ACORD 83 (2013/09) - Personal Umbrella Application
ACORD 83 (2013/09) - Personal Umbrella Application
ACORD 83, Personal Umbrella Application, is used to capture Personal Umbrella or Personal Excess insurance policies. These policies are
personal lines insurance contracts that provide for indemnification of third parties as a result of damages and/or injuries sustained due to the
insured's negligence with respect to personal acts. Coverage for negligence arising out of any professional activities and nearly all business
pursuits conducted by the insured is normally excluded. It is important to note that personal umbrellas normally provide personal injury in addition to
bodily injury coverage. While the latter coverage deals solely with physical injuries, the former includes injuries sustained as a result of libel,
slander, defamation of character, false arrest and other non-physical perils.
Personal umbrellas typically operate in excess of or overlay the primary liability coverage contained in other personal lines insurance contracts
such as private passenger auto, homeowners and watercraft. Coverage limits are written on a combined single limit (CSL) basis. In some cases,
Personal umbrellas may provide basic or first dollar coverage for certain types of negligence for which there is no primary coverage. Personal
umbrellas can also overlay coverages afforded under certain commercial insurance contracts such as owners, landlords and tenants liability
policies. They also provide that the insurer will pay legal defense costs on a first-dollar basis in addition to the policy limits. The majority of personal
umbrellas contain a provision for a retained limit which effectively operates as a per occurrence deductible.
Although insurance coverage afforded by a personal umbrella is typically operative worldwide and specific units at risk (such as automobiles) may
be related to locations in varying geographical locations (rotary territories), premiums are developed on the basis of unique personal umbrella rates
applicable at the insured's primary residence. No known requirement for allocating premiums back to other exposure locations exists.
The underwriting process for any personal lines policy begins with the submission of a completed application.
In South Dakota, use of ACORD 61 SD is mandatory with this form.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Address Line One
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Address Line Two
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
City
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
State
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Zip + 4
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.
ACORD 83 (2013/09) rev. 07-31-2013 P age 1 of 32
IDENTIFICATION SECTION
Phone
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
E-Mail Address
Enter text: The producer's contact person 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., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
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 company 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.
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant's Name and
Mailing Address
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Address Line One
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Address Line Two
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
County
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Zip + 4
Enter code: The named insured's mailing address postal code.
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IDENTIFICATION SECTION
Date at Curr Res
Enter date: The date insured moved into their current residence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Primary Phone #
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
IDENTIFICATION SECTION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
IDENTIFICATION SECTION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
IDENTIFICATION SECTION
Secondary Phone #
Enter number: The named insured's secondary phone number.
IDENTIFICATION SECTION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
IDENTIFICATION SECTION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
IDENTIFICATION SECTION
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
IDENTIFICATION SECTION
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
IDENTIFICATION SECTION
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
UMBRELLA INFORMATION
Policy Amount
Enter limit: The policy liability limit for personal umbrella coverage.
UMBRELLA INFORMATION
Retention
Enter amount: The amount of liability retained by the insured. Retention is usually expressed in
whole dollars, but can be a percentage.
UMBRELLA INFORMATION
Uninsured Motorist
Enter limit: The limit for personal umbrella uninsured motorist coverage. As used here, if
applicable in your state.
UMBRELLA INFORMATION
Underinsured Motorist
Enter limit: The limit for personal umbrella underinsured motorist coverage. As used here, if
applicable in your state.
UMBRELLA INFORMATION
Other Coverage Code
Enter code: The code associated with the type of coverage being requested.
UMBRELLA INFORMATION
Other Description
Enter text: The description of other underlying coverages.
UMBRELLA INFORMATION
Other Limit
Enter limit: The limit for the coverage.
UMBRELLA INFORMATION
Other Coverage Code
Enter code: The code associated with the type of coverage being requested.
UMBRELLA INFORMATION
Other Description
Enter text: The description of other underlying coverages.
UMBRELLA INFORMATION
Other Limit
Enter limit: The limit for the coverage.
UMBRELLA INFORMATION
Premiums - Basic
Enter amount: The premium for basic personal umbrella coverage.
