LIABILITY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Base Type

Enter code: The deductible type (e.g. flat, percentage) for the base deductible.

DEDUCTIBLES

Base Amount

Enter deductible: The base deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Base Percentage

Enter percentage: The base percentage deductible if the deductible is expressed as a

percentage.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Wind Type

Enter code: The deductible type (e.g. flat, percentage) for the wind / hail deductible.

DEDUCTIBLES

Wind Amount

Enter deductible: The wind / hail deductible amount if the deductible is expressed as a dollar

amount.

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DEDUCTIBLES

Wind Percentage

Enter percentage: The wind / hail percentage deductible if the deductible is expressed as a

percentage.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Theft Type

Enter code: The deductible type (e.g. flat, percentage) for the theft deductible.

DEDUCTIBLES

Theft Amount

Enter deductible: The theft deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Theft Percentage

Enter percentage: The theft percentage deductible if the deductible is expressed as a

percentage.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Named Hurricane Type

Enter code: The deductible type (e.g. flat, percentage) for the named hurricane deductible.

DEDUCTIBLES

Named Hurricane Amount

Enter deductible: The named hurricane deductible amount if the deductible is expressed as a

dollar amount.

DEDUCTIBLES

Named Hurricane

Percentage

Enter percentage: The named hurricane percentage deductible if the deductible is expressed as

a percentage.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Annual Hurricane Type

Enter code: The deductible type (e.g. flat, percentage) for the annual hurricane deductible.

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DEDUCTIBLES

Annual Hurricane Amount

Enter deductible: The annual hurricane deductible amount if the deductible is expressed as a

dollar amount.

DEDUCTIBLES

Annual Hurricane

Percentage

Enter percentage: The annual hurricane percentage deductible if the deductible is expressed as

a percentage.

DEDUCTIBLES

Other

Enter text: The coverage associated with the deductible you are entering.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Other Type

Enter code: The deductible type (e.g. flat, percentage) for the other deductible.

DEDUCTIBLES

Other Amount

Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Other Percentage

Enter percentage: The percentage deductible if the deductible is expressed as a percentage.

DEDUCTIBLES

Other

Enter text: The coverage associated with the deductible you are entering.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Other Type

Enter code: The deductible type (e.g. flat, percentage) for the other deductible.

DEDUCTIBLES

Other Amount

Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Other Percentage

Enter percentage: The percentage deductible if the deductible is expressed as a percentage.

DEDUCTIBLES

Other

Enter text: The coverage associated with the deductible you are entering.

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DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Other Type

Enter code: The deductible type (e.g. flat, percentage) for the other deductible.

DEDUCTIBLES

Other Amount

Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Other Percentage

Enter percentage: The percentage deductible if the deductible is expressed as a percentage.

DEDUCTIBLES

Other

Enter text: The coverage associated with the deductible you are entering.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Other Type

Enter code: The deductible type (e.g. flat, percentage) for the other deductible.

DEDUCTIBLES

Other Amount

Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.

DEDUCTIBLES

Other Percentage

Enter percentage: The percentage deductible if the deductible is expressed as a percentage.

DEDUCTIBLES

Other

Enter text: The coverage associated with the deductible you are entering.

DEDUCTIBLES

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

DEDUCTIBLES

Other Type

Enter code: The deductible type (e.g. flat, percentage) for the other deductible.

DEDUCTIBLES

Other Amount

Enter deductible: The deductible amount if the deductible is expressed as a dollar amount.

ACORD 70 (2012/03) rev. 08-20-2014

Page 10 of 67

DEDUCTIBLES

Other Percentage

Enter percentage: The percentage deductible if the deductible is expressed as a percentage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - # Premises

Enter number: The number of premises covered by the additional premises liability extension.

This is used when you don't have the full detail about the individual locations.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension Form Number

Enter identifier: The form number used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Date

Enter date: The edition date of the form used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Premium

Enter amount: The premium associated with additional premises liability extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Loc #

Enter number: The producer assigned location number for the premises covered by additional

premises liability extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Number

Enter identifier: The form number used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Date

Enter date: The edition date of the form used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Premium

Enter amount: The premium associated with additional premises liability extension.

ACORD 70 (2012/03) rev. 08-20-2014

Page 11 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Loc #

Enter number: The producer assigned location number for the premises covered by additional

premises liability extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Number

Enter identifier: The form number used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Date

Enter date: The edition date of the form used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Premium

Enter amount: The premium associated with additional premises liability extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Loc #

Enter number: The producer assigned location number for the premises covered by additional

premises liability extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Number

Enter identifier: The form number used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Form Date

Enter date: The edition date of the form used by the company for additional premises liability

extension.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Premises Liability

Extension - Premium

Enter amount: The premium associated with additional premises liability extension.

ACORD 70 (2012/03) rev. 08-20-2014

Page 12 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - # of

Premises

Enter number: The number of premises covered by the additional residence rented to others.

This is used when you don't have the full detail about the individual locations.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Med Pay

Enter Y for a Yes response. Input N for No response. Indicates if medical payments

coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Number

Enter identifier: The form number used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Date

Enter date: The edition date of the form used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Premium

Enter amount: The premium for additional residence rented to others coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Loc #

Enter number: The producer assigned location number for the premises covered by additional

residence rented to others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others- Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - #

Families

Enter number: The number of families of the additional residence rented to others .

ACORD 70 (2012/03) rev. 08-20-2014

Page 13 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Med Pay

Enter Y for a Yes response. Input N for No response. Indicates if medical payments

coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Number

Enter identifier: The form number used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Date

Enter date: The edition date of the form used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Premium

Enter amount: The premium for additional residence rented to others coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Loc #

Enter number: The producer assigned location number for the premises covered by additional

residence rented to others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others- Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - #

Families

Enter number: The number of families of the additional residence rented to others .

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Med Pay

Enter Y for a Yes response. Input N for No response. Indicates if medical payments

coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Number

Enter identifier: The form number used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Date

Enter date: The edition date of the form used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Premium

Enter amount: The premium for additional residence rented to others coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 14 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Loc #

Enter number: The producer assigned location number for the premises covered by additional

residence rented to others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others- Terr

Enter code: The liability territory for the location specified.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - #

Families

Enter number: The number of families of the additional residence rented to others .

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Med Pay

Enter Y for a Yes response. Input N for No response. Indicates if medical payments

coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Number

Enter identifier: The form number used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Form

Date

Enter date: The edition date of the form used by the company for additional residence rented to

others.

OPTIONAL COVERAGES -

ENDORSEMENTS

Additional Residence

Rented To Others - Premium

Enter amount: The premium for additional residence rented to others coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only - Theft of

building Materials - Included

Check the box (if applicable): Indicates the builders risk theft of building materials coverage is

included.

ACORD 70 (2012/03) rev. 08-20-2014

Page 15 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only - Theft of

building Materials - Form

Number

Enter identifier: The form number used by the company for builders risk theft of building

materials.

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only - Theft of

building Materials - Form

Date

Enter date: The edition date of the form used by the company for builders risk theft of building

materials.

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only - Theft of

building Materials -

Premium

Enter amount: The premium for builders risk theft of building materials coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only -

Collapse due to hydro-static

pressure - Included

Check the box (if applicable): Indicates the builders risk collapse due to hydro-static pressure

coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only -

Collapse due to hydro-static

pressure - Form Number

Enter identifier: The form number used by the company for builders risk collapse due to

hydro-static pressure.

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only -

Collapse due to hydro-static

pressure - Form Date

Enter date: The edition date of the form used by the company for builders risk collapse due to

hydro-static pressure.

