ACORD 80 (2013/09) - Homeowner Application
ACORD 80 (2013/09) - Homeowner Application
ACORD 80, Homeowner Application, is used in the underwriting process for the homeowners line of business.
Form Page 1
Section Name
Field Name
Description
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 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
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
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the National Association of
Insurance Commissioners (NAIC).
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
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IDENTIFICATION SECTION
Policy #
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
Plan
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION
Facility Code
Enter identifier: The identification code used by assigned risk plans, FAIR plans and other
associations (only applicable in a few states). When using this field, also enter the name of the
facility in the carrier or plan field.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
STATUS OF TRANSACTION
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
STATUS OF TRANSACTION
Renew
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
STATUS OF TRANSACTION
Policy Change
Check the box (if applicable): Indicates the policy is being submitted for a policy change.
STATUS OF TRANSACTION
Other
Check the box (if applicable): Indicates the response expected from the company is a policy
other than those listed.
STATUS OF TRANSACTION
Other Description
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
STATUS OF TRANSACTION
Policy Change Effective
Date
Enter date: The date the policy status becomes effective. This date is used for policy statuses
of bound, change, and cancel. (MM/DD/YYYY)
STATUS OF TRANSACTION
Time
Enter time: The time the policy status becomes effective. The time is used for policy statuses of
bound, change, and cancel.
STATUS OF TRANSACTION
AM
Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm.
STATUS OF TRANSACTION
PM
Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or
later.
STATUS OF TRANSACTION
Date agent last inspected
property
Enter date: The date the producer last inspected the structure. (MM/DD/YYYY)
STATUS OF TRANSACTION
How long have you known
the applicant
Enter text: The length of time the named insured has been known by the producer.
APPLICANT INFORMATION
Applicant's Name (First,
Middle, Last)
Enter text: The named insured's given name.
APPLICANT INFORMATION
Enter text: The named insured's other given name initial.
APPLICANT INFORMATION
Enter text: The named insured's surname.
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APPLICANT INFORMATION
Date of Birth
Enter date: The date of birth of the insured. (MM/DD/YYYY)
APPLICANT INFORMATION
Social Security #
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION
Marital Status / Civil Union
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* F Fianc or Fiance
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union / Registered Domestic Partner
* U Unknown
* O Other
As used here, this field may not be utilized for policyholders applying for residential property
insurance in CA.
APPLICANT INFORMATION
Applicant's Mailing Address
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Address 2
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
City
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
State
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Zip
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
APPLICANT INFORMATION
Primary Phone #
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
APPLICANT INFORMATION
Secondary Phone #
Enter number: The named insured's secondary phone number.
APPLICANT INFORMATION
Primary e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION
Secondary e-mail address
Enter text: The named insured's secondary e-mail address.
APPLICANT INFORMATION
Years At Previous Address
Enter number: The number of years at the previous address.
APPLICANT INFORMATION
Previous Address
Enter text: The first address line of the previous residence address.
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APPLICANT INFORMATION
Address Continued
Enter text: The second address line of the previous residence.
APPLICANT INFORMATION
City
Enter text: The city of the previous residence.
APPLICANT INFORMATION
State
Enter code: The state or province code of the previous residence.
APPLICANT INFORMATION
Zip
Enter code: The postal code of the previous residence.
APPLICANT INFORMATION
Check if same as mailing
Address
Check the box (if applicable): Indicates the named insured's physical address is the same as the
mailing address.
APPLICANT INFORMATION
Owned
Check the box (if applicable): Indicates if the insured owns their current residence.
APPLICANT INFORMATION
Rented
Check the box (if applicable): Indicates if the insured rents their current residence.
APPLICANT INFORMATION
Current Residence
Enter text: The named insured's physical address line one. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter text: The named insured's physical address line two. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter text: The named insured's physical address city name. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter code: The named insured's physical address state or province code. As used here, this is
the current residence.
APPLICANT INFORMATION
Enter code: The named insured's physical address postal code. As used here, this is the current
residence.
APPLICANT INFORMATION
Date at Current Residence
Enter date: The date insured moved into their current residence. (MM/DD/YYYY)
APPLICANT INFORMATION
Yrs with Current Employer
Enter number: The number of years the named insured has been with their current employer.
APPLICANT INFORMATION
Applicant's Employer Name
And Address
Enter text: The employer name (business name if self-employed).
APPLICANT INFORMATION
Enter text: The first address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The second address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The city of the employer's physical address.
APPLICANT INFORMATION
Enter code: The state code of the employer's physical address.
APPLICANT INFORMATION
Enter code: The postal code of the employer's physical address.
APPLICANT INFORMATION
Applicant's Occupation
(State Nature of Business if
Self-Employed)
Enter text: The named insured's primary occupation or business activity.
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APPLICANT INFORMATION
Years in Current Occupation
Enter number: The number of years the named insured has been employed in their current
occupation.
APPLICANT INFORMATION
Years with Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
APPLICANT INFORMATION
Co-Applicant's Name (First,
Middle, Last)
Enter text: The named insured's given name.
APPLICANT INFORMATION
Enter text: The named insured's other given name initial.
APPLICANT INFORMATION
Enter text: The named insured's surname.
APPLICANT INFORMATION
Date of Birth
Enter date: The date of birth of the insured. (MM/DD/YYYY)
APPLICANT INFORMATION
Social Security #
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION
Marital Status / Civil Union
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* F Fianc or Fiance
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union / Registered Domestic Partner
* U Unknown
* O Other
As used here, this field may not be utilized for policyholders applying for residential property
insurance in CA.
APPLICANT INFORMATION
Check if same as Applicant
Check the box (if applicable): Indicates the co-named insured's mailing address is the same as
the named insured's mailing address.
APPLICANT INFORMATION
Co-Applicant's Address
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
APPLICANT INFORMATION
Primary Phone #
Enter number: The named insured's primary phone number.
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APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
APPLICANT INFORMATION
Secondary Phone #
Enter number: The named insured's secondary phone number.
APPLICANT INFORMATION
Primary e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION
Secondary e-mail address
Enter text: The named insured's secondary e-mail address.
APPLICANT INFORMATION
Yrs with Current Employer
Enter number: The number of years the named insured has been with their current employer.
APPLICANT INFORMATION
Co-Applicant's Employer
Name And Address
Enter text: The employer name (business name if self-employed).
APPLICANT INFORMATION
Enter text: The first address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The second address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The city of the employer's physical address.
APPLICANT INFORMATION
Enter code: The state code of the employer's physical address.
APPLICANT INFORMATION
Enter code: The postal code of the employer's physical address.
APPLICANT INFORMATION
Co-Applicant's Occupation
(State Nature of Business if
Self-Employed)
Enter text: The named insured's primary occupation or business activity.
APPLICANT INFORMATION
Years in Current Occupation
Enter number: The number of years the named insured has been employed in their current
occupation.
APPLICANT INFORMATION
Years with Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
COVERAGES / LIMITS OF
LIABILITY
LOC #
Enter number: The producer assigned number of the location.
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
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.
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COVERAGES / LIMITS OF
LIABILITY
Personal Property Limit
Enter limit: The limit associated with personal property coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Property
Premiums
Enter amount: The premium associated with personal property coverage.