UMBRELLA INFORMATION
Residences
Enter amount: The premium for residences.
UMBRELLA INFORMATION
Automobiles
Enter amount: The premium for automobiles.
UMBRELLA INFORMATION
Recreational Vehicles
Enter amount: The premium for recreational vehicles.
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UMBRELLA INFORMATION
Uninsured Motorist
Enter amount: The premium for uninsured motorist coverage.
UMBRELLA INFORMATION
Underinsured Motorist
Enter amount: The premium for underinsured motorist coverage.
UMBRELLA INFORMATION
Watercraft
Enter amount: The premium for watercraft.
UMBRELLA INFORMATION
Other
Enter text: The description of other underlying coverages.
UMBRELLA INFORMATION
Other Amount
Enter amount: The premium for the coverage.
UMBRELLA INFORMATION
Deposit
Enter amount: The amount of the premium received as a deposit.
UMBRELLA INFORMATION
Estimated Total Premium
Enter amount: The estimated total cost amount of the policy.
UMBRELLA INFORMATION
Calculations
Enter text: The insurance company may require use of specific multipliers or factors which can
be shown here.
PRIMARY POLICY
INFORMATION
Company
Enter text: The full name of the insurer of the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Liability Ea Per
Enter limit: The bodily injury each person limit on the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Liability Ea Acc or CSL
Enter limit: The bodily injury each accident limit or combined single limit on the underlying
automobile policy.
PRIMARY POLICY
INFORMATION
Property Damage Ea Acc
Enter limit: The property damage each accident limit on the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Uninsured Motorists Ea Per
Enter limit: The uninsured motorists bodily injury each person limit on the underlying automobile
policy.
PRIMARY POLICY
INFORMATION
Uninsured Motorists Ea Acc
or CSL
Enter limit: The uninsured motorists bodily injury each accident or combined single limit on the
underlying automobile policy.
PRIMARY POLICY
INFORMATION
PD Ea Acc
Enter limit: The uninsured motorists property damage on the underlying automobile policy.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer of the underlying homeowners policy.
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PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying homeowners policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying homeowners policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying homeowners policy.
PRIMARY POLICY
INFORMATION
Personal Liability Ea Occ
Enter limit: The liability limit on the underlying homeowners policy.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer of the underlying dwelling fire policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying dwelling fire policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying dwelling fire policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying dwelling fire policy.
PRIMARY POLICY
INFORMATION
Personal Liability Ea Occ
Enter limit: The liability limit on the underlying dwelling fire policy.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer on the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Liability Ea Per
Enter limit: The bodily injury each person limit on the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Liability Ea Acc or CSL
Enter limit: The bodily injury each accident or combined single limit on the underlying watercraft
policy.
PRIMARY POLICY
INFORMATION
Property Damage Ea Acc
Enter limit: The property damage each accident limit on the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Uninsured Boaters Ea Per
Enter limit: The uninsured motorists (boaters) bodily injury each person limit on the underlying
watercraft policy.
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PRIMARY POLICY
INFORMATION
Uninsured Boaters Ea Acc
or CSL
Enter limit: The uninsured motorists (boaters) bodily injury each accident or combined single
limit on the underlying watercraft policy.
PRIMARY POLICY
INFORMATION
PD Ea Acc
Enter limit: The uninsured motorists (boaters) property damage each accident limit on the
underlying watercraft policy.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer on the underlying recreation vehicle policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number on the underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Liability Ea Per
Enter limit: The bodily injury each person limit on the underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Liability Ea Acc or CSL
Enter limit: The bodily injury each accident or combined single limit on the underlying
recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Property Damage
Enter limit: The property damage limit on the underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
Uninsured Motorists Ea Per
Enter limit: The uninsured motorists bodily injury each person limit on the underlying recreational
vehicle policy.
PRIMARY POLICY
INFORMATION
Uninsured Motorists Ea Acc
or CSL
Enter limit: The uninsured motorists bodily injury each accident or combined single limit on the
underlying recreational vehicle policy.