OPTIONAL COVERAGES -

ENDORSEMENTS

Builders Risk Only -

Collapse due to hydro-static

pressure - Premium

Enter amount: The premium for builders risk collapse due to hydro-static pressure coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

ACORD 70 (2012/03) rev. 08-20-2014

Page 16 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Aggregate Limit

Enter limit: The aggregate limit for building ordinance or law coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Increase Limit

Enter limit: The increased limit for building ordinance or law coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Included

Check the box (if applicable): Indicates the building ordinance or law coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Rebuild

Percentage

Enter percentage: The rebuild percentage for building ordinance or law coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Form Number

Enter identifier: The form number used by the company for building ordinance or law coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Form Date

Enter date: The edition date of the form used by the company for building ordinance or law

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Building Ordinance or Law

Coverage - Premium

Enter amount: The premium for building ordinance or law coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property At Home

- Included

Check the box (if applicable): Indicates the business property at home coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property At Home

- Limit

Enter limit: The limit for business property at home coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property At Home

- Form Number

Enter identifier: The form number used by the company for business property at home

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property At Home

- Form Date

Enter date: The edition date of the form used by the company for business property at home

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property At Home

- Premium

Enter amount: The premium for business property at home coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 17 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property Away

From Home - Included

Check the box (if applicable): Indicates the business property away from home coverage is

included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property Away

From Home - Limit

Enter limit: The limit for business property away from home coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property Away

From Home - Form Number

Enter identifier: The form number used by the company for business property away from home

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property Away

From Home - Form Date

Enter date: The edition date of the form used by the company for business property away from

home coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Business Property Away

From Home - Premium

Enter amount: The premium for business property away from home coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Debris Removal - Included

Check the box (if applicable): Indicates the debris removal coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

Debris Removal - Limit

Enter limit: The limit for debris removal coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Debris Removal - Form

Number

Enter identifier: The form number used by the company for debris removal coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Debris Removal - Form Date

Enter date: The edition date of the form used by the company for debris removal coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Debris Removal - Premium

Enter amount: The premium for debris removal coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 18 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - % Ded

Enter percentage: The percentage deductible for earthquake coverage if the deductible is

expressed as a percentage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Deductible

Amount

Enter deductible: The deductible amount for earthquake coverage if the deductible is expressed

in dollars.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Zone

Enter code: The earthquake zone (territory) associated with the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Retrofit Type

Enter text: The type of earthquake retrofit for the residence.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - % Masonry

Veneer

Enter percentage: The percentage of construction that is masonry veneer.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Form Number

Enter identifier: The form number used by the company for earthquake coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Form Date

Enter date: The edition date of the form used by the company for earthquake coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Earthquake - Premium

Enter amount: The premium for earthquake coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Employers Liability Limit

Enter limit: The limit amount for employers liability coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 19 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Employers Liability - # of

Employees

Enter number: The number of employees associated with employers liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Employers Liability - Form

Number

Enter identifier: The form number used by the company for employers liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Employers Liability - Form

Date

Enter date: The edition date of the form used by the company for employers liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Employers Liability -

Premium

Enter amount: The premium for employers liability coverage.

Form Page 2

Section Name

Field Name

Description

IDENTIFICATION SECTION

Agency Customer ID

Enter identifier: The customer's identification number assigned by the producer (e.g., agency or

brokerage).

IDENTIFICATION SECTION

Loc #

Enter number: The producer assigned number of the location.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Included

Check the box (if applicable): Indicates the equipment breakdown coverage is included. As

used here, not applicable in North Carolina.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Deductible Amount

Enter deductible: The deductible associated with equipment breakdown coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Limit

Enter limit: The limit associated with equipment breakdown coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 20 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Form Number

Enter identifier: The form number used by the company for equipment breakdown coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Form Date

Enter date: The edition date of the form used by the company for equipment breakdown

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Equipment Breakdown -

Premium

Enter amount: The premium for equipment breakdown coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fire Dept Service Charge -

Included

Check the box (if applicable): Indicates the fire department service charge coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fire Dept Service Charge -

Form Number

Enter identifier: The form number used by the company for fire department surcharge coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fire Dept Service Charge -

Form Date

Enter date: The edition date of the form used by the company for fire department surcharge

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fire Dept Service Charge -

Premium

Enter amount: The premium for fire department service charge coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

ACORD 70 (2012/03) rev. 08-20-2014

Page 21 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Flood - Building Limit

Enter limit: The building limit for flood coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Flood - Contents Limit

Enter limit: The contents limit for flood coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Flood - Form Number

Enter identifier: The form number used by the company for flood coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Flood - Form Date

Enter date: The edition date of the form used by the company for flood coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Flood - Premium

Enter amount: The premium for flood coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Excl

Liability

Check the box (if applicable): Indicates that liability is excluded from fungus and mold coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Excl

Prop Damage

Check the box (if applicable): Indicates that property damage is excluded from fungus and mold

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Property

Enter limit: The property limit for fungus and mold coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Liability

Enter limit: The liability limit for fungus and mold coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 22 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Form

Number

Enter identifier: The form number used by the company for fungus and mold coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Form

Date

Enter date: The edition date of the form used by the company for fungus and mold coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Fungus and Mold - Premium

Enter amount: The premium for fungus and mold coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability -

Included

Check the box (if applicable): Indicates the golf cart liability coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability - # of

Golf Carts

Enter number: The number of golf carts to be covered.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability -

Description

Enter text: The description of the golf carts.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability - Form

Number

Enter identifier: The form number used by the company for golf cart liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability - Form

Date

Enter date: The edition date of the form used by the company for golf cart liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts Liability -

Premium

Enter amount: The premium for golf cart liability coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 23 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts - Physical

Damage - Limit

Enter limit: The limit for golf cart physical damage coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts - Physical

Damage - Form Number

Enter identifier: The form number used by the company for golf cart physical damage coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts - Physical

Damage - Form Date

Enter date: The edition date of the form used by the company for golf cart physical damage

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Golf Carts - Physical

Damage - Premium

Enter amount: The premium for golf cart physical damage coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Identity Fraud Expense -

Included

Check the box (if applicable): Indicates identity fraud expense coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Identity Fraud Expense -

Form Number

Enter identifier: The form number used by the company for identity fraud expense coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Identity Fraud Expense -

Form Date

Enter date: The edition date of the form used by the company for identity fraud expense.

ACORD 70 (2012/03) rev. 08-20-2014

Page 24 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Identity Fraud Expense -

Premium

Enter amount: The premium for identity fraud expense coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Incidentals Farming Pers

Liab - Medical Payments

Enter Y for a Yes response. Input N for No response. Indicates if medical payments is

included in the incidental farming personal liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Incidentals Farming Pers

Liab - Form Number

Enter identifier: The form number used by the company for incidental farming coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Incidentals Farming Pers

Liab - Form Date

Enter date: The edition date of the form used by the company for incidental farming coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Incidentals Farming Pers

Liab - Premium

Enter amount: The premium for incidental farming coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In and Out Of

Vehicle - Total Limit

Enter limit: The total limit amount for increased coverage c special liability limit - electronic

apparatus in and out of vehicle.

ACORD 70 (2012/03) rev. 08-20-2014

Page 25 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In and Out Of

Vehicle - Increased Limit

Enter limit: The increased limit amount for increased coverage c special liability limit - electronic

apparatus in and out of vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In and Out Of

Vehicle - Form Number

Enter identifier: The form number used by the company for increased coverage c special liability

limit - electronic apparatus in and out of vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In and Out Of

Vehicle - Form Date

Enter date: The edition date of the form used by the company for increased coverage c special

liability limit - electronic apparatus in and out of vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In and Out Of

Vehicle - Premium

Enter amount: The premium for increased coverage C special liability limit - electronic apparatus

in and out of vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In Vehicle - Total

Limit

Enter limit: The total limit amount for increased coverage C special liability limit - electronic

apparatus in vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In Vehicle -

Increased Limit

Enter limit: The increased limit amount for increased coverage C special liability limit - electronic

apparatus in vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In Vehicle - Form

Number

Enter identifier: The form number used by the company for increased coverage c special liability

limit - electronic apparatus in vehicle.

ACORD 70 (2012/03) rev. 08-20-2014

Page 26 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In Vehicle - Form

Date

Enter date: The edition date of the form used by the company for increased coverage c special

liability limit - electronic apparatus in vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability Limits - Electrical

Apparatus In Vehicle -

Premium

Enter amount: The premium for increased coverage C special liability limit - electronic apparatus

in vehicle.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Guns - Total Limit

Enter limit: The total limit amount for increased coverage C special liability limit - guns.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Guns - Increased

Limit

Enter limit: The increased limit amount for increased coverage C special liability limit - guns.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Guns - Form

Number

Enter identifier: The form number used by the company for increased coverage C special liability

limit - guns.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Guns - Form Date

Enter date: The edition date of the form used by the company for increased coverage C special

liability limit - guns.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Guns - Premium

Enter amount: The premium for increased coverage C special liability limit - guns.

ACORD 70 (2012/03) rev. 08-20-2014

Page 27 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Money - Total

Limit

Enter limit: The total limit amount for increased coverage C special liability limit - money.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Money- Increased

Limit

Enter limit: The increased limit amount for increased coverage C special liability limit - money.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Money- Form

Number

Enter identifier: The form number used by the company for increased coverage C special liability

limit - money.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Money- Form Date

Enter date: The edition date of the form used by the company for increased coverage C special

liability limit - money.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Money- Premium

Enter amount: The premium for increased coverage C special liability limit - money.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Securities - Total

Limit

Enter limit: The total limit amount for increased coverage C special liability limit - securities.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Securities -

Increased Limit

Enter limit: The increased limit amount for increased coverage C special liability limit - securities.