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
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
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.
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
Coverage Description
Enter text: The description of the coverage.
COVERAGES / LIMITS OF
LIABILITY
Limit 1
Enter amount: The first limit associated with the coverage.
COVERAGES / LIMITS OF
LIABILITY
Premium
Enter amount: The premium for the coverage.
COVERAGES / LIMITS OF
LIABILITY
Form #
Enter code: Indicates the policy form being used (e.g. HO-2, HO-4, etc.)
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost - Full
Value - Included
Check the box (if applicable): Indicates that replacement cost full value coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Max %
Enter percentage: The maximum percentage of increased replacement cost selected in
accordance with the company rules.
ACORD 80 (2013/09) rev. 08-20-2014
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COVERAGES / LIMITS OF
LIABILITY
Premium
Enter amount: The premium for full value replacement cost coverage.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Dwelling - Included
Check the box (if applicable): Indicates that replacement cost - dwelling coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Dwelling - Premium
Enter amount: The premium for replacement cost - dwelling coverage.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Contents - Included
Check the box (if applicable): Indicates that replacement cost - contents coverage is included.
COVERAGES / LIMITS OF
LIABILITY
Replacement Cost -
Contents - Premium
Enter amount: The premium for replacement cost - contents coverage.
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
Base Type
Enter code: The deductible type (e.g. flat, percentage) for the base deductible.
DEDUCTIBLES
Wind / Hail Amount
Enter deductible: The wind / hail deductible amount if the deductible is expressed as a dollar
amount.
DEDUCTIBLES
Wind / Hail Percentage
Enter percentage: The wind / hail percentage deductible if the deductible is expressed as a
percentage.
DEDUCTIBLES
Wind / Hail Type
Enter code: The deductible type (e.g. flat, percentage) for the wind / hail 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
Theft Type
Enter code: The deductible type (e.g. flat, percentage) for the theft deductible.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
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 Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
DEDUCTIBLES
Named Hurricane Amount
Enter deductible: The named hurricane deductible amount if the deductible is expressed as a
dollar amount. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Named Hurricane
Percentage
Enter percentage: The named hurricane percentage deductible if the deductible is expressed as
a percentage. As used here, in North Carolina, this is the named storm percentage deductible.
ACORD 80 (2013/09) rev. 08-20-2014
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DEDUCTIBLES
Named Hurricane Type
Enter code: The deductible type (e.g. flat, percentage) for the named hurricane deductible. As
used here, in North Carolina, this is the named storm percentage deductible.
DEDUCTIBLES
Annual Hurricane Amount
Enter deductible: The annual hurricane deductible amount if the deductible is expressed as a
dollar amount. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Annual Hurricane
Percentage
Enter percentage: The annual hurricane percentage deductible if the deductible is expressed as
a percentage. As used here, this is not applicable in North Carolina.
DEDUCTIBLES
Annual Hurricane Type
Enter code: The deductible type (e.g. flat, percentage) for the annual hurricane deductible. As
used here, this is not applicable in North Carolina.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
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 Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
DEDUCTIBLES
Other
Enter text: The coverage associated with the deductible you are entering.
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 Type
Enter code: The deductible type (e.g. flat, percentage) for the other deductible.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
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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).
PAYMENT PLAN
Billing Account #
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.
PAYMENT PLAN
Deposit Amount $
Enter amount: The amount of the premium received as a deposit.
PAYMENT PLAN
Est Total Premium $
Enter amount: The estimated total cost amount of the policy.
PAYMENT PLAN
Direct Bill - Policy
Check the box (if applicable): Indicates if the policy is to be direct billed.
PAYMENT PLAN
Direct Bill - Acct
Check the box (if applicable): Indicates if the account is to be direct billed.
PAYMENT PLAN
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer / agency billed.
PAYMENT PLAN
Full Pay
Check the box (if applicable): Indicates a full payment will be made on the policy.
PAYMENT PLAN
Annual
Check the box (if applicable): Indicates the policy will be paid annually.
PAYMENT PLAN
Semi-Annual
Check the box (if applicable): Indicates the policy will be paid semi-annually.
PAYMENT PLAN
Quarterly
Check the box (if applicable): Indicates the policy will be paid quarterly.
PAYMENT PLAN
Bi-Monthly
Check the box (if applicable): Indicates the policy will be paid bi-monthly.
PAYMENT PLAN
Monthly
Check the box (if applicable): Indicates the policy will be paid monthly.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those
listed.
PAYMENT PLAN
Other Description
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
PAYMENT PLAN
Payment Method - Cash
Check the box (if applicable): Indicates the invoice will be paid in cash.
PAYMENT PLAN
Check
Check the box (if applicable): Indicates the invoice will be paid by check.
PAYMENT PLAN
Credit Card
Check the box (if applicable): Indicates the invoice will be paid by credit card. As used here, this
is not applicable in North Carolina.
PAYMENT PLAN
EFT
Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer
(EFT).
PAYMENT PLAN
Payroll Deduction
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction.
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PAYMENT PLAN
Pre-authorization
Draft/Check (PAC)
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or
draft.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the invoice will be paid by a means other than those
listed.
PAYMENT PLAN
Other Description
Enter text: The method the invoice will be paid.
PAYMENT PLAN
Agent
Check the box (if applicable): Indicates if the policy paper should be sent to the producer.
PAYMENT PLAN
Insured
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the
named insured.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the
agent or applicant.
PAYMENT PLAN
Other Description
Enter text: The description to whom the policy paper should be mailed.
PAYMENT PLAN
Payor Insured
Check the box (if applicable): Indicates the payor of the policy is the insured.
PAYMENT PLAN
Mortgagee
Check the box (if applicable): Indicates the payor of the policy is the mortgagee.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the payor of the policy is other than those listed.
PAYMENT PLAN
Other Description
Enter text: The description of the payor of the policy.
PAYMENT PLAN
Premium Financed? Y/N
Enter Y for a Yes response. Input N for No response. Indicates if the premium has been
financed.
PAYMENT PLAN
Finance Company
Enter text: The name of the company financing the premium, if applicable.
RATING / UNDERWRITING
LOC #
Enter number: The producer assigned number of the location.
RATING / UNDERWRITING
Masonry Veneer (checkbox)
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
Percent Masonry Veneer
(checkbox)
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
Frame (checkbox)
Check the box (if applicable): Indicates the construction of the structure is frame. As used here,
this is the primary construction type.
RATING / UNDERWRITING
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
Masonry (checkbox)
Check the box (if applicable): Indicates the construction of the structure is masonry. As used
here, this is the primary construction type.
RATING / UNDERWRITING
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.
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RATING / UNDERWRITING
Other (checkbox)
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
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
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
Aluminum Siding
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is aluminum.
RATING / UNDERWRITING
Percent Aluminum Siding
Enter percentage: The percentage of the structure that is sided in aluminum.
RATING / UNDERWRITING
Stucco (checkbox)
Check the box (if applicable): Indicates the siding on the structure is stucco.
RATING / UNDERWRITING
Percent Stucco
Enter percentage: The percentage of the structure that is sided in stucco.