PRIMARY POLICY
INFORMATION
PD Ea Acc
Enter limit: The uninsured motorists property damage limit on the underlying recreational vehicle
policy.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer of the underlying employers liability policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying employers liability policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying employers liability policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying employers liability policy.
PRIMARY POLICY
INFORMATION
Employers Liability Limit
Enter limit: The limit of the underlying employers liability policy.
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PRIMARY POLICY
INFORMATION
Type of Policy
Enter text: The description of the underlying policy type.
PRIMARY POLICY
INFORMATION
Company Name
Enter text: The full name of the insurer of the underlying policy.
PRIMARY POLICY
INFORMATION
Policy Number
Enter identifier: The policy number of the underlying policy.
PRIMARY POLICY
INFORMATION
Eff
Enter date: The effective date of the underlying policy.
PRIMARY POLICY
INFORMATION
Exp
Enter date: The expiration date of the underlying policy.
PRIMARY POLICY
INFORMATION
Other Coverage Description
Enter text: The description of the coverage.
PRIMARY POLICY
INFORMATION
Other Coverage Limit
Enter limit: The limit on the underlying policy.
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.
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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.
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.
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 of whom the policy paper should be mailed to.
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.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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PRIOR COVERAGE
No Prior Coverage
(checkbox)
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.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
ACORD 83 (2013/09)
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PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
ACORD 83 (2013/09)
Page 10 of 32
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
ACORD 83 (2013/09)
Page 11 of 32
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
PROPERTY
#
Enter number: The producer assigned number of the location.
PROPERTY
Location
Enter text: The first address line of the physical location.
PROPERTY
Enter text: The second address line of the physical location.
PROPERTY
Enter text: The city of the physical location.
PROPERTY
Enter text: The county of the location.
PROPERTY
Enter code: The state or province of the physical location.
PROPERTY
Enter code: The postal code of the physical location.
PROPERTY
Description
Enter text: The description of the location used to differentiate locations such as vacant land,
apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if
farm land.
PROPERTY
Yr Built
Enter year: The year the structure was built (YYYY).
PROPERTY
Interest
Enter text: The interest the insured has in the location (e.g. owner, lessor, lessee, etc.)
PROPERTY
Occupancy
Enter text: The description of the inhabitants of the residence.
PROPERTY
Usage
Enter text: The description of the usage of the residence.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
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AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
ACORD 83 (2013/09)
Page 13 of 32
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
#
Enter number: The producer assigned vehicle number.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Year
Enter year: The model year of the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
AUTOMOBILES AND
RECREATIONAL VEHICLES
Model
Enter text: The manufacturer's model name for the vehicle.
AUTOMOBILES AND
RECREATIONAL VEHICLES
Body
Enter code: The body type of the vehicle.
ACORD 83 (2013/09)
Page 14 of 32
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Year
Enter year: The model year of the watercraft.
WATERCRAFT
Manufacturer
Enter text: The manufacturer of the watercraft.
WATERCRAFT
Model
Enter text: The manufacturer's model name for the watercraft.
WATERCRAFT
Length
Enter number: The length of the watercraft expressed in feet.
WATERCRAFT
Horsepower
Enter number: The horsepower of the engine. There is a method for determining the maximum
safe horsepower for a specific boat based on length and width. If the company employs this
formula, it may be helpful to make note of the width in remarks.
WATERCRAFT
Max Speed
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles
per hour or knots per hour.
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Power - Inboard
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor.
WATERCRAFT
Power - Outboard
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor.
WATERCRAFT
Power - Inboard / Outdrive
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor.
WATERCRAFT
Power - Waterjet
Check the box (if applicable): Indicates the watercraft is propelled by a water jet.
WATERCRAFT
Power - Sail
Check the box (if applicable): Indicates the watercraft is propelled by a sail.
WATERCRAFT
Power - Other
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those
listed.
WATERCRAFT
Power - Other Description
Enter text: The method of propulsion of the watercraft.
WATERCRAFT
Waters Navigated - Atlantic
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean.
WATERCRAFT
Waters Navigated - Great
Lakes
Check the box (if applicable): Indicates the waters navigated are the Great Lakes.