ACORD 70 (2012/03) rev. 08-20-2014

Page 28 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Securities- Form

Number

Enter identifier: The form number used by the company for increased coverage C special liability

limit - securities.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Securities- Form

Date

Enter date: The edition date of the form used by the company for increased coverage C special

liability limit - securities.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Securities-

Premium

Enter amount: The premium for increased coverage C special liability limit - securities.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Silverware - Total

Limit

Enter limit: The total limit amount for increased coverage C special liability limit - silverware.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Silverware -

Increased Limit

Enter limit: The increased limit amount for increased coverage C special liability limit -silverware.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Silverware - Form

Number

Enter identifier: The form number used by the company for increased coverage C special liability

limit -silverware.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Silverware - Form

Date

Enter date: The edition date of the form used by the company for increased coverage C special

liability limit -silverware.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Increased Cov C Special

Liability - Silverware -

Premium

Enter amount: The premium for increased coverage C special liability limit -silverware.

ACORD 70 (2012/03) rev. 08-20-2014

Page 29 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Inflation Guard -

Percentage Increase

Enter percentage: The increase percentage for inflation guard coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Inflation Guard - Form

Number

Enter identifier: The form number used by the company for inflation guard coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Inflation Guard Form Date

Enter date: The edition date of the form used by the company for inflation guard coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Inflation Guard Premium

Enter amount: The premium for inflation guard coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Loss Assessment - Limit

Enter limit: The limit amount for loss assessment coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Loss Assessment - Form

Number

Enter identifier: The form number used by the company for loss assessment coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Loss Assessment - Form

Date

Enter date: The edition date of the form used by the company for loss assessment coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 30 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Loss Assessment - Premium

Enter amount: The premium for loss assessment coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Limit

Enter limit: The limit for mine subsidence coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Const

Material

Enter code: The type of construction material.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Property

Desc

Enter text: The description of the property.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Form

Number

Enter identifier: The form number used by the company for mine subsidence coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Form

Date

Enter date: The edition date of the form used by the company for mine subsidence coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Mine Subsidence - Premium

Enter amount: The premium for mine subsidence coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

ACORD 70 (2012/03) rev. 08-20-2014

Page 31 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Requires Incr

Contents

Check the box (if applicable): Indicates that increased contents is required for office,

professional private school, studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Incr Cont Not

Required

Check the box (if applicable): Indicates that increased contents is not required for office,

professional private school, studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Other Structures

Enter limit: The other structures limit for office, professional private school, studio - residence

premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Territory

Enter code: The territory for office, professional private school, studio - residence premises

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Structure Type

Enter code: The type of structure for office, professional private school, studio - residence

premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Med Pay

Enter Y for a Yes response. Input N for No response. Indicates if medical payments is

included in the office, professional private school, studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises -

Business/Structure

Description

Enter text: The description of the business or structure for office, professional private school,

studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Form Number

Enter identifier: The form number used by the company for office, professional private school,

studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Form Date

Enter date: The edition date of the form used by the company for office, professional private

school, studio - residence premises coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Office, Professional Private

School, Studio - Residence

Premises - Premium

Enter amount: The premium for office, professional private school, studio - residence premises

coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 32 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Other Structures - Individual

Structure - Limit

Enter limit: The limit for other structures - individual structure coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Other Structures - Individual

Structure - Structure Desc

Enter text: The description of the individual structure for other structures - individual structure

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Other Structures - Individual

Structure - Form Number

Enter identifier: The form number used by the company for other structures - individual structure

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Other Structures - Individual

Structure - Form Date

Enter date: The edition date of the form used by the company for other structures - individual

structure coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Other Structures - Individual

Structure - Premium

Enter amount: The premium for other structures - individual structure coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Plants, Shrubs & Trees -

Included

Check the box (if applicable): Indicates that plants, shrubs and trees coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Plants, Shrubs & Trees -

Limit

Enter limit: The limit for plants, shrubs and trees coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 33 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Plants, Shrubs & Trees -

Form Number

Enter identifier: The form number used by the company for plants, shrubs and trees coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Plants, Shrubs & Trees -

Form Date

Enter date: The edition date of the form used by the company for plants, shrubs and trees

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Plants, Shrubs & Trees -

Premium

Enter amount: The premium for plants, shrubs and trees coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Refrigerated Food Products

- Included

Check the box (if applicable): Indicates that refrigerated food products coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Refrigerated Food Products

- Limit

Enter amount: The limit for refrigerated food products coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Refrigerated Food Products

- Form Number

Enter identifier: The form number used by the company for refrigerated food products coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Refrigerated Food Products

- Form Date

Enter date: The edition date of the form used by the company for refrigerated food products

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Refrigerated Food Products

- Premium

Enter amount: The premium for refrigerated food products coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 34 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Contents - Included

Check the box (if applicable): Indicates that replacement cost - contents coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Contents - Form Number

Enter identifier: The form number used by the company for replacement cost - contents

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Contents - Form Date

Enter date: The edition date of the form used by the company for replacement cost - contents

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Contents - Premium

Enter amount: The premium for replacement cost - contents coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Dwelling - Included

Check the box (if applicable): Indicates that replacement cost - dwelling coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Dwelling - Form Number

Enter identifier: The form number used by the company for replacement cost - dwelling

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Dwelling - Form Date

Enter date: The edition date of the form used by the company for replacement cost - dwelling

coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 35 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost -

Dwelling - Premium

Enter amount: The premium for replacement cost - dwelling coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost - Full

Value - Included

Check the box (if applicable): Indicates that replacement cost full value coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost - Full

Value Cost - Max %

Enter percentage: The maximum percentage of increased replacement cost selected in

accordance with the company rules.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost - Full

Value - Form Number

Enter identifier: The form number used by the company for full value replacement cost

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost - Full

Value - Form Date

Enter date: The edition date of the form used by the company for full value replacement cost

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Replacement Cost - Full

Value - Premium

Enter amount: The premium for full value replacement cost coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Sink Hole Collapse -

Included

Check the box (if applicable): Indicates sink hole collapse coverage is included.

ACORD 70 (2012/03) rev. 08-20-2014

Page 36 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Sink Hole Collapse - Form

Number

Enter identifier: The form number used by the company for sink hole collapse.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Sink Hole Collapse - Form

Date

Enter date: The edition date of the form used by the company for sink hole collapse.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Sink Hole Collapse -

Premium

Enter amount: The premium for sink hole collapse.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unit-Owners Additions &

Alterations Special

Coverage - Included

Check the box (if applicable): Indicates unit owners additions and alterations special coverage is

included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unit-Owners Additions &

Alterations Special

Coverage - Limit

Enter limit: The limit for unit owners additions and alterations special coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unit-Owners Additions &

Alterations Special

Coverage - Form Number

Enter identifier: The form number used by the company for unit owners additions and alterations

special coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unit-Owners Additions &

Alterations Special

Coverage - Form Date

Enter date: The edition date of the form used by the company for unit owners additions and

alterations special coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unit-Owners Additions &

Alterations Special

Coverage - Premium

Enter amount: The premium for unit owners additions and alterations special coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 37 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unscheduled Jewelry,

Watches, Furs - Aggregate

Enter limit: The aggregate limit for unscheduled jewelry, watches and furs coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unscheduled Jewelry,

Watches, Furs - Increased

Enter limit: The increased limit for unscheduled jewelry, watches and furs coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unscheduled Jewelry,

Watches, Furs - Form

Number

Enter identifier: The form number used by the company for unscheduled jewelry, watches and

furs coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unscheduled Jewelry,

Watches, Furs - Form Date

Enter date: The edition date of the form used by the company for unscheduled jewelry, watches

and furs coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Unscheduled Jewelry,

Watches, Furs - Premium

Enter amount: The premium for unscheduled jewelry, watches and furs coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Water Backup of Sewers &

Drains - Included

Check the box (if applicable): Indicates water backup of sewers and drains coverage is included.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Water Backup of Sewers &

Drains - Limit

Enter limit: The limit for water backup of sewers and drains coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 38 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Water Backup of Sewers &

Drains - Form Number

Enter identifier: The form number used by the company for water backup of sewers and drains

