Acord 125

ACORD 125 Instructions

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ACORD 125 Instructions

NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Apartments	Check the box (if applicable): Indicates the nature of business is apartments.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Condominiums	Check the box (if applicable): Indicates the nature of business is condominiums.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Contractor	Check the box (if applicable): Indicates the nature of business is a contractor.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Institutional	Check the box (if applicable): Indicates the nature of business is institutional.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Manufacturing	Check the box (if applicable): Indicates the nature of business is manufacturing.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Office	Check the box (if applicable): Indicates the nature of business is an office.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Restaurant	Check the box (if applicable): Indicates the nature of business is a restaurant.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Retail	Check the box (if applicable): Indicates the nature of business is retail.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Service	Check the box (if applicable): Indicates the nature of business is service.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Wholesale	Check the box (if applicable): Indicates the nature of business is wholesale.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Other	Check the box (if applicable): Indicates the nature of business is other than those listed.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Other Description	Enter text: The description of the nature/type of business.
APPLICANT INFORMATION	Date Business Started	Enter date: The date the applicant began in business. This is important because it helps the underwriter determine the expertise and business success of the applicant.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Description Primary Of Operations	Enter text: The text description of the operations of this risk or insured. As used here, this is the primary description of operations.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Installation, Service or Repair Work Percent	Enter percentage: The percentage of total sales of a retail store attributed to installation, service or repair work.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Off Premises Installation, Service or Repair Work Percent	Enter percentage: The percentage of total sales of a retail store attributed to installation, service or repair work completed off premises.
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS	Description of Operations of Other Named Insureds	Enter text: The text description of the operations of this risk or insured. As used here, this is the description of operations for other named insureds.
ADDITIONAL INTEREST	Interest Additional Insured	Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST	Breach of Warranty	Check the box (if applicable): Indicates the additional interest type is a breach of warranty.
ADDITIONAL INTEREST	Co-Owner	Check the box (if applicable): Indicates the additional interest type is a co-owner.
ADDITIONAL INTEREST	Employee As Lessor	Check the box (if applicable): Indicates the additional interest type is an employee as lessor.
ADDITIONAL INTEREST	Leaseback Owner	Check the box (if applicable): Indicates the additional interest type is a leaseback owner.
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	Owner	Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST	Registrant	Check the box (if applicable): Indicates the additional interest type is a registrant.
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 not any of the types listed on the form.
ADDITIONAL INTEREST	Other Description	Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST	Reason for Interest	Enter text: The description for the interest in the item.
ADDITIONAL INTEREST	Rank:	Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTEREST	Evidence – Certificate	Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance,
ADDITIONAL INTEREST	Evidence – Policy	Check the box (if applicable): Indicates the additional interest requires a copy of the policy.
ADDITIONAL INTEREST	Evidence – 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 Number	Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST	Interest End Date	Enter date: The date the interest holder’s interest terminates.
ADDITIONAL INTEREST	Lien Amount	Enter amount: The amount of the loan.
ADDITIONAL INTEREST	Phone Number	Enter number: The primary phone number of the additional interest.
ADDITIONAL INTEREST	Fax Number	Enter number: The primary fax number of the additional interest.
ADDITIONAL INTEREST	E-Mail Address	Enter text: The primary e-mail address for the additional interest.
ADDITIONAL INTEREST	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	Airport:	Enter identifier: The Federal Aviation Administration’s designator for the airport (e.g. ORD O’Hare International Airport).
ADDITIONAL INTEREST	Aircraft:	Enter number: The producer assigned number of the aircraft which has an additional interest.
ADDITIONAL INTEREST	Item Class	Enter text: 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.
IDENTIFICATION SECTION	Agency Customer ID	Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION	Is the applicant a subsidiary of another entity?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is this company a subsidiary of another entity?”.
GENERAL INFORMATION	Parent Company Name	Enter text: The name of the parent organization.
GENERAL INFORMATION	Relationship Description	Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION	% Owned	Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION	Does the applicant have any subsidiaries?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does the applicant have subsidiaries? If yes, explain.”.
GENERAL INFORMATION	Subsidiary Company Name	Enter text: The name of the subsidiary of the company. This may also contain owned foundations or charitable trusts.
GENERAL INFORMATION	Relationship Description	Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION	% Owned	Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION	Is a formal safety program in operation?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Is a formal safety Program in existence? If yes, explain.”.
GENERAL INFORMATION	Safety Manual	Check the box (if applicable): Indicates a safety manual is part of the formal safety program.
GENERAL INFORMATION	Safety Position	Check the box (if applicable): Indicates a safety position is part of the formal safety program.
GENERAL INFORMATION	Monthly Meetings	Check the box (if applicable): Indicates monthly meetings are is part of the formal safety program.
GENERAL INFORMATION	OSHA	Check the box (if applicable): Indicates the formal safety program meets OSHA guidelines.
GENERAL INFORMATION	Other	Check the box (if applicable): Indicates there is a formal safety program other than those listed.
GENERAL INFORMATION	Other Description	Enter text: The description of the formal safety program.
GENERAL INFORMATION	Any exposure to flammables, explosives, chemicals?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any exposure to flammables, explosives, chemicals?”.
GENERAL INFORMATION	Remarks	Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION	Any other insurance with this company?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response 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 text: The description of the other policy not listed on the form.
GENERAL INFORMATION	Line of Business	Enter code: The line of business of the other policy.