WATERCRAFT
Waters Navigated - Inland
Waterways
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland
Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding
rivers and the great lakes.
WATERCRAFT
Waters Navigated - Pacific
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean.
WATERCRAFT
Waters Navigated - Rivers
Check the box (if applicable): Indicates the waters navigated are rivers.
WATERCRAFT
Waters Navigated - Gulf of
Mexico
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico.
WATERCRAFT
Waters Navigated - Other
Check the box (if applicable): Indicates the waters navigated are other than those listed.
ACORD 83 (2013/09)
Page 15 of 32
WATERCRAFT
Waters Navigated - Other
Description
Enter text: The waters where the watercraft is predominantly used.
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Year
Enter year: The model year of the watercraft.
WATERCRAFT
Manufacturer
Enter text: The manufacturer of the watercraft.
WATERCRAFT
Model
Enter text: The manufacturer's model name for the watercraft.
WATERCRAFT
Length
Enter number: The length of the watercraft expressed in feet.
WATERCRAFT
Horsepower
Enter number: The horsepower of the engine. There is a method for determining the maximum
safe horsepower for a specific boat based on length and width. If the company employs this
formula, it may be helpful to make note of the width in remarks.
WATERCRAFT
Max Speed
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles
per hour or knots per hour.
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Power - Inboard
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor.
WATERCRAFT
Power - Outboard
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor.
WATERCRAFT
Power - Inboard / Outdrive
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor.
WATERCRAFT
Power - Waterjet
Check the box (if applicable): Indicates the watercraft is propelled by a water jet.
WATERCRAFT
Power - Sail
Check the box (if applicable): Indicates the watercraft is propelled by a sail.
WATERCRAFT
Power - Other
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those
listed.
WATERCRAFT
Power - Other Description
Enter text: The method of propulsion of the watercraft.
WATERCRAFT
Waters Navigated - Atlantic
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean.
WATERCRAFT
Waters Navigated - Great
Lakes
Check the box (if applicable): Indicates the waters navigated are the Great Lakes.
WATERCRAFT
Waters Navigated - Inland
Waterways
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland
Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding
rivers and the great lakes.
WATERCRAFT
Waters Navigated - Pacific
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean.
WATERCRAFT
Waters Navigated - Rivers
Check the box (if applicable): Indicates the waters navigated are rivers.
WATERCRAFT
Waters Navigated - Gulf of
Mexico
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico.
ACORD 83 (2013/09)
Page 16 of 32
WATERCRAFT
Waters Navigated - Other
Check the box (if applicable): Indicates the waters navigated are other than those listed.
WATERCRAFT
Waters Navigated - Other
Description
Enter text: The waters where the watercraft is predominantly used.
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Year
Enter year: The model year of the watercraft.
WATERCRAFT
Manufacturer
Enter text: The manufacturer of the watercraft.
WATERCRAFT
Model
Enter text: The manufacturer's model name for the watercraft.
WATERCRAFT
Length
Enter number: The length of the watercraft expressed in feet.
WATERCRAFT
Horsepower
Enter number: The horsepower of the engine. There is a method for determining the maximum
safe horsepower for a specific boat based on length and width. If the company employs this
formula, it may be helpful to make note of the width in remarks.
WATERCRAFT
Max Speed
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles
per hour or knots per hour.
WATERCRAFT
#
Enter number: The producer assigned number for the watercraft.
WATERCRAFT
Power - Inboard
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor.
WATERCRAFT
Power - Outboard
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor.
WATERCRAFT
Power - Inboard / Outdrive
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor.
WATERCRAFT
Power - Waterjet
Check the box (if applicable): Indicates the watercraft is propelled by a water jet.
WATERCRAFT
Power - Sail
Check the box (if applicable): Indicates the watercraft is propelled by a sail.
WATERCRAFT
Power - Other
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those
listed.
WATERCRAFT
Power - Other Description
Enter text: The method of propulsion of the watercraft.
WATERCRAFT
Waters Navigated - Atlantic
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean.
WATERCRAFT
Waters Navigated - Great
Lakes
Check the box (if applicable): Indicates the waters navigated are the Great Lakes.