RATING / UNDERWRITING
Vinyl Siding / Plastic
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is vinyl or plastic.
RATING / UNDERWRITING
Percent Vinyl Siding /
Plastic
Enter percentage: The percentage of the structure that is sided in vinyl or plastic.
RATING / UNDERWRITING
Cedar Wood Shingle
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is cedar or wood shingle.
RATING / UNDERWRITING
Percent Cedar Wood
Shingle
Enter percentage: The percentage of the structure that is sided in cedar or wood shingle.
RATING / UNDERWRITING
EIFSCB (on Cinder Block)
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and
finishing system on cinder block (EIFSCB).
RATING / UNDERWRITING
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
EIFSS (on Studs)
(checkbox)
Check the box (if applicable): Indicates the siding on the structure is exterior insulation and
finishing system on studs (EIFSS).
RATING / UNDERWRITING
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
Other (checkbox)
Check the box (if applicable): Indicates the siding on the structure is other than those listed.
ACORD 80 (2013/09) rev. 08-20-2014
Page 12 of 46
RATING / UNDERWRITING
Other Description
Enter text: The type of siding on the structure.
RATING / UNDERWRITING
Percent Other Siding
Enter percentage: The percentage of the structure that is sided in other than the those types
listed.
RATING / UNDERWRITING
Year EIFS Installed
Enter year: The year the EIFS (exterior insulation and finishing system) was installed.
RATING / UNDERWRITING
Primary (checkbox)
Check the box (if applicable): Indicates that this is the primary residence.
RATING / UNDERWRITING
Secondary (checkbox)
Check the box (if applicable): Indicates that this is a secondary residence.
RATING / UNDERWRITING
Seasonal (checkbox)
Check the box (if applicable): Indicates that this is a seasonal residence.
RATING / UNDERWRITING
Farm (checkbox)
Check the box (if applicable): Indicates the residence is a farm.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the usage of the residence is other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the usage of the residence.
RATING / UNDERWRITING
Builders Risk (checkbox)
Check the box (if applicable): Indicates the structure is new construction (builders risk).
RATING / UNDERWRITING
Renovation (checkbox)
Check the box (if applicable): Indicates the structure is being renovated.
RATING / UNDERWRITING
Reconstruction (checkbox)
Check the box (if applicable): Indicates the structure is being reconstructed.
RATING / UNDERWRITING
Owner (checkbox)
Check the box (if applicable): Indicates the residence is occupied by the owner.
RATING / UNDERWRITING
Tenant (checkbox)
Check the box (if applicable): Indicates the residence is occupied by tenants.
RATING / UNDERWRITING
Unoccupied (checkbox)
Check the box (if applicable): Indicates the residence is unoccupied.
RATING / UNDERWRITING
Vacant (checkbox)
Check the box (if applicable): Indicates the residence is vacant.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the residence is occupied by other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the inhabitants of the residence.
RATING / UNDERWRITING
Residence Type- Dwelling
(checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a dwelling.
RATING / UNDERWRITING
Apartment (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is an apartment.
RATING / UNDERWRITING
Condominium (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a condominium or
multiplex.
RATING / UNDERWRITING
Townhouse (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a townhouse.
RATING / UNDERWRITING
Rowhouse (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a row house.
RATING / UNDERWRITING
Co-Op (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is a cooperative.
ACORD 80 (2013/09) rev. 08-20-2014
Page 13 of 46
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the type of residence being insured is other than those
listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the type of residence (e.g., apartment, condominium, etc.).
RATING / UNDERWRITING
Housekeeping Condition -
Excellent (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
excellent.
RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the evaluation of the interior upkeep of the residence is
below average.
RATING / UNDERWRITING
Plumbing Condition -
Excellent (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is excellent.
RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the plumbing system condition is below average.
RATING / UNDERWRITING
Any Known Leaks? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates there are known leaks in the
plumbing system.
RATING / UNDERWRITING
Roof Condition - Excellent
(checkbox)
Check the box (if applicable): Indicates the condition of the roof is excellent.
RATING / UNDERWRITING
Good (checkbox)
Check the box (if applicable): Indicates the condition of the roof is good.
RATING / UNDERWRITING
Average (checkbox)
Check the box (if applicable): Indicates the condition of the roof is average.
RATING / UNDERWRITING
Below Average (checkbox)
Check the box (if applicable): Indicates the condition of the roof is below average.
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)
RATING / UNDERWRITING
Distance To Tidal Water
Enter number: The distance to the nearest tidal water.
RATING / UNDERWRITING
Miles (checkbox)
Check the box (if applicable): Indicates the distance to tidal water entered is in miles.
ACORD 80 (2013/09) rev. 08-20-2014
Page 14 of 46
RATING / UNDERWRITING
Feet (checkbox)
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
Security - Visible from road
(checkbox)
Check the box (if applicable): Indicates the structure is visible from the road.
RATING / UNDERWRITING
Visible to neighbors
(checkbox)
Check the box (if applicable): Indicates the structure is visible from another dwelling that is
occupied during the day.
RATING / UNDERWRITING
Occupied Daily (checkbox)
Check the box (if applicable): Indicates the residence usually has an adult home during the day.
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
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.
RATING / UNDERWRITING
Central / Burglar
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
RATING / UNDERWRITING
Direct / Smoke
Check the box (if applicable): Indicates the smoke alarm reports directly to the appropriate fire
station.
RATING / UNDERWRITING
Direct / Temp
Check the box (if applicable): Indicates the temperature alarm reports directly to the appropriate
fire station.
RATING / UNDERWRITING
Direct / Burglar
Check the box (if applicable): Indicates the burglar alarm reports directly to the appropriate
police station.
RATING / UNDERWRITING
Local / Smoke
Check the box (if applicable): Indicates that the smoke alarm sounds or appears on the
premises.
RATING / UNDERWRITING
Local / Temp
Check the box (if applicable): Indicates the temperature alarm sounds or appears on the
premises.
RATING / UNDERWRITING
Local / Burglar
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
RATING / UNDERWRITING
Distance to Hydrant Feet
Enter number: The distance in feet from the nearest hydrant that supports the protection class
used.
RATING / UNDERWRITING
Distance to Fire Station
Miles
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
Deadbolt (checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with deadbolt locks.
ACORD 80 (2013/09) rev. 08-20-2014
Page 15 of 46
RATING / UNDERWRITING
Spring (checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with spring locks.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that all exterior entry doors are fitted with locks other
than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The type of locks on exterior entry doors.
RATING / UNDERWRITING
Sprinkler: Partial (checkbox)
Check the box (if applicable): Indicates the building is equipped with a partial fire sprinkler
system.
RATING / UNDERWRITING
Full (checkbox)
Check the box (if applicable): Indicates the building is equipped with a full fire sprinkler system.
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 Extinguisher (Y / N):
Enter Y for a Yes response. Input N for No response. Indicate if the residence is equipped
with fire extinguisher(s).
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.
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
Primary Heat
Enter text: The primary type of fuel/power used for heating.
RATING / UNDERWRITING
None (checkbox)
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 (checkbox)
Check the box (if applicable): Indicates the residence has no secondary heat source.