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Water Backup of Sewers &

Drains - Form Date

Enter date: The edition date of the form used by the company for water backup of sewers and

drains coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Water Backup of Sewers &

Drains - Premium

Enter amount: The premium for water backup of sewers and drains coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Liability - Limit

Enter limit: The limit for watercraft liability coverage if you are not using a Watercraft application.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Liability - Form

Number

Enter identifier: The form number used by the company for watercraft liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Liability - Form

Date

Enter date: The edition date of the form used by the company for watercraft liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Liability -

Premium

Enter amount: The premium for watercraft liability coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

ACORD 70 (2012/03) rev. 08-20-2014

Page 39 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Physical Damage

Physical Damage - Limit

Enter limit: The limit for watercraft physical damage coverage if you are not using a Watercraft

application.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Physical Damage

- Form Number

Enter identifier: The form number used by the company for watercraft physical damage

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Physical Damage

- Form Date

Enter date: The edition date of the form used by the company for watercraft physical damage

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Watercraft Physical Damage

- Premium

Enter amount: The premium for watercraft physical damage coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Windstorm Exclusion - Yes

Check the box (if applicable): Indicates that windstorm exclusion applies.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Windstorm Exclusion - Form

Number

Enter identifier: The form number used by the company for windstorm exclusion.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Windstorm Exclusion - Form

Date

Enter date: The edition date of the form used by the company for windstorm exclusion.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Windstorm Exclusion -

Premium

Enter amount: The premium for windstorm exclusion.

ACORD 70 (2012/03) rev. 08-20-2014

Page 40 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Full Time Inservant - # of

Employees

Enter number: The number of employees associated with workers compensation full time In

Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Full Time Inservant - Form

Number

Enter identifier: The form number used by the company for workers compensation full time In

Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Full Time Inservant - Form

Date

Enter date: The edition date of the form used by the company for workers compensation full

time In Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Full Time Inservant -

Premium

Enter amount: The premium for workers compensation full time In Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Incidental - # of Employees

Enter number: The number of employees associated with workers compensation incidental

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Incidental - Form Number

Enter identifier: The form number used by the company for workers compensation incidental

coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Incidental - Form Date

Enter date: The edition date of the form used by the company for workers compensation

incidental coverage.

ACORD 70 (2012/03) rev. 08-20-2014

Page 41 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Incidental - Premium

Enter amount: The premium for workers compensation incidental coverage.

Form Page 3

Section Name

Field Name

Description

IDENTIFICATION SECTION

Agency Customer ID

Enter identifier: The customer's identification number assigned by the producer (e.g., agency or

brokerage).

IDENTIFICATION SECTION

Loc #

Enter number: The producer assigned number of the location.

OPTIONAL COVERAGES -

ENDORSEMENTS

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Part Time Outservant - # of

Employees

Enter number: The number of employees associated with workers compensation part time Out

Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Part Time Outservant - Form

Number

Enter identifier: The form number used by the company for workers compensation part time Out

Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Part Time Outservant - Form

Date

Enter date: The edition date of the form used by the company for workers compensation part

time Out Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Workers Compensation -

Part Time Outservant -

Premium

Enter amount: The premium for workers compensation part time Out Servant coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Coverage Description

Enter text: The description of the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Coverage Code

Enter code: The code associated with the type of coverage being requested.

ACORD 70 (2012/03) rev. 08-20-2014

Page 42 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Type Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Limit 1

Enter amount: The first limit associated with the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Applies To 1

Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,

etc.).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Limit 2

Enter amount: The second limit associated with the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Applies To 2

Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per

Occurrence, etc.).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Deductible

Enter amount: The deductible associated with the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Deductible Type

Enter code: The type of deductible (e.g. Flat, Percent, etc.)

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Territory

Enter code: The rating territory for the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Options

Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,

Rejected, etc.).

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Y/N

Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the

coverage, if applicable.

ACORD 70 (2012/03) rev. 08-20-2014

Page 43 of 67

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Coverage - Form Number

Enter identifier: The form number used by the company for the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Coverage - Form Date

Enter date: The edition date of the form used by the company for the coverage.

OPTIONAL COVERAGES -

ENDORSEMENTS

(continued)

Coverage - Premium

Enter amount: The premium for the coverage.

RATING / UNDERWRITING

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

RATING / UNDERWRITING

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

RATING / UNDERWRITING

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

RATING / UNDERWRITING

Construction - Masonry

Veneer

Check the box (if applicable): Indicates the construction of the structure is masonry veneer. As

used here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent

Masonry Veneer

Enter percentage: The percentage of the structure that is masonry veneer. As used here, this is

the primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Fire Resistive

Check the box (if applicable): Indicates the construction of the structure is fire resistive. As used

here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent Fire

Resistive

Enter percentage: The percentage of the structure that is fire resistive. As used here, this is the

primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Frame

Check the box (if applicable): Indicates the construction of the structure is frame. As used here,

this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent

Frame

Enter percentage: The percentage of the structure that is frame. As used here, this is the

primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Masonry

Check the box (if applicable): Indicates the construction of the structure is masonry. As used

here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent

Masonry

Enter percentage: The percentage of the structure that is masonry. As used here, this is the

primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - MFG Home

Check the box (if applicable): Indicates the construction of the structure is a manufactured

home. As used here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent

Manufactured

Enter percentage: The percentage of the structure that is manufactured. As used here, this is

the primary percentage of the primary construction type.

ACORD 70 (2012/03) rev. 08-20-2014

Page 44 of 67

RATING / UNDERWRITING

Construction - Steel

Check the box (if applicable): Indicates the construction of the structure is steel. As used here,

this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent Steel

Enter percentage: The percentage of the structure that is steel. As used here, this is the

primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Poured

Concrete

Check the box (if applicable): Indicates the construction of the structure is poured concrete. As

used here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent

Poured Concrete

Enter percentage: The percentage of the structure that is poured concrete. As used here, this is

the primary percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Log

Check the box (if applicable): Indicates the construction of the structure is log. As used here,

this is the primary construction type.

RATING / UNDERWRITING

Construction - Percent Log

Enter percentage: The percentage of the structure that is log. As used here, this is the primary

percentage of the primary construction type.

RATING / UNDERWRITING

Construction - Other

Check the box (if applicable): Indicates the construction of the structure is other than those

listed. As used here, this is the primary construction type.

RATING / UNDERWRITING

Construction - Other

Description

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

RATING / UNDERWRITING

Construction - Percent

Other

Enter percentage: The percentage of the structure that is other than those types listed. As used

here, this is the primary percentage of the primary construction type.

RATING / UNDERWRITING

Siding Type - Aluminum

Siding

Check the box (if applicable): Indicates the siding on the structure is aluminum.

RATING / UNDERWRITING

Siding Type - Percent

Aluminum Siding

Enter percentage: The percentage of the structure that is sided in aluminum.

RATING / UNDERWRITING

Siding Type - Stucco

Check the box (if applicable): Indicates the siding on the structure is stucco.

RATING / UNDERWRITING

Siding Type - Percent

Stucco

Enter percentage: The percentage of the structure that is sided in stucco.

RATING / UNDERWRITING

Siding Type - Vinyl

Siding/Plastic

Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic.

RATING / UNDERWRITING

Siding Type - Percent Vinyl

Siding/Plastic

Enter percentage: The percentage of the structure that is sided in vinyl or plastic.

ACORD 70 (2012/03) rev. 08-20-2014

Page 45 of 67

RATING / UNDERWRITING

Siding Type - Cedar Wood

Shingle

Check the box (if applicable): Indicates the siding on the structure is cedar or wood shingle.

RATING / UNDERWRITING

Siding Type - Percent Cedar

Wood Shingle

Enter percentage: The percentage of the structure that is sided in cedar or wood shingle.

RATING / UNDERWRITING

Siding Type - EIFSCB (on

Cinder Block)

Check the box (if applicable): Indicates the siding on the structure is exterior insulation and

finishing system on cinder block (EIFSCB).

RATING / UNDERWRITING

Siding Type - Percent

EIFSCB (on Cinder Block)

Enter percentage: The percentage of the structure that is sided in exterior insulation and

finishing system on cinder block (EIFSCB)

RATING / UNDERWRITING

Siding Type - EIFSS (on

Studs)

Check the box (if applicable): Indicates the siding on the structure is exterior insulation and

finishing system on studs (EIFSS).

RATING / UNDERWRITING

Siding Type - Percent EIFSS

(on Studs)

Enter percentage: The percentage of the structure that is sided in exterior insulation and

finishing system on studs (EIFSS).