WATERCRAFT
Waters Navigated - Inland
Waterways
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland
Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding
rivers and the great lakes.
WATERCRAFT
Waters Navigated - Pacific
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean.
WATERCRAFT
Waters Navigated - Rivers
Check the box (if applicable): Indicates the waters navigated are rivers.
ACORD 83 (2013/09)
Page 17 of 32
WATERCRAFT
Waters Navigated - Gulf of
Mexico
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico.
WATERCRAFT
Waters Navigated - Other
Check the box (if applicable): Indicates the waters navigated are other than those listed.
WATERCRAFT
Waters Navigated - Other
Description
Enter text: The waters where the watercraft is predominantly used.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Last Name
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
ACORD 83 (2013/09)
Page 18 of 32
OPERATORS
Last Name
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Last Name
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
ACORD 83 (2013/09)
Page 19 of 32
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Last Name
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
ACORD 83 (2013/09)
Page 20 of 32
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Last Name
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
First Name
Enter text: The driver's first name (given name).
OPERATORS
Middle Name
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Last Name
Enter text: The driver's last name (surname).
ACORD 83 (2013/09)
Page 21 of 32
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Mar Stat
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Date Lic
Enter date: The original date on which a driver's license was issued to this driver.
OPERATORS
Drivers License #
Enter identifier: The driver's license number.
OPERATORS
Lic State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security #
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
Vehicle
Enter number: The producer assigned vehicle number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle
that this driver uses.
OPERATORS
Craft
Enter number: The producer assigned watercraft number that this driver primarily uses.
OPERATORS
% Use
Enter percentage: Indicates the percentage of driving done by this driver in the primary
watercraft that this driver uses.
OPERATORS
Other
Enter text: The annual mileage or any other information required by the insurance company for
the driver.
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).
OPERATOR INFORMATION
Losses - Number of Years
Enter number: The number of years of loss information required by the insurer.
OPERATOR INFORMATION
Has any auto accident or
liability loss on any primary
or excess policy occurred,
regardless of fault during
the last (enter number)
years?
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. As
used here, indicates if there has been an auto accident or liability loss on a primary or excess
policy, regardless of fault.
OPERATOR INFORMATION
Driver #
Enter number: The producer assigned number for the driver involved in the loss, if applicable.
OPERATOR INFORMATION
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
ACORD 83 (2013/09)
Page 22 of 32
OPERATOR INFORMATION
Description
Enter text: A brief description of the loss.
OPERATOR INFORMATION
Cost
Enter amount: The amount that has been paid on this claim to date.
OPERATOR INFORMATION
Driver #
Enter number: The producer assigned number for the driver involved in the loss, if applicable.
OPERATOR INFORMATION
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
OPERATOR INFORMATION
Description
Enter text: A brief description of the loss.
OPERATOR INFORMATION
Cost
Enter amount: The amount that has been paid on this claim to date.
OPERATOR INFORMATION
Driver #
Enter number: The producer assigned number for the driver involved in the loss, if applicable.
OPERATOR INFORMATION
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
OPERATOR INFORMATION
Description
Enter text: A brief description of the loss.
OPERATOR INFORMATION
Cost
Enter amount: The amount that has been paid on this claim to date.
OPERATOR INFORMATION
Driver #
Enter number: The producer assigned number for the driver involved in the loss, if applicable.
OPERATOR INFORMATION
Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
OPERATOR INFORMATION
Description
Enter text: A brief description of the loss.
OPERATOR INFORMATION
Cost
Enter amount: The amount that has been paid on this claim to date.
OPERATOR INFORMATION
2. Any operators convicted
for any traffic violations
during the last three (3)
years?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
operators convicted for any traffic violations during the mandated number of years?.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Date
Enter date: The date of the accident or conviction.
OPERATOR INFORMATION
Description
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Date
Enter date: The date of the accident or conviction.
OPERATOR INFORMATION
Description
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Date
Enter date: The date of the accident or conviction.
ACORD 83 (2013/09)
Page 23 of 32
OPERATOR INFORMATION
Description
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Date
Enter date: The date of the accident or conviction.