RATING / UNDERWRITING
Date Heating System Last
Serviced
Enter date: The date (MM/DD/YYYY) the heating system was last serviced.
RATING / UNDERWRITING
Copper (checkbox)
Check the box (if applicable): Indicates the residence has copper wiring.
RATING / UNDERWRITING
Aluminum (checkbox)
Check the box (if applicable): Indicates the residence has aluminum wiring.
RATING / UNDERWRITING
Knob & Tube (checkbox)
Check the box (if applicable): Indicates the residence has knob and tube wiring.
RATING / UNDERWRITING
Last Inspected Date
Enter date: The date the wiring was last inspected.
RATING / UNDERWRITING
Circuit Breakers (checkbox)
Check the box (if applicable): Indicates the electrical panel uses circuit breakers.
RATING / UNDERWRITING
Fuses (checkbox)
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).
ACORD 80 (2013/09) rev. 08-20-2014
Page 16 of 46
RATING / UNDERWRITING
Year Built
Enter year: The year the structure was built (YYYY).
RATING / UNDERWRITING
Market Value ($)
Enter amount: The current market value for which the residence could be sold.
RATING / UNDERWRITING
Replacement Cost ($)
Enter amount: The estimated total dollar amount required to rebuild the residence without
depreciation.
RATING / UNDERWRITING
Total Living Area Sq Ft
Enter number: The residence's total square footage of living area (excluding basements).
RATING / UNDERWRITING
Basement Area
Enter number: The residence's total square footage of the basement.
RATING / UNDERWRITING
Garage Area
Enter number: The residence's total square footage of the garage.
RATING / UNDERWRITING
Breezeway Area
Enter number: The residence's total square footage of the breezeway.
RATING / UNDERWRITING
# Rooms
Enter number: The total number of rooms in the residence, including full and half bathrooms.
RATING / UNDERWRITING
# Apartments
Enter number: The number of separate living units in structure.
RATING / UNDERWRITING
# Weeks Rented
Enter number: The number of weeks the unit on the residence premises is or will be rented to
others.
RATING / UNDERWRITING
# Families
Enter number: The number of separate family units in the dwelling.
RATING / UNDERWRITING
# Household Residents
Enter number: The number of residents in the household.
RATING / UNDERWRITING
Tax Code
Enter code: The code which normally represents the location for which a surcharge is being
applied (city, county or state).
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.
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.
RATING / UNDERWRITING
Fireplaces - Chimneys
Enter number: The total number of outside and inside chimneys in the residence. As used here,
enter '0' for none.
RATING / UNDERWRITING
Hearths
Enter number: The total number of hearths in the residence. As used here, enter '0' for none.
RATING / UNDERWRITING
Pre-Fab
Enter number: The total number of prefabricated fireplaces in the residence. As used here,
enter '0' for none.
RATING / UNDERWRITING
Wood stove insert
Enter number: The total number of wood stove inserts in the residence. As used here, enter '0'
for none.
RATING / UNDERWRITING
Rating Credits -
Non-Smoker (checkbox)
Check the box (if applicable): Indicates that a non-smoking rating credit may apply to the
location.
RATING / UNDERWRITING
Manned Security (checkbox)
Check the box (if applicable): Indicates that a manned security rating credit may apply to the
location.
ACORD 80 (2013/09) rev. 08-20-2014
Page 17 of 46
RATING / UNDERWRITING
Lightning Protection
(checkbox)
Check the box (if applicable): Indicates that a lightning protection rating credit may apply to the
location.
RATING / UNDERWRITING
Off Premises Theft
Exclusion (checkbox)
Check the box (if applicable): Indicates that an off premises theft exclusion rating credit may
apply to the location.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that other rating credits may apply to the location.
RATING / UNDERWRITING
Other Description
Enter text: The description of the other rating credits that may apply.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates that other rating credits may apply to the location.
RATING / UNDERWRITING
Other Description
Enter text: The description of the other rating credits that may apply.
RATING / UNDERWRITING
Swimming Pool - None
(checkbox)
Check the box (if applicable): Indicates there is no swimming pool on the premises.
RATING / UNDERWRITING
Above ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is above ground.
RATING / UNDERWRITING
In-Ground (checkbox)
Check the box (if applicable): Indicates the swimming pool is in the ground.
RATING / UNDERWRITING
Approved Fence (checkbox)
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an
approved height.
RATING / UNDERWRITING
Diving Board (checkbox)
Check the box (if applicable): Indicates the swimming pool has a diving board.
RATING / UNDERWRITING
Slide (checkbox)
Check the box (if applicable): Indicates the swimming pool has a slide.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates there is additional information to describe the pool.
RATING / UNDERWRITING
Other Description
(checkbox)
Enter text: The additional information to describe the swimming pool.
RATING / UNDERWRITING
Dwelling Location - In City
Limits (checkbox)
Check the box (if applicable): Indicates the residence is within the city limits.
RATING / UNDERWRITING
In Fire District (checkbox)
Check the box (if applicable): Indicates the residence is within a fire district.
RATING / UNDERWRITING
In Protected Suburb
(checkbox)
Check the box (if applicable): Indicates the residence is within a protected suburb.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the residence is other than those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the residence location.
RATING / UNDERWRITING
Rating- Class (checkbox)
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is
class rating.
RATING / UNDERWRITING
Specific (checkbox)
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is
specific rating.
ACORD 80 (2013/09) rev. 08-20-2014
Page 18 of 46
RATING / UNDERWRITING
Foundation - Open
(checkbox)
Check the box (if applicable): Indicates the foundation of the structure is open.
RATING / UNDERWRITING
Closed (checkbox)
Check the box (if applicable): Indicates the foundation of the structure is closed.
RATING / UNDERWRITING
None (checkbox)
Check the box (if applicable): Indicates there is no foundation on the structure.
RATING / UNDERWRITING
Fuel Storage Tank - None
(checkbox)
Check the box (if applicable): Indicates there is no fuel storage tank on the premises.
RATING / UNDERWRITING
Indoors, Above ground
masonry floor (checkbox)
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground
on a masonry floor.
RATING / UNDERWRITING
Indoors, Above ground no
masonry floor (checkbox)
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground
not on a masonry floor.
RATING / UNDERWRITING
Outdoors, Above ground
(checkbox)
Check the box (if applicable): Indicates the fuel storage tank is outdoors and above ground.
RATING / UNDERWRITING
Outdoors, Below ground
(checkbox)
Check the box (if applicable): Indicates the fuel storage tank is outdoors and below ground.
RATING / UNDERWRITING
Fuel Line Location -
Underground (checkbox)
Check the box (if applicable): Indicates the fuel line is underground.
RATING / UNDERWRITING
Through foundation
(checkbox)
Check the box (if applicable): Indicates the fuel line goes through the foundation.
RATING / UNDERWRITING
Renovations - Wiring - Part
Check the box (if applicable): Indicates if partial wiring improvements have been made since the
original construction.
RATING / UNDERWRITING
Wiring - Complete
Check the box (if applicable): Indicates if complete wiring improvements have been made since
the original construction.
RATING / UNDERWRITING
Wiring - Year
Enter year: The year the wiring improvements took place.