RATING / UNDERWRITING

Siding Type - Other

Check the box (if applicable): Indicates the siding on the structure is other than those listed.

RATING / UNDERWRITING

Siding Type - Other

Description

Enter text: The type of siding on the structure.

RATING / UNDERWRITING

Siding Type - Percent Other

Siding

Enter percentage: The percentage of the structure that is sided in other than the those types

listed.

RATING / UNDERWRITING

Siding Type - Year EIFS

Installed

Enter year: The year the EIFS (exterior insulation and finishing system) was installed.

RATING / UNDERWRITING

Course of Construction -

Builders Risk

Check the box (if applicable): Indicates the structure is new construction (builders risk).

RATING / UNDERWRITING

Course of Construction -

Renovation

Check the box (if applicable): Indicates the structure is being renovated.

RATING / UNDERWRITING

Course of Construction -

Reconstruction

Check the box (if applicable): Indicates the structure is being reconstructed.

RATING / UNDERWRITING

Usage Type - Primary

Check the box (if applicable): Indicates that this is the primary residence.

RATING / UNDERWRITING

Usage Type - Secondary

Check the box (if applicable): Indicates that this is a secondary residence.

RATING / UNDERWRITING

Usage Type - Seasonal

Check the box (if applicable): Indicates that this is a seasonal residence.

RATING / UNDERWRITING

Usage Type - Farm

Check the box (if applicable): Indicates the residence is a farm.

RATING / UNDERWRITING

Usage Type - Other

Check the box (if applicable): Indicates the usage of the residence is other than those listed.

RATING / UNDERWRITING

Usage Type - Other

Description

Enter text: The description of the usage of the residence.

ACORD 70 (2012/03) rev. 08-20-2014

Page 46 of 67

RATING / UNDERWRITING

Occupancy - Owner

Check the box (if applicable): Indicates the residence is occupied by the owner.

RATING / UNDERWRITING

Occupancy - Tenant

Check the box (if applicable): Indicates the residence is occupied by tenants.

RATING / UNDERWRITING

Occupancy - Unoccupied

Check the box (if applicable): Indicates the residence is unoccupied.

RATING / UNDERWRITING

Occupancy - Vacant

Check the box (if applicable): Indicates the residence is vacant.

RATING / UNDERWRITING

Occupancy - Other

Check the box (if applicable): Indicates the residence is occupied by other than those listed.

RATING / UNDERWRITING

Occupancy - Other

Description

Enter text: The description of the inhabitants of the residence.

RATING / UNDERWRITING

Housekeeping Condition -

Excellent

Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is

excellent.

RATING / UNDERWRITING

Housekeeping Condition -

Good

Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is

good.

RATING / UNDERWRITING

Housekeeping Condition -

Average

Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is

average.

RATING / UNDERWRITING

Housekeeping Condition -

Below Average

Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is

below average.

RATING / UNDERWRITING

Distance To Tidal Water

Enter number: The distance to the nearest tidal water.

RATING / UNDERWRITING

Distance To Tidal Water

Miles

Check the box (if applicable): Indicates the distance to tidal water entered is in miles.

RATING / UNDERWRITING

Distance To Tidal Water

Feet

Check the box (if applicable): Indicates the distance to tidal water entered is in feet.

RATING / UNDERWRITING

Purchase Price

Enter amount: The purchase price of the residence.

RATING / UNDERWRITING

Purchase Date

Enter date: The date the residence was purchased (MM/DD/YYYY).

RATING / UNDERWRITING

Wiring - Copper

Check the box (if applicable): Indicates the residence has copper wiring.

RATING / UNDERWRITING

Wiring - Aluminum

Check the box (if applicable): Indicates the residence has aluminum wiring.

RATING / UNDERWRITING

Wiring - Knob & Tube

Check the box (if applicable): Indicates the residence has knob and tube wiring.

RATING / UNDERWRITING

Wiring - Last Inspected Date

Enter date: The date the wiring was last inspected.

RATING / UNDERWRITING

Protection Device Type -

Central/Smoke

Check the box (if applicable): Indicates the smoke alarm notifies an outside service that in turn

reports to the appropriate police or fire station.

RATING / UNDERWRITING

Protection Device Type -

Central/Temp

Check the box (if applicable): Indicates the temperature alarm reports to an outside service that

in turn reports to the appropriate police or fire station.

ACORD 70 (2012/03) rev. 08-20-2014

Page 47 of 67

RATING / UNDERWRITING

Protection Device Type -

Central/Burglar

Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.

RATING / UNDERWRITING

Protection Device Type -

Direct/Smoke

Check the box (if applicable): Indicates the smoke alarm reports directly to the appropriate fire

station.

RATING / UNDERWRITING

Protection Device Type -

Direct/Temp

Check the box (if applicable): Indicates the temperature alarm reports directly to the appropriate

fire station.

RATING / UNDERWRITING

Protection Device Type -

Direct/Burglar

Check the box (if applicable): Indicates the burglar alarm reports directly to the appropriate

police station.

RATING / UNDERWRITING

Protection Device Type -

Local/Smoke

Check the box (if applicable): Indicates that the smoke alarm sounds or appears on the

premises.

RATING / UNDERWRITING

Protection Device Type -

Local/Temp

Check the box (if applicable): Indicates the temperature alarm sounds or appears on the

premises.

RATING / UNDERWRITING

Protection Device Type -

Local/Burglar

Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the

premises.

RATING / UNDERWRITING

Door Lock - Deadbolt

Check the box (if applicable): Indicates that all exterior entry doors are fitted with deadbolt locks.

RATING / UNDERWRITING

Door Lock - Spring

Check the box (if applicable): Indicates that all exterior entry doors are fitted with spring locks.

RATING / UNDERWRITING

Door Lock - Other

Check the box (if applicable): Indicates that all exterior entry doors are fitted with locks other

than those listed.

RATING / UNDERWRITING

Door Lock - Description

Enter text: The type of locks on exterior entry doors.

RATING / UNDERWRITING

Sprinkler - Partial

Check the box (if applicable): Indicates the building is equipped with a partial fire sprinkler

system.

RATING / UNDERWRITING

Sprinkler - Full

Check the box (if applicable): Indicates the building is equipped with a full fire sprinkler system.

RATING / UNDERWRITING

Fire Extinguisher

Enter Y for a Yes response. Input N for No response. Indicate if the residence is equipped

with fire extinguisher(s).

RATING / UNDERWRITING

Distance to Hydrant

Enter number: The distance in feet from the nearest hydrant that supports the protection class

used.

RATING / UNDERWRITING

Distance to Fire Station

Enter number: The distance in miles from the nearest fire station that supports the protection

class used.

RATING / UNDERWRITING

# of Fire Divisions

Enter number: The number of fire divisions in the building.

RATING / UNDERWRITING

# Units Fire Div

Enter number: The number of units within a fire division.

RATING / UNDERWRITING

Territory

Enter code: The industry or company specific code that identifies the rating territory for this item.

The source of this code is individual insurer, Insurance Services Office or State Insurance

Department manuals.

ACORD 70 (2012/03) rev. 08-20-2014

Page 48 of 67

RATING / UNDERWRITING

Fire Premium Group

Enter identifier: The fire premium group used to determine the applicable rate based upon the

dwelling's location, construction, and fire protection code.

RATING / UNDERWRITING

Pers Liab Terr

Enter code: The personal liability territory code unique to owners, landlords and tenants needed

for liability coverage.

RATING / UNDERWRITING

EC Prem Group

Enter identifier: The premium group for extended coverage.

RATING / UNDERWRITING

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.

RATING / UNDERWRITING

Fire/EC Rate

Enter rate: The Fire and extended coverage rate used to develop a rate for additional coverage

of hazards or risks.

RATING / UNDERWRITING

Fire District Name

Enter text: The property's fire district name.

RATING / UNDERWRITING

Fire District Code

Enter code: The property's fire district code number which can be found in the individual states

manual pages.

RATING / UNDERWRITING

Electrical System Circuit

Breakers

Check the box (if applicable): Indicates the electrical panel uses circuit breakers.

RATING / UNDERWRITING

Electrical System Fuses

Check the box (if applicable): Indicates the electrical panel uses fuses.

RATING / UNDERWRITING

Number of Amps

Enter number: The electrical capacity of the wiring in amperes (amps).

RATING / UNDERWRITING

Date Heating System Last

Serviced

Enter date: The date (MM/DD/YYYY) the heating system was last serviced.

RATING / UNDERWRITING

Primary Heat

Enter text: The primary type of fuel/power used for heating.