GENERAL INFORMATION	Policy Number	Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION	Line of Business	Enter code: The line of business of the other policy.
GENERAL INFORMATION	Policy Number	Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION	Line of Business	Enter code: The line of business of the other policy.
GENERAL INFORMATION	Policy Number	Enter text: The description of the other policy not listed on the form.
GENERAL INFORMATION	Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operation? (Not Applicable in MO)	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”. As used here, not applicable in Missouri.
GENERAL INFORMATION	Non-Payment	Check the box (if applicable): Indicates the policy is being cancelled due to non-payment of premium.
GENERAL INFORMATION	Non-Renewal	Check the box (if applicable): Indicates the policy is being cancelled due to non-renewal.
GENERAL INFORMATION	Agent No Longer Represents Carrier	Check the box (if applicable): Indicates the policy is being cancelled because the agent is no longer writing business for the insurer.
GENERAL INFORMATION	Underwriting	Check the box (if applicable): Indicates the policy is being cancelled due to underwriting reasons.
GENERAL INFORMATION	Condition Corrected	Check the box (if applicable): Indicates the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION	Correction Description	Enter text: The description of how the underwriting condition that caused the policy to not be written has been corrected.
GENERAL INFORMATION	Other	Check the box (if applicable): Indicates the policy is being cancelled due to reasons other than those listed.
GENERAL INFORMATION	Other Description	Enter text: The description of why the policy is being cancelled or terminated.
GENERAL INFORMATION	Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?”.
GENERAL INFORMATION	Remarks	Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION	During the last five years (ten in RI), 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 response to the question, “During the mandated number of years, 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?”.
GENERAL INFORMATION	Remarks	Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION	Any uncorrected fire code violations?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any uncorrected fire code violations?”.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
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 response to the question, “Has applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the past specified number of years?”.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
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 response to the question, “Has applicant had a judgment or lien during the past specified number of years?”.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION	Occurrence Date	Enter date: The date of occurrence associated with the underwriting question.
GENERAL INFORMATION	Explanation	Enter text: The explanation for the answer to an underwriting question.
GENERAL INFORMATION	Resolution	Enter text: The resolution associated with an underwriting question.
GENERAL INFORMATION	Resolution Date	Enter date: The resolution date associated with an underwriting question.
GENERAL INFORMATION	Has business been placed in a trust?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has business been placed in a trust?”.
GENERAL INFORMATION	Name of Trust	Enter text: The additional interest’s full name. As used here, this is the name of the trust.
GENERAL INFORMATION	Any foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries?”.
GENERAL INFORMATION	Does applicant have other business ventures for which coverage is not requested?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Does applicant have other business ventures for which coverage is not requested?”.
GENERAL INFORMATION	Remarks	Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION	REMARKS/PROCESSING INSTRUCTIONS	Enter text: The commercial policy general remarks.
IDENTIFICATION SECTION	Agency Customer ID	Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
PRIOR CARRIER INFORMATION	Year	Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Automobile Liability Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Property Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Other Section	Enter text: The line of business used in the “other” section of prior coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Other Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Other Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Year	Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Other Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Other Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Year	Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Other Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Other Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Year	Enter year: The year for which you are providing information.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Commercial General Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Automobile Liability policy.
PRIOR CARRIER INFORMATION	Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Property policy.
PRIOR CARRIER INFORMATION	Other Carrier	Enter text: The name of the previous insurer. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Other Policy Number	Enter identifier: The policy number of the previous coverage. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Premium	Enter amount: The annual modified premium charged (not including taxes or service charges) for the specified line of business. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Effective Date	Enter date: The effective date of the prior policy. As used here, this applies to the Other line of business.
PRIOR CARRIER INFORMATION	Expiration Date	Enter date: The expiration date of the previous coverage. As used here, this applies to the Other line of business.
LOSS HISTORY	Check if None	Check the box (if applicable): Indicates there are no prior losses or occurrences that may give rise to claims for the mandated number of years.
LOSS HISTORY	Losses Last Number of Years	Enter number: The number of years of loss information required by the insurer.
LOSS HISTORY	Total Losses	Enter amount: The amount that has been paid on all losses to date.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
LOSS HISTORY	Date Of Occurrence	Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY	Line	Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability).
LOSS HISTORY	Type/Description of Occurrence or Claim	Enter text: A brief description of the loss.
LOSS HISTORY	Date of Claim	Enter date: The date the claim was filed.
LOSS HISTORY	Amount Paid	Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY	Amount Reserved	Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY	Subrogation Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in subrogation. As used here, this is the name of the trust.
LOSS HISTORY	Claim Status Open Y / N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is still open. As used here, this is the name of the trust.
GENERAL INFORMATION	Notice Of Information Practices	Check the box (if applicable): Indicates that a copy of the Notice of Information Practices has been given to the applicant.
SIGNATURE SECTION	Producer’s Signature	Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
SIGNATURE SECTION	Producers Name	Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE SECTION	State Producer License Number	Enter identifier: The State License Number of the producer.
SIGNATURE SECTION	Applicant’s Signature	Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION	Date	Enter date: The date the form was signed by the named insured.
SIGNATURE SECTION	National Producer Number	Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number.
Edition	Date	The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).