RATING / UNDERWRITING
Plumbing - Part
Check the box (if applicable): Indicates if partial plumbing improvements have been made since
the original construction.
RATING / UNDERWRITING
Plumbing - Complete
Check the box (if applicable): Indicates if complete plumbing improvements have been made
since the original construction.
RATING / UNDERWRITING
Plumbing - Year
Enter year: The year the plumbing improvements took place.
RATING / UNDERWRITING
Heating - Part
Check the box (if applicable): Indicates if partial heating improvements have been made since
the original construction.
RATING / UNDERWRITING
Heating - Complete
Check the box (if applicable): Indicates if complete heating improvements have been made
since the original construction.
RATING / UNDERWRITING
Heating - Year
Enter year: The year the heating improvements took place.
ACORD 80 (2013/09) rev. 08-20-2014
Page 19 of 46
RATING / UNDERWRITING
Roofing - Part
Check the box (if applicable): Indicates if partial roofing improvements have been made since
the original construction.
RATING / UNDERWRITING
Roofing - Complete
Check the box (if applicable): Indicates if complete roofing improvements have been made
since the original construction.
RATING / UNDERWRITING
Roofing - Year
Enter year: The year the roofing improvements took place.
RATING / UNDERWRITING
Exterior Paint - Year
Enter year: The year the exterior of the structure was last painted.
RATING / UNDERWRITING
Wind Class - Resistive
(checkbox)
Check the box (if applicable): Indicates the wind class is resistive.
RATING / UNDERWRITING
Semi-resistive (checkbox)
Check the box (if applicable): Indicates the wind class is semi-resistive.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the wind class is other than those listed.
RATING / UNDERWRITING
Other Description.
Enter text: The description of the other wind class.
RATING / UNDERWRITING
Storm Shutters - A
(checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class that provides
protection from wind and debris.
RATING / UNDERWRITING
B (checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class that provides
protection from wind only.
RATING / UNDERWRITING
Other (checkbox)
Check the box (if applicable): Indicates the wind storm shutters are a class other than those
listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the wind storm shutter class.
RATING / UNDERWRITING
Hurricane Resistive Glass
(checkbox)
Check the box (if applicable): Indicates the glass is resistive to hurricanes.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
LOCATION SCHEDULE
County
Enter text: The county of the physical location.
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
LOCATION SCHEDULE
County
Enter text: The county of the physical location.
ACORD 80 (2013/09) rev. 08-20-2014
Page 20 of 46
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
LOCATION SCHEDULE
County
Enter text: The county of the physical location.
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
PRIOR COVERAGE
No Prior Coverage
Check the box (if applicable): Indicates there was no prior coverage.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
LOSS HISTORY
Any Losses, whether or not
paid by insurance, during
the last__years, at this or at
any other location?
Enter number: The number of years of loss information required by the insurer.
LOSS HISTORY
Any Losses at this or at any
other location?
Enter Y for a Yes response. Input N for No response. Indicates if there have been any losses
at any location, whether paid or not paid by insurance, in the last mandated number of years.
LOSS HISTORY
Applicant's Initials
Initial here: The named insured's initials.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
ACORD 80 (2013/09) rev. 08-20-2014
Page 21 of 46
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
ACORD 80 (2013/09) rev. 08-20-2014
Page 22 of 46
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
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).
OPTIONAL COVERAGES -
ENDORSEMENTS
LOC #
Enter number: The producer assigned number of the location.
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
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
premises liability extension.
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium ($)
Enter amount: The premium associated with additional premises liability extension.
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
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
ACORD 80 (2013/09) rev. 08-20-2014
Page 23 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
residence rented to others.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
# Families
Enter number: The number of families of the additional residence rented to others .
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loc #
Enter number: The producer assigned location number for the premises covered by additional
residence rented to others.
OPTIONAL COVERAGES -
ENDORSEMENTS
Med Pay (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if medical payments
coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
# Families
Enter number: The number of families of the additional residence rented to others .
OPTIONAL COVERAGES -
ENDORSEMENTS
Terr:
Enter code: The liability territory for the location specified.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for additional residence rented to others coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Theft of building Materials
Included (checkbox)
Check the box (if applicable): Indicates the builders risk theft of building materials coverage is
included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for builders risk theft of building materials coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for builders risk theft of building materials coverage.
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
Limit
Enter limit: The limit for builders risk collapse due to hydro-static pressure coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 24 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for builders risk collapse due to hydro-static pressure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Building Ordinance or Law
Coverage - Aggregate Limit
Enter limit: The aggregate limit for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increase Limit
Enter limit: The increased limit for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Included (checkbox)
Check the box (if applicable): Indicates the building ordinance or law coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Rebuild %
Enter percentage: The rebuild percentage for building ordinance or law coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for building ordinance or law coverage.
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
Limit
Enter limit: The limit for business property at home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for business property at home coverage.
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
Limit
Enter limit: The limit for business property away from home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for business property away from home coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Debris Removal - Included
Check the box (if applicable): Indicates the debris removal coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for debris removal coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for debris removal coverage.
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.
ACORD 80 (2013/09) rev. 08-20-2014
Page 25 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Earthquake - Territory
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 - Premium
Enter amount: The premium for earthquake coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability Limit
Enter limit: The limit amount for employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability - # of
Employees
Enter number: The number of employees associated with employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Employers Liability -
Premium
Enter amount: The premium for employers liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown
Included (checkbox)
Check the box (if applicable): Indicates the equipment breakdown coverage is included. As
used here, not applicable in North Carolina.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown
Deductible
Enter deductible: The deductible associated with equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown Limit
Enter limit: The limit associated with equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Equipment Breakdown
Premium
Enter amount: The premium for equipment breakdown coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fire Department Service
Charge - Included
(checkbox)
Check the box (if applicable): Indicates the fire department service charge coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for fire department service charge coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Building Limit
Enter limit: The building limit for flood coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Contents Limit
Enter limit: The contents limit for flood coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Flood - Premium
Enter amount: The premium for flood coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 26 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Excl
Liability
Check the box (if applicable): Indicates that liability is excluded from fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Fungus and Mold - Property
Enter limit: The property limit for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Liability
Enter limit: The liability limit for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Fungus and Mold - Premium
Enter amount: The premium for fungus and mold coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts Included
(checkbox)
Check the box (if applicable): Indicates the golf cart liability coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - # of Golf Carts
Enter number: The number of golf carts to be covered.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Description
Enter text: The description of the golf carts.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Premium
Enter amount: The premium for golf cart liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Physical
Damage - Limit
Enter limit: The limit for golf cart physical damage coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Golf Carts - Physical
Damage - Premium
Enter amount: The premium for golf cart physical damage coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Included (checkbox)
Check the box (if applicable): Indicates identity fraud expense coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Limit
Enter limit: The limit for identity fraud expense coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Identity Fraud Expense -
Premium
Enter amount: The premium for identity fraud expense coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Incidentals Farming Pers
Liab - Premium
Enter amount: The premium for incidental farming coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 27 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
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.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Premium
Enter amount: The premium for increased coverage C special liability limit - electronic apparatus
in and out of vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - electronic
apparatus in vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - electronic apparatus
in vehicle.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - guns.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - guns.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - money.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - money.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit - securities.