RATING / UNDERWRITING

Primary Heat - None

Check the box (if applicable): Indicates the residence has no primary heat source.

RATING / UNDERWRITING

Secondary:

Enter text: The secondary type of fuel/power used for heating.

RATING / UNDERWRITING

None

Check the box (if applicable): Indicates the residence has no secondary heat source.

RATING / UNDERWRITING

Security - Visible from road

Check the box (if applicable): Indicates the structure is visible from the road.

RATING / UNDERWRITING

Security - Visible to

neighbors

Check the box (if applicable): Indicates the structure is visible from another dwelling that is

occupied during the day.

RATING / UNDERWRITING

Security - Occupied Daily

Check the box (if applicable): Indicates the residence usually has an adult home during the day.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

ACORD 70 (2012/03) rev. 08-20-2014

Page 49 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Year Built

Enter year: The year the structure was built (YYYY).

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Market Value

Enter amount: The current market value for which the residence could be sold.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Replacement Cost

Enter amount: The estimated total dollar amount required to rebuild the residence without

depreciation.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Total Living Area Sq Ft

Enter number: The residence's total square footage of living area (excluding basements).

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Basement Area

Enter number: The residence's total square footage of the basement.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Garage

Enter number: The residence's total square footage of the garage.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Breezeway

Enter number: The residence's total square footage of the breezeway.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fireplaces - Chimneys

Enter number: The total number of outside and inside chimneys in the residence.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fireplaces - Hearths

Enter number: The total number of hearths in the residence.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fireplaces - Pre-Fab

Enter number: The total number of prefabricated fireplaces in the residence.

ACORD 70 (2012/03) rev. 08-20-2014

Page 50 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fireplaces - Wood stove

insert

Enter number: The total number of wood stove inserts in the residence.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

# Rooms

Enter number: The total number of rooms in the residence, including full and half bathrooms.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

# Apartments

Enter number: The number of separate living units in structure.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

# Families

Enter number: The number of separate family units in the dwelling.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

# Household Residents

Enter number: The number of residents in the household.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

# Weeks Rented

Enter number: The number of weeks the unit on the residence premises is or will be rented to

others.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Tax Code

Enter code: The code which normally represents the location for which a surcharge is being

applied (city, county or state).

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Bldg Code Grade

Enter code: The industry code used to collect the building code effectiveness grade code. The

source of this code list is public protection classification or individual insurer rating manuals.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Building Code Grade -

Inspected Y/N

Enter Y for a Yes response. Input N for No response. Indicate if the structure has been

inspected specific to its Building Code effectiveness grade.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits -

Non-Smoker

Check the box (if applicable): Indicates that a non-smoking rating credit may apply to the

location.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits - Manned

Security

Check the box (if applicable): Indicates that a manned security rating credit may apply to the

location.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits - Lighting

Protection

Check the box (if applicable): Indicates that a lightning protection rating credit may apply to the

location.

ACORD 70 (2012/03) rev. 08-20-2014

Page 51 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits - Off

Premises Theft Exclusion

Check the box (if applicable): Indicates that an off premises theft exclusion rating credit may

apply to the location.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits - Other

Check the box (if applicable): Indicates that other rating credits may apply to the location.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating Credits - Other

Description

Enter text: The description of the other rating credits that may apply.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Dwelling

Check the box (if applicable): Indicates the type of residence being insured is a dwelling.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Apartment

Check the box (if applicable): Indicates the type of residence being insured is an apartment.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type -

Condominium

Check the box (if applicable): Indicates the type of residence being insured is a condominium or

multiplex.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type -

Townhouse

Check the box (if applicable): Indicates the type of residence being insured is a townhouse.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Rowhouse

Check the box (if applicable): Indicates the type of residence being insured is a row house.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Co-Op

Check the box (if applicable): Indicates the type of residence being insured is a cooperative.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Mobile

Home

Check the box (if applicable): Indicates the type of residence being insured is a mobile home.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Other

Check the box (if applicable): Indicates the type of residence being insured is other than those

listed.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Residence Type - Other

Description

Enter text: The description of the type of residence (e.g., apartment, condominium, etc.).

ACORD 70 (2012/03) rev. 08-20-2014

Page 52 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - None

Check the box (if applicable): Indicates there is no swimming pool on the premises.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Above

ground

Check the box (if applicable): Indicates the swimming pool is above ground.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - In-Ground

Check the box (if applicable): Indicates the swimming pool is in the ground.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Approved

Fence

Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an

approved height.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Diving

Board

Check the box (if applicable): Indicates the swimming pool has a diving board.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Slide

Check the box (if applicable): Indicates the swimming pool has a slide.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Other

Check the box (if applicable): Indicates there is additional information to describe the pool.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Swimming Pool - Other

Description

Enter text: The additional information to describe the swimming pool.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Dwelling Location - In City

Limits

Check the box (if applicable): Indicates the residence is within the city limits.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Dwelling Location - In Fire

District

Check the box (if applicable): Indicates the residence is within a fire district.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Dwelling Location - In

Protected Suburb

Check the box (if applicable): Indicates the residence is within a protected suburb.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Dwelling Location - Other

Check the box (if applicable): Indicates the residence is other than those listed.

ACORD 70 (2012/03) rev. 08-20-2014

Page 53 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Dwelling Location - Other

Description

Enter text: The description of the residence location.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Wind Class - Resistive

Check the box (if applicable): Indicates the wind class is resistive.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Wind Class - Semi-resistive

Check the box (if applicable): Indicates the wind class is semi-resistive.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Wind Class - Other

Check the box (if applicable): Indicates the wind class is other than those listed.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Wind Class - Other

Description.

Enter text: The description of the other wind class.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating - Class

Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is

class rating.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Rating - Specific

Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is

specific rating.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Foundation - Open

Check the box (if applicable): Indicates the foundation of the structure is open.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Foundation - Closed

Check the box (if applicable): Indicates the foundation of the structure is closed.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Foundation - None

Check the box (if applicable): Indicates there is no foundation on the structure.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Storm Shutters - A

Check the box (if applicable): Indicates the wind storm shutters are a class that provides

protection from wind and debris.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Storm Shutters - B

Check the box (if applicable): Indicates the wind storm shutters are a class that provides

protection from wind only.

ACORD 70 (2012/03) rev. 08-20-2014

Page 54 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Other

Check the box (if applicable): Indicates the wind storm shutters are a class other than those

listed.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Describe Other

Enter text: The description of the wind storm shutter class.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Hurricane Resistive Glass

Check the box (if applicable): Indicates the glass is resistive to hurricanes.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Storage Tank - None

Check the box (if applicable): Indicates there is no fuel storage tank on the premises.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Storage Tank - Indoors,

Above ground masonry

floor

Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground

on a masonry floor.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Storage Tank - Indoors,

Above ground no masonry

floor

Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground

not on a masonry floor.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Storage Tank -

Outdoors, Above ground

Check the box (if applicable): Indicates the fuel storage tank is outdoors and above ground.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Storage Tank -

Outdoors, Below ground

Check the box (if applicable): Indicates the fuel storage tank is outdoors and below ground.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Line Location -

Underground

Check the box (if applicable): Indicates the fuel line is underground.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Fuel Line Location -

Through foundation

Check the box (if applicable): Indicates the fuel line goes through the foundation.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Wiring - Part

Check the box (if applicable): Indicates if partial wiring improvements have been made since the

original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Wiring -

Complete

Check the box (if applicable): Indicates if complete wiring improvements have been made since

the original construction.

ACORD 70 (2012/03) rev. 08-20-2014

Page 55 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Wiring - Year

Enter year: The year the wiring improvements took place.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Plumbing -

Part

Check the box (if applicable): Indicates if partial plumbing improvements have been made since

the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Plumbing -

Complete

Check the box (if applicable): Indicates if complete plumbing improvements have been made

since the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Plumbing -

Year

Enter year: The year the plumbing improvements took place.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Heating - Part

Check the box (if applicable): Indicates if partial heating improvements have been made since

the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Heating -

Complete

Check the box (if applicable): Indicates if complete heating improvements have been made

since the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Heating - Year

Enter year: The year the heating improvements took place.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Roofing - Part

Check the box (if applicable): Indicates if partial roofing improvements have been made since

the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Roofing -

Complete

Check the box (if applicable): Indicates if complete roofing improvements have been made

since the original construction.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Roofing -

Year

Enter year: The year the roofing improvements took place.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Renovations - Exterior Paint

- Year

Enter year: The year the exterior of the structure was last painted.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Plumbing Condition -

Excellent

Check the box (if applicable): Indicates the plumbing system condition is excellent.

