ACORD 75 (2013/09) - Insurance Binder

ACORD 75 (2013/09) - Insurance Binder
ACORD 75, Insurance Binder, addresses both Personal Lines and Commercial Lines risks, although most ACORD Personal Lines applications
contain a built-in binder.
Before issuing any binder, the following important considerations should be reviewed and considered carefully:
* A Binder (Cover Note is some states) is a temporary insurance contract which provides coverage in advance of the issuance of an insurance
policy.
* The improper use of binders has become a major cause of producers Errors and Omissions claims. It is imperative that only authorized people
prepare them. Preparation must be complete and accurate.
* All binders must conform to the state insurance code for the state in which the subject of insurance in located.
* The maximum and/or minimum term of a binder may be governed by state statute and/or company underwriting instructions. * At the end of the
binders specified term, all coverage expires unless a new binder has been issued or the expired binder has been replaced with a policy .
* The language in the binder must be precise. Do not use vague or all-encompassing terms which may imply coverages not intended, such as All
Risk. If possible, use the same language and terminology that will appear on policy.
* An agent may only issue binders which comply with the companys underwriting instructions (per company manual, agency agreement,
correspondence and/or company underwriter). If the authority is not in writing, the agent should obtain written authority. Most agency agreements
contain stated time frames within which the company must be notified of any risk bound.
* Generally, a broker cannot bind insurance. A broker may only exercise the authority extended by the company. It is recommended that
individual binders be issued for each company affording coverage.
* Most agency agreements dealing with surplus lines and specialty market contracts do not allow the agent or broker to bind coverage.
Authorization must be secured prior to binding.
* A binder provides coverage for a specified period. In most jurisdictions, a premium must be charged for this period unless the binder is replaced
by a policy. A deposit should be obtained when issuing a binder. A deposit premium may be required by some companies.
* Most companies prohibit issuing or extending binders where coverage has been refused or cancelled by any carrier.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer / agency.
ACORD 75 (2013/09) rev. 07-31-2013 P age 1 of 9
IDENTIFICATION SECTION
Phone No.
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax No.
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Insured
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.
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
Name of Insurance
Company
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
Binder #
Enter identifier: The number assigned to uniquely identify the binder.
IDENTIFICATION SECTION
Effective Date
Enter date: The date on which the terms and conditions of the binder commenced. This date
normally coincides with the effective date of the policy or of an endorsement to the policy.
IDENTIFICATION SECTION
Effective Time
Enter time: The time of the binder effective date that the binder becomes effective.
IDENTIFICATION SECTION
AM
Check the box (if applicable): Indicates the binder effective time is in the morning (AM).
IDENTIFICATION SECTION
PM
Check the box (if applicable): Indicates the binder effective time is in the afternoon or evening
(PM).
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will or have expired.
Certain state laws limit the terms of a binder, so this date may not coincide with the policy
expiration date.
IDENTIFICATION SECTION
12:01 AM
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
IDENTIFICATION SECTION
Noon
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
ACORD 75 (2013/09)
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IDENTIFICATION SECTION
This Binder is issued to
extend coverage in the
above named company per
expiring policy # (Checkbox)
Check the box (if applicable): Indicates the binder is issued to extend coverage on a policy
where renewal is not yet available.
IDENTIFICATION SECTION
Expiring Policy Number
Enter identifier: The policy number of the policy that is expiring.
IDENTIFICATION SECTION
Description Of Operations /
Vehicle / Property (Including
Location)
Enter text: The description of operations of the insured, vehicle information and usage, and, for
property exposures, location information. Examples include: Machine Tool Die Casters; 91
Chevy H10 Pick Up Truck - VIN C12345P8991, used for delivery; Location 1 - 123 North Main
St, Hartford, Ct. If the location is the same as the mailing address, and this address is properly
descriptive, state same as mailing address, rather than repeat the address.
COVERAGES
Basic
Check the box (if applicable): Indicates the type of policy / perils insured is basic.
COVERAGES
Broad
Check the box (if applicable): Indicates the type of policy / perils insured is broad.
COVERAGES
Spec
Check the box (if applicable): Indicates the type of policy / perils insured is special.
COVERAGES
Other Type of Insurance
One
Check the box (if applicable): Indicates the type of policy / perils insured is other than those
listed.
COVERAGES
Other Type of Insurance
Description One
Enter text: The description of the type of policy issued to the insured.
COVERAGES
Other Type of Insurance
Two
Check the box (if applicable): Indicates the type of policy / perils insured is other than those
listed.
COVERAGES
Other Type of Insurance
Description Two
Enter text: The description of the type of policy issued to the insured.
COVERAGES
Coverage/Forms
Enter text: The subjects of insurance that are being covered and any necessary location
information (e.g., Loc 1 Building Personal Property Dwelling).
COVERAGES
Deductible
Enter deductible: The deductible amount that is to apply to this subject of insurance.
COVERAGES
Enter percentage: The Coinsurance Percentage is the percentage of the total value of the
subject of insurance being insured. If the amount of insurance falls below this percentage, the
insured must share in the amount of the loss. This field should be completed even when writing
agreed amount coverage.