ACORD 80 (2013/09) rev. 08-20-2014
Page 28 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit - securities.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Increased Limit
Enter limit: The increased limit amount for increased coverage C special liability limit -silverware.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for increased coverage C special liability limit -silverware.
OPTIONAL COVERAGES -
ENDORSEMENTS
Inflation Guard -
Percentage Increase
Enter percentage: The increase percentage for inflation guard coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Inflation Guard Premium
Enter amount: The premium for inflation guard coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loss Assessment - Limit
Enter limit: The limit amount for loss assessment coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Loss Assessment - Premium
Enter amount: The premium for loss assessment coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Limit
Enter limit: The limit for mine subsidence coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Const
Material
Enter code: The type of construction material.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Property
Desc
Enter text: The description of the property.
OPTIONAL COVERAGES -
ENDORSEMENTS
Mine Subsidence - Premium
Enter amount: The premium for mine subsidence coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Office, Professional Private
School, Studio - Residence
Premises - Requires Incr
Contents (checkbox)
Check the box (if applicable): Indicates that increased contents is required for office,
professional private school, studio - residence premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Office, Professional Private
School, Studio - Residence
Premises - Incr Contents
Limit
Enter limit: The increased contents limit for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Incr Cont Not Required
(checkbox)
Check the box (if applicable): Indicates that increased contents is not required for office,
professional private school, studio - residence premises coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 29 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Other Structures
Enter limit: The other structures limit for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Territory
Enter code: The territory for office, professional private school, studio - residence premises
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Structure Type
Enter code: The type of structure for office, professional private school, studio - residence
premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Business / Structure
Description
Enter text: The description of the business or structure for office, professional private school,
studio - residence premises coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for office, professional private school, studio - residence premises
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Other Structures - Individual
Structure - Limit
Enter limit: The limit for other structures - individual structure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Structure Desc
Enter text: The description of the individual structure for other structures - individual structure
coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for other structures - individual structure coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Included (checkbox)
Check the box (if applicable): Indicates that plants, shrubs and trees coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Limit
Enter limit: The limit for plants, shrubs and trees coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Plants, Shrubs & Trees -
Premium
Enter amount: The premium for plants, shrubs and trees coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Included
Check the box (if applicable): Indicates that refrigerated food products coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Limit
Enter amount: The limit for refrigerated food products coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Refrigerated Food Products
- Premium
Enter amount: The premium for refrigerated food products coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Sink Hole Collapse -
Included
Check the box (if applicable): Indicates sink hole collapse coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Sink Hole Collapse -
Premium
Enter amount: The premium for sink hole collapse.
ACORD 80 (2013/09) rev. 08-20-2014
Page 30 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Limit
Enter limit: The limit for unit owners additions and alterations special coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for unit owners additions and alterations special coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Unscheduled Jewelry,
Watches, Furs - Aggregate
Enter limit: The aggregate limit for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Increased
Enter limit: The increased limit for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for unscheduled jewelry, watches and furs coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Water Backup of Sewers &
Drains - Included
Check the box (if applicable): Indicates water backup of sewers and drains coverage is included.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit
Enter limit: The limit for water backup of sewers and drains coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for water backup of sewers and drains coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Liability - Limit
Enter limit: The limit for watercraft liability coverage if you are not using a Watercraft application.
OPTIONAL COVERAGES -
ENDORSEMENTS
Watercraft Liability -
Premium
Enter amount: The premium for watercraft liability coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
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
Watercraft Physical Damage
- Premium
Enter amount: The premium for watercraft physical damage coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Windstorm Exclusion - Yes
Check the box (if applicable): Indicates that windstorm exclusion applies. As used here, this is
not applicable in Arkansas.
OPTIONAL COVERAGES -
ENDORSEMENTS
Windstorm Exclusion -
Premium
Enter amount: The premium for windstorm exclusion.
OPTIONAL COVERAGES -
ENDORSEMENTS
Workers Compensation -
Full Time Inservant - # of
Employees
Enter number: The number of employees associated with workers compensation full time In
Servant coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 31 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for workers compensation full time In Servant coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 32 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
ACORD 80 (2013/09) rev. 08-20-2014
Page 33 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Code
Enter code: The code associated with the type of coverage being requested.
OPTIONAL COVERAGES -
ENDORSEMENTS
Coverage Description
Enter text: The description of the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Options
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded,
Rejected, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1
Enter amount: The first limit associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 1 Applies To
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence,
etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2
Enter amount: The second limit associated with the coverage.
ACORD 80 (2013/09) rev. 08-20-2014
Page 34 of 46
OPTIONAL COVERAGES -
ENDORSEMENTS
Limit 2 Applies To
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per
Occurrence, etc.).
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible
Enter amount: The deductible associated with the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Deductible Type
Enter code: The type of deductible (e.g. Flat, Percent, etc.)
OPTIONAL COVERAGES -
ENDORSEMENTS
Territory
Enter code: The rating territory for the coverage.
OPTIONAL COVERAGES -
ENDORSEMENTS
Yes / No
Enter Y for a Yes response. Input N for No response. Indicates a Yes or No option for the
coverage, if applicable.
OPTIONAL COVERAGES -
ENDORSEMENTS
Premium
Enter amount: The premium for the coverage.
GENERAL INFORMATION
Any other insurance with
this company?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any other insurance with this company?.
GENERAL INFORMATION
Line Of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line Of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Any coverage declined,
cancelled, or non-renewed
during the last 3 years?
Not applicable for
applications for auto
insurance.
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any coverage declined, cancelled or non-renewed during the mandated number of years
(Missouri Applicants - Do not answer this question)?. As used here, this is not applicable for
applications for auto insurance. Missouri applicant: Do not answer this question.
GENERAL INFORMATION
Enter text: An explanation of any coverage declined within the last 3 years.
GENERAL INFORMATION
Has applicant had a
foreclosure, repossession,
bankruptcy or filed for
bankruptcy during the past
five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the
past specified number of years?.
GENERAL INFORMATION
Enter text: An explanation of any foreclosures or bankruptcies.
ACORD 80 (2013/09) rev. 08-20-2014
Page 35 of 46
GENERAL INFORMATION
Has applicant had a
judgement or lien during the
past five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a judgement or lien during the past specified number of years?.
GENERAL INFORMATION
Enter text: An explanation of any judgment or liens within the last 5 years
GENERAL INFORMATION
Any other residence, not
listed on any application,
owned, occupied or rented?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any other residence, not listed on any application, owned, occupied or rented?.
GENERAL INFORMATION
Enter text: An explanation of any other residence owned or occupied.
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).
GENERAL INFORMATION
(Continued)
Has insurance been
transferred within agency?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has insurance been transferred within agency?.
GENERAL INFORMATION
(Continued)
Enter text: An explanation of insurance transferred within the agency.
GENERAL INFORMATION
(Continued)
Does applicant own any
recreational vehicles
(snowmobiles, dune
buggies, mini bikes, ATVs,
etc.), not scheduled on this
policy?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes,
ATVs, etc.), not scheduled on this policy?.