ACORD 70 (2012/03) rev. 08-20-2014

Page 56 of 67

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Plumbing Condition - Good

Check the box (if applicable): Indicates the plumbing system condition is good.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Plumbing Condition -

Average

Check the box (if applicable): Indicates the plumbing system condition is average.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Plumbing Condition - Below

Average

Check the box (if applicable): Indicates the plumbing system condition is below average.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Any Known Leaks

Enter Y for a Yes response. Input N for No response. Indicates there are known leaks in the

plumbing system.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Roof Condition - Excellent

Check the box (if applicable): Indicates the condition of the roof is excellent.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Roof Condition - Good

Check the box (if applicable): Indicates the condition of the roof is good.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Roof Condition - Average

Check the box (if applicable): Indicates the condition of the roof is average.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Roof Condition - Below

Average

Check the box (if applicable): Indicates the condition of the roof is below average.

HOMEOWNER / DWELLING

FIRE RATING /

UNDERWRITING

Roof Material

Enter code: The material used to construct the roof. Examples include:

* Composition (fiberglass, asphalt, etc.)

* Metal

* Poured

* Slate

* Tile

* Wood Shake

(Please note this list is not all inclusive)

MOBILE HOME RATING /

UNDERWRITING

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

MOBILE HOME RATING /

UNDERWRITING

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

ACORD 70 (2012/03) rev. 08-20-2014

Page 57 of 67

MOBILE HOME RATING /

UNDERWRITING

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home - New

Enter Y for a Yes response. Input N for No response. Indicates if the mobile home was

purchased new.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home - Year

Enter year: The model year of the mobile home.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home - Make

Enter text: The name of the manufacturer of the mobile home.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home - Model

Enter text: The manufacturer's model name for the mobile home.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home - ID Number

Enter identifier: The serial number for this mobile home.

MOBILE HOME RATING /

UNDERWRITING

Length

Enter number: The length of the mobile home expressed in feet.

MOBILE HOME RATING /

UNDERWRITING

Width

Enter number: The width of the mobile home expressed in feet.

MOBILE HOME RATING /

UNDERWRITING

Doublewide

Enter Y for a Yes response. Input N for No response. Indicates if the mobile home is a

doublewide construction.

MOBILE HOME RATING /

UNDERWRITING

Skirted

Enter Y for a Yes response. Input N for No response. Indicates if the mobile home is skirted.

MOBILE HOME RATING /

UNDERWRITING

# of Bedrooms

Enter number: The number of bedrooms in the mobile home.

MOBILE HOME RATING /

UNDERWRITING

Tie Down - None

Check the box (if applicable): Indicates the mobile home has no tie downs.

MOBILE HOME RATING /

UNDERWRITING

Tie Down - Full

Check the box (if applicable): Indicates the mobile home tie downs are full.

MOBILE HOME RATING /

UNDERWRITING

Tie Down - Chassis Only

Check the box (if applicable): Indicates the mobile home tie downs are chassis only.

MOBILE HOME RATING /

UNDERWRITING

Tie Down - Overtop Only

Check the box (if applicable): Indicates the mobile home tie downs are overtop only.

MOBILE HOME RATING /

UNDERWRITING

Permanent Connection -

Electricity

Check the box (if applicable): Indicates the mobile home has a permanent connection to

electricity.

MOBILE HOME RATING /

UNDERWRITING

Permanent Connection -

Water

Check the box (if applicable): Indicates the mobile home has a permanent connection to water.

ACORD 70 (2012/03) rev. 08-20-2014

Page 58 of 67

MOBILE HOME RATING /

UNDERWRITING

Permanent Connection -

Sewer

Check the box (if applicable): Indicates the mobile home has a permanent connection to the

sewer.

MOBILE HOME RATING /

UNDERWRITING

Cooking Location - End

Check the box (if applicable): Indicates the mobile home has a cooking location at the end of the

residence.

MOBILE HOME RATING /

UNDERWRITING

Cooking Location - Middle

Check the box (if applicable): Indicates the mobile home has a cooking location in the middle of

the residence.

MOBILE HOME RATING /

UNDERWRITING

Cooking Location - None

Check the box (if applicable): Indicates the mobile home has no cooking location.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home Foundation -

Continuous Masonry

Check the box (if applicable): Indicates the foundation is continuous masonry.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home Foundation -

Post & Pier

Check the box (if applicable): Indicates the foundation is post and pier.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home Foundation -

Other

Check the box (if applicable): Indicates the foundation is other than those listed.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home Foundation -

Other Description

Enter text: The foundation of the mobile home.

MOBILE HOME RATING /

UNDERWRITING

Mobile Home Park Name

Enter text: The name of the mobile home park.

MOBILE HOME RATING /

UNDERWRITING

Date park established

Enter date: The date the mobile home park was established.

MOBILE HOME RATING /

UNDERWRITING

Number of permanent

spaces in park

Enter number: The number of permanent spaces in the mobile home park.

MOBILE HOME RATING /

UNDERWRITING

Consecutive Months

Occupied Each Year

Enter number: The number of consecutive months the mobile home is occupied each year.

Form Page 4

Section Name

Field Name

Description

IDENTIFICATION SECTION

Agency Customer ID

Enter identifier: The customer's identification number assigned by the producer (e.g., agency or

brokerage).

IDENTIFICATION SECTION

Loc #

Enter number: The producer assigned number of the location.

ADDITIONAL INTEREST

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

ADDITIONAL INTEREST

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

ACORD 70 (2012/03) rev. 08-20-2014

Page 59 of 67

ADDITIONAL INTEREST

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

ADDITIONAL INTEREST

Interest Additional Insured

Check the box (if applicable): Indicates the additional interest type is an additional insured.

ADDITIONAL INTEREST

Lienholder

Check the box (if applicable): Indicates the additional interest type is a lien holder.

ADDITIONAL INTEREST

Loss Payee

Check the box (if applicable): Indicates the additional interest type is a loss payee.

ADDITIONAL INTEREST

Mortgagee

Check the box (if applicable): Indicates the additional interest type is a mortgagee.

ADDITIONAL INTEREST

Trustee

Check the box (if applicable): Indicates the additional interest type is a trustee.

ADDITIONAL INTEREST

Other

Check the box (if applicable): Indicates the additional interest is other than those listed.

ADDITIONAL INTEREST

Other Description

Enter text: The description of the other type of additional interest.

ADDITIONAL INTEREST

Rank:

Enter number: The ranking of 'this' additional interest when multiple additional interests are

associated with the same item.

ADDITIONAL INTEREST

Certificate Required

Check the box (if applicable): Indicates if the additional interest requires a Certificate of

Insurance.

ADDITIONAL INTEREST

Name And Address

Enter text: The additional interest's full name.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address line one.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address line two.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address city name.

ADDITIONAL INTEREST

Enter code: The additional interest's mailing address state or province code.

ADDITIONAL INTEREST

Enter code: The additional interest's mailing address postal code.

ADDITIONAL INTEREST

Enter code: The additional interest's country code.

ADDITIONAL INTEREST

Reference #:

Enter identifier: The loan number, account number or other controlling number that the

additional interest may have assigned the insured.

ADDITIONAL INTEREST

Interest in Item Number

Location:

Enter number: The producer assigned number of the location which has an additional interest.

ADDITIONAL INTEREST

Building:

Enter number: The producer assigned number of the building which has an additional interest.

ADDITIONAL INTEREST

Vehicle:

Enter number: The producer assigned number of the vehicle which has an additional interest.

ADDITIONAL INTEREST

Boat:

Enter number: The producer assigned number of the boat which has an additional interest.

ADDITIONAL INTEREST

Item Class

Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,

Contractors Equipment, etc.).

ACORD 70 (2012/03) rev. 08-20-2014

Page 60 of 67

ADDITIONAL INTEREST

Item

Enter number: The producer assigned number of the scheduled item which has an additional

interest.

ADDITIONAL INTEREST

Item Description:

Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list

the make, model and VIN number. For a scheduled item, list the description, such as three

carat diamond in six point setting.

ADDITIONAL INTEREST

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

ADDITIONAL INTEREST

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

ADDITIONAL INTEREST

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

ADDITIONAL INTEREST

Interest Additional Insured

Check the box (if applicable): Indicates the additional interest type is an additional insured.

ADDITIONAL INTEREST

Lienholder

Check the box (if applicable): Indicates the additional interest type is a lien holder.

ADDITIONAL INTEREST

Loss Payee

Check the box (if applicable): Indicates the additional interest type is a loss payee.