COVERAGES
Amount
Enter limit: The maximum amount of coverage provided for this subject of insurance or
premium-bearing option.
COVERAGES
Commercial General
Liability
Check the box (if applicable): Indicates the claims made or occurrence option applies for the
general liability policy.
COVERAGES
Claims Made
Check the box (if applicable): Indicates the claims made option applies on the general liability
policy.
ACORD 75 (2013/09)
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COVERAGES
Occur
Check the box (if applicable): Indicates the general liability policy, occurrence basis applies.
COVERAGES
Other General Liability
Coverages One
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGES
Other General Liability
Coverages Description One
Enter text: The description of other coverage (not the limit) on the general liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Other General Liability
Coverages Two
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGES
Other General Liability
Coverages Description Two
Enter text: The description of other coverage (not the limit) on the general liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Other General Liability
Coverages Three
Check the box (if applicable): Indicates other coverage not found on the form exists for the
general liability policy.
COVERAGES
Other General Liability
Coverages Description
Three
Enter text: The description of other coverage (not the limit) on the general liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Coverage/Forms
Enter text: The commercial lines classification code(s) and description of the class(es) for which
the binder is being issued. Include any form numbers. For Personal Lines enter the policy form
numbers.
COVERAGES
Retro Date For Claims Made
Enter date: The retroactive date you are requesting for the policy being applied for. This is the
proposed earliest date for which an occurrence could trigger coverage under a Claims Made
policy.
COVERAGES
Each Occurrence
Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate
limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Damage to Rented Premises
Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Med Exp (any one person)
Enter limit: The general liability, medical expense each person limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGES
Personal & Adv Injury
Enter limit: The general liability, personal and advertising injury limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGES
General Aggregate
Enter limit: The general liability, general aggregate limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
ACORD 75 (2013/09)
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COVERAGES
Products - Comp/Op Agg
Enter limit: The general liability, products and completed operations aggregate limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Any Auto
Check the box (if applicable): Indicates the commercial vehicle policy covers any auto.
COVERAGES
All Owned Autos
Check the box (if applicable): Indicates the commercial vehicle policy covers all owned autos.
COVERAGES
Scheduled Autos
Check the box (if applicable): Indicates the vehicle policy covers scheduled autos.
COVERAGES
Hired Autos
Check the box (if applicable): Indicates the vehicle policy covers hired autos.
COVERAGES
Non-Owned Autos
Check the box (if applicable): Indicates the vehicle policy covers non-owned autos.
COVERAGES
Other Vehicle Liability One
Check the box (if applicable): Indicates other coverage not found on the form exists for the
vehicle policy.
COVERAGES
Other Vehicle Liability
Description One
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGES
Other Vehicle Liability Two
Check the box (if applicable): Indicates other coverage not found on the form exists for the
vehicle policy.
COVERAGES
Other Vehicle Liability
Description Two
Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s).
COVERAGES
Coverage/Forms
Enter text: The description of any policy form numbers associated with vehicle liability coverage.
COVERAGES
Combined Single Limit
Enter limit: The vehicle combined single limit liability each accident amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Bodily Injury (per person)
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Bodily Injury (per accident)
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Property Damage
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Medical Payments
Enter limit: The medical payments per person limit.
COVERAGES
Personal Injury
Enter limit: The personal injury protection (PIP) limit amount.
COVERAGES
Uninsured Motorist
Enter limit: The uninsured motorists combined single limit per accident limit amount.
COVERAGES
Other Limit
Enter text: The description of the coverage.
COVERAGES
Other Limit Description
Enter limit: The limit amount of the other coverage.
ACORD 75 (2013/09)
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COVERAGES
Collision
Check the box (if applicable): Indicates the vehicle has collision coverage.
COVERAGES
Deductible
Enter deductible: The collision deductible amount.
COVERAGES
Other than Col
Check the box (if applicable): Indicates the vehicle has comprehensive coverage.
COVERAGES
Deductible
Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES
All Vehicles
Check the box (if applicable): Indicates collision coverage applies to all vehicles.
COVERAGES
Scheduled Vehicles
Check the box (if applicable): Indicates collision coverage applies to scheduled vehicles only.
COVERAGES
Coverage Forms
Enter text: The description of any policy form numbers associated with vehicle physical damage
coverage.
COVERAGES
Actual Cash Value
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the actual cash value or market value.
COVERAGES
Stated Amount
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is the stated amount.
COVERAGES
Other Amount
Check the box (if applicable): Indicates the valuation method used in determining the value of
the vehicle at the time of loss is other than those listed.
COVERAGES
Other Amount Description
Enter text: The valuation method used in determining the value of the vehicle at the time of loss.
COVERAGES
Amount
Enter limit: The limit associated with comprehensive and collision coverage is the actual cash
value of the vehicle, unless an amount is stated here. As used here, the combined sum of the
vehicles physical damage valuation.