GENERAL INFORMATION
(Continued)
Year
Enter year: The model year of the vehicle.
GENERAL INFORMATION
(Continued)
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
GENERAL INFORMATION
(Continued)
Model
Enter text: The manufacturer's model name for the vehicle.
GENERAL INFORMATION
(Continued)
Body Type
Enter code: The body type of the vehicle.
GENERAL INFORMATION
(Continued)
Year
Enter year: The model year of the vehicle.
ACORD 80 (2013/09) rev. 08-20-2014
Page 36 of 46
GENERAL INFORMATION
(Continued)
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
GENERAL INFORMATION
(Continued)
Model
Enter text: The manufacturer's model name for the vehicle.
GENERAL INFORMATION
(Continued)
Body Type
Enter code: The body type of the vehicle.
GENERAL INFORMATION
(Continued)
During the last five (5) years
[ten (10) in Rhode Island],
has any applicant been
indicted for or convicted of
any degree of the crime of
fraud, bribery, arson or any
other arson-related crime in
connection with this or any
other property?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
During the last five (5) years [ten (10) years in Rhode Island], has any applicant been indicted
for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related
crime in connection with this or any other property? (In RI, failure to disclose the existence of an
arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of
imprisonment.).
GENERAL INFORMATION
(Continued)
Enter text: An explanation of applicant convicted of fraud, bribery or arson.
GENERAL INFORMATION -
RESIDENTIAL
LOC #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION -
RESIDENTIAL
1. Any business conducted
on premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any business conducted on premises?.
GENERAL INFORMATION -
RESIDENTIAL
Farming (checkbox)
Check the box (if applicable): Indicates farming is done on the premises.
GENERAL INFORMATION -
RESIDENTIAL
Telecommuter (checkbox)
Check the box (if applicable): Indicates an individual telecommutes from the premises.
GENERAL INFORMATION -
RESIDENTIAL
Day Care (checkbox)
Check the box (if applicable): Indicates a day care is run from the premises.
GENERAL INFORMATION -
RESIDENTIAL
Day Care # of children
(checkbox)
Enter number: The number of children attending the day care.
GENERAL INFORMATION -
RESIDENTIAL
Home Office / business
(checkbox)
Check the box (if applicable): Indicates a home office or business is on the premises.
GENERAL INFORMATION -
RESIDENTIAL
Other
Check the box (if applicable): Indicates business is conducted on the premises other than those
listed.
GENERAL INFORMATION -
RESIDENTIAL
Other Description
Enter text: The description of the business conducted on the premises.
ACORD 80 (2013/09) rev. 08-20-2014
Page 37 of 46
GENERAL INFORMATION -
RESIDENTIAL
2. Any residence
employees?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any residence employees?.
GENERAL INFORMATION -
RESIDENTIAL
# of Full Time Employees
Enter number: The number of full time residence employees.
GENERAL INFORMATION -
RESIDENTIAL
Description of Full Time
Employees
Enter text: The description of the type of work performed by full time residence employees.
GENERAL INFORMATION -
RESIDENTIAL
# of Part Time Employees
Enter number: The number of part time residence employees.
GENERAL INFORMATION -
RESIDENTIAL
Description of Part Time
Employees
Enter text: The description of the type of work performed by part time residence employees.
GENERAL INFORMATION -
RESIDENTIAL
3. Any flooding, brush,
forest fire or landslide
hazard?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any flooding, brush, forest fire or landslide hazard?.
GENERAL INFORMATION -
RESIDENTIAL
Hazards - Description
Enter text: An explanation of any flooding, brush, forest fire or landslide hazard.
GENERAL INFORMATION -
RESIDENTIAL
4. Are there any animals or
exotic pets kept on the
premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Are there any animals or exotic pets on the premises?.
GENERAL INFORMATION -
RESIDENTIAL
Animals - Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION -
RESIDENTIAL
Animals - Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION -
RESIDENTIAL
Animals - Bite History
Enter Y for a Yes response. Input N for No response. Indicates if any animal currently in the
household has ever been involved in a bite incident.
GENERAL INFORMATION -
RESIDENTIAL
Animals - Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION -
RESIDENTIAL
Animals - Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION -
RESIDENTIAL
Animals - Bite History
Enter Y for a Yes response. Input N for No response. Indicates if any animal currently in the
household has ever been involved in a bite incident.
GENERAL INFORMATION -
RESIDENTIAL
5. Is property situated on
more than one acre?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is property situated on more than 1 acre?.
GENERAL INFORMATION -
RESIDENTIAL
Number of acres
Enter number: The total area of the land in acres.
ACORD 80 (2013/09) rev. 08-20-2014
Page 38 of 46
GENERAL INFORMATION -
RESIDENTIAL
Land Used for
Enter text: The description of what the land is used for.
GENERAL INFORMATION -
RESIDENTIAL
6. Any uncorrected fire or
building code violations?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any uncorrected fire or building code violations?.
GENERAL INFORMATION -
RESIDENTIAL
Description
Enter text: An explanation of or any uncorrected fire or building code violations.
GENERAL INFORMATION -
RESIDENTIAL
7. Is the dwelling / mobile
home for sale?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the dwelling/mobile home for sale?.
GENERAL INFORMATION -
RESIDENTIAL
8. Is property within 300 ft.
of a commercial or
non-Residential property
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the property within 300 feet of a commercial or non-residential property?.
GENERAL INFORMATION -
RESIDENTIAL
Enter text: An explanation if property is within 300 ft. of a commercial or non-residential property.
GENERAL INFORMATION -
RESIDENTIAL
9. Is there a trampoline on
the premises
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a trampoline on the premises?.
GENERAL INFORMATION -
RESIDENTIAL
Trampoline - Safety Net
Enter Y for a Yes response. Input N for No response. Indicates whether the trampoline on the
premises has a safety net.
GENERAL INFORMATION -
RESIDENTIAL
10. Was the structure
originally built for other than
private residence and then
converted?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Was the structure originally built for other than a private residence and then converted?.
GENERAL INFORMATION -
RESIDENTIAL
Original Occupancy
Enter text: The description of the original occupancy of the building.
GENERAL INFORMATION -
RESIDENTIAL
11. Any lead paint?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any lead paint?.
GENERAL INFORMATION -
RESIDENTIAL
Lead Paint - Description
Enter text: An explanation of any lead paint on the premises.
GENERAL INFORMATION -
RESIDENTIAL
12. If a fuel tank is on
premises, has other
insurance been obtained for
the tank?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, If
a fuel tank is on premises, has other insurance been obtained for the tank?.
GENERAL INFORMATION -
RESIDENTIAL
Insurance Company
Enter text: The insurer name on any other applicable insurance.
GENERAL INFORMATION -
RESIDENTIAL
Limit
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or
applicable policy coverage(s) should be answered by the issuing insurer(s).
ACORD 80 (2013/09) rev. 08-20-2014
Page 39 of 46
GENERAL INFORMATION -
RESIDENTIAL
Clean-up / Sub Limit
Enter limit: The other policy, coverage sub limit amount.
GENERAL INFORMATION -
RESIDENTIAL
13. Is the residence in a
gated community?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the residence in a gated community?.