OPERATOR INFORMATION
Description
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
OPERATOR INFORMATION
3. Any driver have a
physical impairment that
would affect the ability to
drive? (Not applicable in
Montana and Wisconsin)
Enter Y for a Yes response. Input N for No response. The response to the question, Any
driver have physical impairment that would affect the ability to drive?.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Description of Special
Equipment in Vehicle
Enter text: The description of any special equipment.
OPERATOR INFORMATION
4. Any driver undergoing a
course of medical treatment
for a physical / mental
impairment? (Not applicable
in Montana, Oregon,
Vermont and Wisconsin)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any driver undergoing a course of medical treatment for a physical or mental impairment that
would affect the ability to drive?.
OPERATOR INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
OPERATOR INFORMATION
Explanation
Enter text: The description of any medication or treatments for a driver with physical or mental
impairments.
EMPLOYMENT
INFORMATION
Applicant's Occupation
Enter text: The named insured's primary occupation or business activity.
EMPLOYMENT
INFORMATION
Applicant's Employer Name
and Address
Enter text: The employer name (business name if self-employed).
EMPLOYMENT
INFORMATION
Enter text: The first address line of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter text: The second address line of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter text: The city of the employer's physical address.
ACORD 83 (2013/09)
Page 24 of 32
EMPLOYMENT
INFORMATION
Enter code: The state code of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter code: The postal code of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter number: The number of years employed.
EMPLOYMENT
INFORMATION
Co-Applicant's Occupation
Enter text: The named insured's primary occupation or business activity.
EMPLOYMENT
INFORMATION
Co-Applicant's Employer
Name and Address
Enter text: The employer name (business name if self-employed).
EMPLOYMENT
INFORMATION
Enter text: The first address line of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter text: The second address line of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter text: The city of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter code: The state code of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter code: The postal code of the employer's physical address.
EMPLOYMENT
INFORMATION
Enter number: The number of years employed.
GENERAL INFORMATION
1. Any swimming pool, spa
or hot tub on premises?
Enter Y for a Yes response. Input N for No response. The response to the question, Is there
a swimming pool, spa or hot tub on the premises?.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Description
Enter text: The description of the swimming pool.
GENERAL INFORMATION
Above Ground
Check the box (if applicable): Indicates the swimming pool is above ground.
GENERAL INFORMATION
In Ground
Check the box (if applicable): Indicates the swimming pool is in the ground.
GENERAL INFORMATION
Approved Fence
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an
approved height.
GENERAL INFORMATION
Diving Board
Check the box (if applicable): Indicates the swimming pool has a diving board.
GENERAL INFORMATION
Slide
Check the box (if applicable): Indicates the swimming pool has a slide.
ACORD 83 (2013/09)
Page 25 of 32
GENERAL INFORMATION
Other
Check the box (if applicable): Indicates there is additional information to describe the pool.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Description
Enter text: The description of the swimming pool.
GENERAL INFORMATION
Above Ground
Check the box (if applicable): Indicates the swimming pool is above ground.
GENERAL INFORMATION
In Ground
Check the box (if applicable): Indicates the swimming pool is in the ground.
GENERAL INFORMATION
Approved Fence
Check the box (if applicable): Indicates the swimming pool is surrounded by a fence that is an
approved height.
GENERAL INFORMATION
Diving Board
Check the box (if applicable): Indicates the swimming pool has a diving board.
GENERAL INFORMATION
Slide
Check the box (if applicable): Indicates the swimming pool has a slide.
GENERAL INFORMATION
Other
Check the box (if applicable): Indicates there is additional information to describe the pool.
GENERAL INFORMATION
2. Any employees?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
employees?.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Full Time # Employees
Inside
Enter number: The number of full time employees that work inside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week full time inside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the full time employees that work inside
the structure.
GENERAL INFORMATION
Full Time # Employees
Outside
Enter number: The number of full time employees that work outside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week full time outside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the full time employees that work outside
the structure.
GENERAL INFORMATION
Part Time # Employees
Inside
Enter number: The number of part time employees that work inside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week part time inside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the part time employees that work inside
the structure.