ADDITIONAL INTEREST

Mortgagee

Check the box (if applicable): Indicates the additional interest type is a mortgagee.

ADDITIONAL INTEREST

Trustee

Check the box (if applicable): Indicates the additional interest type is a trustee.

ADDITIONAL INTEREST

Other

Check the box (if applicable): Indicates the additional interest is other than those listed.

ADDITIONAL INTEREST

Other Description

Enter text: The description of the other type of additional interest.

ADDITIONAL INTEREST

Rank:

Enter number: The ranking of 'this' additional interest when multiple additional interests are

associated with the same item.

ADDITIONAL INTEREST

Certificate Required

Check the box (if applicable): Indicates if the additional interest requires a Certificate of

Insurance.

ADDITIONAL INTEREST

Name And Address

Enter text: The additional interest's full name.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address line one.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address line two.

ADDITIONAL INTEREST

Enter text: The additional interest's mailing address city name.

ADDITIONAL INTEREST

Enter code: The additional interest's mailing address state or province code.

ADDITIONAL INTEREST

Enter code: The additional interest's mailing address postal code.

ADDITIONAL INTEREST

Enter code: The additional interest's country code.

ADDITIONAL INTEREST

Reference #:

Enter identifier: The loan number, account number or other controlling number that the

additional interest may have assigned the insured.

ACORD 70 (2012/03) rev. 08-20-2014

Page 61 of 67

ADDITIONAL INTEREST

Interest in Item Number

Location:

Enter number: The producer assigned number of the location which has an additional interest.

ADDITIONAL INTEREST

Building:

Enter number: The producer assigned number of the building which has an additional interest.

ADDITIONAL INTEREST

Vehicle:

Enter number: The producer assigned number of the vehicle which has an additional interest.

ADDITIONAL INTEREST

Boat:

Enter number: The producer assigned number of the boat which has an additional interest.

ADDITIONAL INTEREST

Item Class

Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,

Contractors Equipment, etc.).

ADDITIONAL INTEREST

Item

Enter number: The producer assigned number of the scheduled item which has an additional

interest.

ADDITIONAL INTEREST

Item Description:

Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list

the make, model and VIN number. For a scheduled item, list the description, such as three

carat diamond in six point setting.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

#

Enter number: The number assigned to the item by the producer.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Property Description

Enter text: The full description of the item including serial numbers, if applicable.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Purchase / Appraisal Date

Enter date: The date on which the item described was either purchased or last appraised.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Amount of Insurance

Enter amount: The value (limit of liability) of the item described.

ACORD 70 (2012/03) rev. 08-20-2014

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PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

#

Enter number: The number assigned to the item by the producer.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Property Description

Enter text: The full description of the item including serial numbers, if applicable.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Purchase / Appraisal Date

Enter date: The date on which the item described was either purchased or last appraised.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Amount of Insurance

Enter amount: The value (limit of liability) of the item described.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Type of Change

Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or

I - Informational Only No Change. Various combinations of changes are permitted in one

submission. Use A to add an item that was not previously in the policy (e.g., add a vehicle,

add a coverage). Use D to delete an item (e.g., delete a vehicle, delete a driver). Use C to

change an item in the policy (e.g., change a deductible, change coverage limits). Use I to

identify a risk or other item that is not being changed but is related to another change on the

form. Example: When adding collision coverage to a vehicle, enter A in the type of change for

Collision. Enter I in the type of change for the Vehicle. Enter enough information to identify the

vehicle that is having coverage changed (e.g. year, make, model, body, VIN).

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

#

Enter number: The number assigned to the item by the producer.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Property Description

Enter text: The full description of the item including serial numbers, if applicable.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Purchase / Appraisal Date

Enter date: The date on which the item described was either purchased or last appraised.

ACORD 70 (2012/03) rev. 08-20-2014

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PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Amount of Insurance

Enter amount: The value (limit of liability) of the item described.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Unattended Car Coverage

(Stamps/Coins)

Check the box (if applicable): Indicates that unattended automobile coverage for stamps and

coins applies to a property class.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Broad Form Pair & Set

Coverage

Check the box (if applicable): Indicates that broad form pair and set coverage applies to a

property class.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Non-Mobile Organ Coverage

Check the box (if applicable): Indicates that non-mobile organ coverage applies to a property

class.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Safe Credit (Identify

Property, Safe Class, etc)

Check the box (if applicable): Indicates that safe credit applies to a property class.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

ACV Loss Settlement

Check the box (if applicable): Indicates the loss settlement basis is the actual cash value of the

item.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Replacement Cost Loss

Settlement

Check the box (if applicable): Indicates the loss settlement basis is the replacement cost of the

item.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Breakage Coverage

Check the box (if applicable): Indicates that breakage coverage applies to a property class.

PERSONAL INLAND

MARINE / SCHEDULE OF

PROPERTY

Blanket Coverage

Check the box (if applicable): Indicates that blanket coverage applies.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Boat Hull No:

Enter number: The producer assigned number for the watercraft.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

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Page 64 of 67

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Hull

Enter limit: The limit for boat (hull) coverage. This may include collision liability.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Outboard Motor 1

Enter limit: The limit for outboard motor coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Outboard Motor 2

Enter limit: The limit for outboard motor coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Portable Accessories

Enter limit: The limit for portable accessories (equipment not permanently attached to the boat)

coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Trailer

Enter limit: The limit for trailer coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Liability

Enter limit: The limit amount for bodily injury each accident or combined single limit liability (may

be called protection and indemnity).

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Medical Payments

Enter limit: The limit for medical payments for bodily injury to occupants of the boat coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Uninsured Boaters Liability

Enter limit: The each accident bodily injury liability limit or combined single limit for uninsured

boaters coverage.

WATERCRAFT COVERAGES

/ LIMITS OF LIABILITY

Deductible

Enter deductible: The deductible for boat (hull) coverage.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Add

Check the box (if applicable): Indicates if the type of change being requested is an add.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Change

Check the box (if applicable): Indicates if the type of change being requested is a change to an

existing piece of data.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Delete

Check the box (if applicable): Indicates if the type of change being request is a delete.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Policy Amount

Enter limit: The policy liability limit for personal umbrella coverage.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Retention

Enter amount: The amount of liability retained by the insured. Retention is usually expressed in

whole dollars, but can be a percentage.

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PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Other Coverages,

Automobile, Personal

Liability, Watercraft,

Recreational Vehicles

Enter text: The description of other underlying coverages.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Automobile BI

Enter limit: The bodily injury each person limit on the underlying automobile policy. As used

here, enter the bodily injury each accident limit in the combined single limit each accident field.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Automobile PD

Enter limit: The property damage each accident limit on the underlying automobile policy.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Automobile CSL

Enter limit: The combined single limit on the underlying automobile policy. As used here,

contains the combined single or bodily injury each accident limit.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Personal Liability

Enter limit: The liability limit on the underlying homeowners policy. As used here, this contains

the personal liability limit from the homeowners or dwelling fire policy.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Watercraft BI

Enter limit: The bodily injury each person limit on the underlying watercraft policy. As used here,

enter the bodily injury each accident limit in the combined single limit each accident field.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Watercraft PD

Enter limit: The property damage each accident limit on the underlying watercraft policy.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Watercraft CSL

Enter limit: The combined single limit on the underlying watercraft policy. As used here, contains

the combined single or bodily injury each accident limit.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Recreational Vehicles BI

Enter limit: The bodily injury each person limit on the underlying recreational vehicle policy. As

used here, enter the bodily injury each accident limit in the combined single limit each accident

field.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Recreational Vehicles PD

Enter limit: The property damage each accident limit on the underlying recreational vehicle

policy.

PERSONAL UMBRELLA

COVERAGES / LIMITS OF

LIABILITY

Recreational Vehicles CSL

Enter limit: The combined single limit on the underlying recreational vehicle policy. As used

here, contains the combined single or bodily injury each accident limit.

SIGNATURES

Producer's Signature /

Insured'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.

ACORD 70 (2012/03) rev. 08-20-2014

Page 66 of 67

SIGNATURES

Producer's Name (Please

Print)

Enter text: The name of the authorized representative of the producer, agency and/or broker

that signed the form.

SIGNATURES

State Producer License

Number

Enter identifier: The State License Number of the producer. As used here, this is required in

Florida.

SIGNATURES

Insured's Signature

Sign here: Accommodates the signature of the applicant or named insured.

SIGNATURES

Date

Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)

SIGNATURES

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.

ACORD 70 (2012/03) rev. 08-20-2014

Page 67 of 67