GENERAL INFORMATION -
RESIDENTIAL
Community - Name of
Community
Enter text: The name of the gated community.
GENERAL INFORMATION -
RESIDENTIAL
14. If building under
construction, is the
applicant the general
contractor?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, If
building is under construction, is the applicant the general contractor?.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor - Start
Date
Enter date: The date construction began.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor -
Completion Date
Enter date: The estimated completion date for this construction project.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor - Int %
Enter percentage: The percentage of construction taking place in the interior of the structure.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor - Ext %
Enter percentage: The percentage of construction taking place in the exterior of the structure.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor -
Addition Sq. Ft.
Enter number: The total area of the addition under construction in square feet.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor -
Additional Level Sq. Ft.
Enter number: The total area of the additional level under construction in square feet.
GENERAL INFORMATION -
RESIDENTIAL
Any structural changes?
Enter Y for a Yes response. Input N for No response. Indicates if there will be structural
changes as part of the construction.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor -
Material Unattached
Included
Check the box (if applicable): Indicates materials that are not attached to the structure are
included.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor -
Material Unattached
Excluded
Check the box (if applicable): Indicates materials that are not attached to the structure are
excluded.
GENERAL INFORMATION -
RESIDENTIAL
House Occupied during
renovation?
Enter Y for a Yes response. Input N for No response. Indicates if the structure will be
occupied during construction and renovation.
GENERAL INFORMATION -
RESIDENTIAL
General Contractor - Cost of
Project.
Enter amount: The total cost of construction of the structure
ACORD 80 (2013/09) rev. 08-20-2014
Page 40 of 46
GENERAL INFORMATION -
RESIDENTIAL
15. Is there a carbon
monoxide alarm, in
operating condition, within
the mandated number of
feet of every room used for
sleeping purposes?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there an approved carbon monoxide alarm in operating condition within the mandated
number of feet of every room used for sleeping purposes?.
GENERAL INFORMATION -
RESIDENTIAL
16. Is the named insured the
owner of the property? (If
NO, provide the name of
the owner).
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the named insured the owner of the property?. As used here, if no, provide the name of the
owner.
GENERAL INFORMATION -
RESIDENTIAL
Owner's Name
Enter text: The additional interest's full name. As used here, this is the name of the owner of the
property.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
LOC #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
1. Is there is a manager on
the premises?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a manager on the premises?. As used here, if yes, provide the full name of the
manager and the manager's phone number, including area code. A No response does not
require an explanation.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Manager's Name
Enter text: Provide the full name of the manger. A No response does not require an
explanation.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Phone Number
Enter number: The phone number of the manager of the structure.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
2. Is there a security
attendant?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is there a security attendant?. As used here, explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY
Description
Enter text: An explanation if no security attendant is provided on the premises. As used here,
explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY (Continued)
3. Is the building entrance
locked?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Is the building entrance locked?. As used here, explain a No response to the question.
GENERAL INFORMATION -
RENTERS AND CONDOS
ONLY (Continued)
Description
Enter text: An explanation if building entrance is not locked. As used here, explain a No
response to the question.
ACORD 80 (2013/09) rev. 08-20-2014
Page 41 of 46
Form Page 5
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).
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
Send Bill
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
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 / Loan #:
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.
ACORD 80 (2013/09) rev. 08-20-2014
Page 42 of 46
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.
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
Send Bill
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
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 / Loan #:
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ACORD 80 (2013/09) rev. 08-20-2014
Page 43 of 46
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.
REMARKS / ATTACHMENTS Earthquake Application
Check the box (if applicable): Indicates an earthquake application is attached.
REMARKS / ATTACHMENTS Flood Exclusion Notice
Check the box (if applicable): Indicates a flood exclusion notice is attached.
REMARKS / ATTACHMENTS Lead Free Paint Certification
Check the box (if applicable): Indicates a lead free paint certification is attached.
REMARKS / ATTACHMENTS Mobile Home Supplement
Check the box (if applicable): Indicates a mobile home supplement is attached to the
application.
REMARKS / ATTACHMENTS Pers Inland Marine Section
Check the box (if applicable): Indicates an inland marine application is attached.
REMARKS / ATTACHMENTS
Personal Umbrella
Application Section
Check the box (if applicable): Indicates a personal umbrella section is attached to the policy.
REMARKS / ATTACHMENTS Photograph
Check the box (if applicable): Indicates a photograph is attached.
REMARKS / ATTACHMENTS Protection Device Certificate
Check the box (if applicable): Indicates a protection device certificate is attached.
REMARKS / ATTACHMENTS Replacement Cost Estimate
Check the box (if applicable): Indicates a replacement cost estimate is attached.
REMARKS / ATTACHMENTS
Residence Based
Businesses Supp
Check the box (if applicable): Indicates a residence based business supplement is attached.
REMARKS / ATTACHMENTS Solid Fuel Supplement
Check the box (if applicable): Indicates a solid fuel supplement is attached.
REMARKS / ATTACHMENTS State Supplement(s)
Check the box (if applicable): Indicates a state supplement form is attached (if applicable).
REMARKS / ATTACHMENTS Watercraft Section
Check the box (if applicable): Indicates a watercraft application is attached.
REMARKS / ATTACHMENTS Windstorm Loss Mitigation
Check the box (if applicable): Indicates a windstorm loss mitigation form is attached.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
ACORD 80 (2013/09) rev. 08-20-2014
Page 44 of 46
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Remarks / Attachments
Enter text: The general remarks associated with this line of business. Use this section to
provide any additional information required for underwriting or rating. ACORD 101, Additional
Remarks Schedule, may be attached if more space is required. As used here, ACORD 101,
Additional Remarks Schedule, may be attached if more space is required.
BINDER / NOTICE OF
INFORMATION PRACTICES
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.
BINDER / NOTICE OF
INFORMATION PRACTICES
Time
Enter time: The time of day on the effective date in which the terms and conditions of the binder
will commence.
BINDER / NOTICE OF
INFORMATION PRACTICES
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.
BINDER / NOTICE OF
INFORMATION PRACTICES
12:01 AM
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
BINDER / NOTICE OF
INFORMATION PRACTICES
Noon
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
BINDER / NOTICE OF
INFORMATION PRACTICES
Coverage is not bound
Check the box (if applicable): Indicates the coverage has not been bound.
BINDER / NOTICE OF
INFORMATION PRACTICES
Applicant's Initials
Initial here: The named insured's initials. As used here, indicates the named insured has read
and understands the credit reporting information.
BINDER / NOTICE OF
INFORMATION PRACTICES
Copy of the Notice of
Information Practices
Privacy has been given to
the applicant. Not applicable
in all states, consult your
agent or broker for your
state's requirements.
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
Form Page 6
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).
ACORD 80 (2013/09) rev. 08-20-2014
Page 45 of 46
FRAUD STATEMENTS /
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
FRAUD STATEMENTS /
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
FRAUD STATEMENTS /
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
FRAUD STATEMENTS /
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
FRAUD STATEMENTS /
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
FRAUD STATEMENTS /
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 80 (2013/09) rev. 08-20-2014
Page 46 of 46