GENERAL INFORMATION
Part Time # Employees
Outside
Enter number: The number of part time employees that work outside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week part time outside employees work.
ACORD 83 (2013/09)
Page 26 of 32
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the part time employees that work outside
the structure.
GENERAL INFORMATION
Total Payroll All Employees
Enter amount: The total annual payroll amount for all employees.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Full Time # Employees
Inside
Enter number: The number of full time employees that work inside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week full time inside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the full time employees that work inside
the structure.
GENERAL INFORMATION
Full Time # Employees
Outside
Enter number: The number of full time employees that work outside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week full time outside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the full time employees that work outside
the structure.
GENERAL INFORMATION
Part Time # Employees
Inside
Enter number: The number of part time employees that work inside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week part time inside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the part time employees that work inside
the structure.
GENERAL INFORMATION
Part Time # Employees
Outside
Enter number: The number of part time employees that work outside the structure.
GENERAL INFORMATION
# Hours Per Week
Enter number: The number of hours per week part time outside employees work.
GENERAL INFORMATION
Duties
Enter text: The description of the duties performed by the part time employees that work outside
the structure.
GENERAL INFORMATION
Total Payroll All Employees
Enter amount: The total annual payroll amount for all employees.
GENERAL INFORMATION
3. Does applicant or any
tenant have any animals or
exotic pets?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
the applicant or any tenant have any animals or exotic pets?.
GENERAL INFORMATION
Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION
Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION
Bite History YN
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.
ACORD 83 (2013/09)
Page 27 of 32
GENERAL INFORMATION
Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION
Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION
Bite History YN
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
Animal Type
Enter code: The type of animal (e.g., cat, dog, horse, etc.)
GENERAL INFORMATION
Breed
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)
GENERAL INFORMATION
Bite History YN
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
4. Is there a trampoline on
the premises?
Enter Y for a Yes response. Input N for No response. The response to the question, Is there
a trampoline on the premises?.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Safety Net YN
Enter Y for a Yes response. Input N for No response. Indicates the trampoline on the
premises has a safety net.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Safety Net YN
Enter Y for a Yes response. Input N for No response. Indicates the trampoline on the
premises has a safety net.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Safety Net YN
Enter Y for a Yes response. Input N for No response. Indicates the trampoline on the
premises has a safety net.
GENERAL INFORMATION
Loc #
Enter number: The producer assigned number of the location.
GENERAL INFORMATION
Safety Net YN
Enter Y for a Yes response. Input N for No response. Indicates the trampoline on the
premises has a safety net.
GENERAL INFORMATION
5. Any aircraft owned,
leased, chartered or
furnished for regular use?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
aircraft owned, leased, chartered or furnished for regular use?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any aircraft owned, leased or chartered.
GENERAL INFORMATION
6. Any real estate, vehicles,
watercraft, aircraft used
commercially or for
business purposes?
Enter Y for a Yes response. Input N for No response. The response to the question, Any real
estate, vehicles, watercraft, aircraft used commercially or for business purposes?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any real estate, vehicles, watercraft or aircraft used commercially.
Form Page 4
ACORD 83 (2013/09)
Page 28 of 32
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
7. Any real estate, vehicles
watercraft, aircraft owned,
hired, leased or regularly
used, not covered by
primary policies?
Enter Y for a Yes response. Input N for No response. The response to the question, Any real
estate, vehicles, watercraft, aircraft, owned, hired, leased or regularly used, not covered by
primary policies?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any real estate, vehicles, watercraft or aircraft not covered by the
primary insurance policy.
GENERAL INFORMATION
8. Do you engage in farming
operation?
Enter Y for a Yes response. Input N for No response. The response to the question, Do you
engage in any type of farming operation?.
GENERAL INFORMATION
Remarks
Enter text: An explanation of any farming operation on the premises.
GENERAL INFORMATION
9. Do you hold any
non-compensated
positions?
Enter Y for a Yes response. Input N for No response. The response to the question, Do you
hold any non-compensated positions?.
GENERAL INFORMATION
Enter text: An explanation of any non-compensated positions.