COVERAGES
Any Auto
Check the box (if applicable): Indicates the Any Auto option applies to the commercial garage
liability policy.
COVERAGES
Other Garage Liability One
Check the box (if applicable): Indicates other coverage not found on the form exists for the
garage liability policy.
COVERAGES
Other Garage Liability
Description One
Enter text: The description of other coverage (not the limit) on the garage liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Other Garage Liability Two
Check the box (if applicable): Indicates other coverage not found on the form exists for the
garage liability policy.
COVERAGES
Other Garage Liability
Description Two
Enter text: The description of other coverage (not the limit) on the garage liability policy. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Coverage Forms
Enter text: The description of any policy form numbers associated with garage liability coverage.
ACORD 75 (2013/09)
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COVERAGES
Auto Only - Ea accident
Enter limit: The garage liability policy, auto only each accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, enter the limits found on the Garage declarations page.
COVERAGES
Other than auto only:
Enter text: The description of the coverage for other than auto only.
COVERAGES
Each Accident
Enter limit: The garage liability policy, other than auto only each accident limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Aggregate
Enter limit: The garage liability policy, other than auto only aggregate limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s).
COVERAGES
Umbrella Form
Check the box (if applicable): Indicates the information provided is for an umbrella policy.
COVERAGES
Other than Umbrella Form
Check the box (if applicable): Indicates the information provided is for a policy type other than
those listed.
COVERAGES
Coverage Forms
Enter text: The description of any policy form numbers associated with excess or umbrella
coverage. If the policy is other than umbrella box is checked, an additional reference should be
made in the Coverage / Forms section stating the kind of policy and to which coverages the
policy applies (e.g., Excess - Auto section).
COVERAGES
Retro Date For Claims Made
Enter date: The current retroactive date should be shown if the Umbrella is over a Claims Made
primary policy. If the current retroactive date is different from the proposed retroactive date, an
explanation must be provided.
COVERAGES
Each Occurrence
Enter limit: The excess umbrella liability each occurrence limit. As used here, enter the limits in
accordance with the policy declarations page
COVERAGES
Aggregate
Enter limit: The excess / umbrella liability aggregate limit should be listed as whole dollar
amount, as found on the policy declarations page. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES
Self-Insured Retention
Enter deductible: The excess or umbrella liability deductible or retention amount.
COVERAGES
Coverage/Forms
Enter text: The description of any policy form numbers associated with workers compensation
coverage.
COVERAGES
Per Statute
Check the box (if applicable): Indicates that workers compensation coverage is per statute.
COVERAGES
Per Statute Description
Enter text: The description of other coverage (not the limit) on the workers compensation and
employers liability policy. Any questions about appropriate limits or applicable policy coverage(s)
should be answered by the issuing insurer(s).
COVERAGES
E.L. Each Accident
Enter limit: The workers compensation and employers liability policy, employers liability each
accident limit amount. Any questions about appropriate limits or applicable policy coverage(s)
should be answered by the issuing insurer(s).
ACORD 75 (2013/09)
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COVERAGES
E.L. Disease Ea Employee
Enter limit: The workers compensation and employers liability policy, employers liability disease
each employee limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s).
COVERAGES
E.L. Disease Policy Limit
Enter limit: The workers compensation and employers liability policy, employers liability disease
policy limit amount. Any questions about appropriate limits or applicable policy coverage(s)
should be answered by the issuing insurer(s).
COVERAGES
Special Conditions/Other
Coverages
Enter text: The description of any additional information pertinent to the bound policies. Include
any special endorsements that are not specified in other sections of the binder. The area can
also be used to add other coverages, refer to other binders, acknowledge receipt of deposit
premium, or show fees, taxes and/or estimated premium
COVERAGES
Fees
Enter amount: The amount of fees associated with the policy.
COVERAGES
Taxes
Enter amount: The amount of taxes associated with the policy.
COVERAGES
Estimated Total Premium
Enter amount: The estimated total cost amount of the policy.
NAME AND ADDRESS
Name And Address
Enter text: The additional interest's full name.
NAME AND ADDRESS
Enter text: The additional interest's mailing address line one.
NAME AND ADDRESS
Enter text: The additional interest's mailing address line two.
NAME AND ADDRESS
Enter text: The additional interest's mailing address city name.
NAME AND ADDRESS
Enter code: The additional interest's mailing address state or province code.
NAME AND ADDRESS
Enter code: The additional interest's mailing address postal code.
NAME AND ADDRESS
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
NAME AND ADDRESS
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
NAME AND ADDRESS
Additional Insured
Check the box (if applicable): Indicates the interest type is an additional insured.
NAME AND ADDRESS
Other
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
NAME AND ADDRESS
Other Description
Enter text: The description of the type of interest in the item.
NAME AND ADDRESS
Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
NAME AND ADDRESS
Authorized Representative
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. As
used here, binders must be signed by authorized representatives of the issuing company.
Form Page 2
ACORD 75 (2013/09)
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Section Name
Field Name
Description
IDENTIFICATION SECTION
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ACORD 75 (2013/09)
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