GENERAL INFORMATION
10. Any non-owned property
exceeding $1,000 in value in
your custody?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
non-owned property exceeding $1,000 in value, in your care, custody or control?.
GENERAL INFORMATION
Enter text: A description of any non-owned property exceeding $1,000.
GENERAL INFORMATION
11. Any business and/or
professional activities
included in primary
policies?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
business and/or professional activities included in the primary policies?.
GENERAL INFORMATION
Enter text: An explanation of any business activities included in the primary policy.
GENERAL INFORMATION
12. Does any primary policy
have reduced limits of
liability?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
any primary policy have reduced limits of liability or eliminated coverage for specific
exposures?.
GENERAL INFORMATION
Enter text: An explanation of any primary policies that have reduced limits of liability.
GENERAL INFORMATION
13. Any pending litigation,
court proceedings or
judgments?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
pending litigation, court proceedings or judgments?.
GENERAL INFORMATION
Enter text: An explanation of pending litigation, court proceedings or judgments.
ACORD 83 (2013/09)
Page 29 of 32
GENERAL INFORMATION
14. Any coverage declined,
cancelled, or non-renewed
during the last five (5)
years? (Missouri Applicants
- Do not answer this
question)
Enter Y for a Yes response. Input N for No response. The response to the question, Any
coverage declined, cancelled or non-renewed during the mandated number of years (not
applicable in Missouri)?.
GENERAL INFORMATION
Drv #
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Reason declined, cancelled,
or non-renewed
Enter text: The description of the reason for coverage being declined, cancelled or non-renewed
within the last mandated number of years.
GENERAL INFORMATION
15. Has insurance been
transferred within the
agency?
Enter Y for a Yes response. Input N for No response. The response to the question, Has
insurance been transferred within agency?.
GENERAL INFORMATION
Enter text: An explanation of insurance transferred within the agency.
REMARKS
Remarks
Enter text: The remarks associated with the personal umbrella line of business.
REMARKS
Attachments - State
Supplement(s)
Check the box (if applicable): Indicates a state supplemental form is attached.
REMARKS
Other
Check the box (if applicable): Indicates there is an attachment to the application other than
those listed.
REMARKS
Other Description
Enter text: The description of an attachment.
REMARKS
Other
Check the box (if applicable): Indicates there is an attachment to the application other than
those listed.
REMARKS
Other Description
Enter text: The description of an attachment.
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).
UM / UIM DISCLOSURES
Applicable Only in Louisiana
Initial here: The named insured's initials. As used here, in Louisiana, indicates the uninsured
motorists limits indicated in this application have been selected.
UM / UIM DISCLOSURES
I Reject UM Coverage
Initial here: The named insured's initials. As used here, in Louisiana, indicates uninsured
motorists coverage has been rejected in its entirety.
UM / UIM DISCLOSURES
Applicable Only in New
Hampshire
Initial here: The named insured's initials. As used here, in New Hampshire, indicates the
uninsured motorists limits indicated in this application have been selected.
ACORD 83 (2013/09)
Page 30 of 32
UM / UIM DISCLOSURES
I Reject UM Coverage
Initial here: The named insured's initials. As used here, in New Hampshire, indicates uninsured
motorists coverage has been rejected in its entirety.
UM / UIM DISCLOSURES
Named Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
UM / UIM DISCLOSURES
Date
Enter date: The date the form was signed by the named insured.
NOTICE OF INFORMATION
PRACTICES
Applicant's Initials
Initial here: The named insured's initials.
FRAUD STATEMENTS /
SIGNATURE
Notice of Information
Practices
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.
BINDER
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
Time
Enter time: The time of the binder effective date that the binder becomes effective.
BINDER
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
12:01 AM
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
BINDER
Noon
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
BINDER
Coverage is not bound
Check the box (if applicable): Indicates the coverage has not been bound.
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).
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
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 Florida)
Enter identifier: The State License Number of the producer.
FRAUD STATEMENTS /
SIGNATURE
Name Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
ACORD 83 (2013/09)
Page 31 of 32
FRAUD STATEMENTS /
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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