ACORD 131 (2013/12) - UMBRELLA SECTION

ACORD 131 (2013/12) - UMBRELLA SECTION
ACORD 131, Umbrella / Excess Section, captures information about a liability coverage affording high limit excess and/or extended coverage. It is
a separate policy over and above other basic liability policies the same insured may have. A completed Umbrella / Excess Application consists of
both the Applicant Information Section, ACORD 125 and the Umbrella / Excess Section, ACORD 131. This is necessary because some
information about the applicant is only shown on the Applicant Information Section.
Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Even
though this data matches the data on the ACORD 125, it is still important to complete it. Many companies separate the applications by line of
business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
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
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
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
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
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
POLICY INFORMATION
Transaction Type - New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
POLICY INFORMATION
Renewal
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
POLICY INFORMATION
Umbrella
Check the box (if applicable): Indicates the type of policy is umbrella.
POLICY INFORMATION
Excess
Check the box (if applicable): Indicates the type of policy is excess.
POLICY INFORMATION
Occurrence
Check the box (if applicable): Indicates coverage trigger is on an occurrence basis on an
excess or umbrella liability policy.
ACORD 131 (2013/12) rev. 08-30-201
Page 1 of 25
POLICY INFORMATION
Claims Made
Check the box (if applicable): Indicates the coverage trigger is on a claims-made basis on an
excess or umbrella liability policy.
POLICY INFORMATION
Voluntary
Check the box (if applicable): Indicates if the excess is voluntary.
POLICY INFORMATION
Other
Check the box (if applicable): Indicates the transaction type is other than those listed.
POLICY INFORMATION
Other Description
Enter text: The description of the other transaction type.
POLICY INFORMATION
Expiring Pol #
Enter identifier: The policy number of the previous coverage.
POLICY INFORMATION
Proposed Retroactive Date
Enter date: The retroactive date you are requesting for the policy being applied for. This is the
proposed earliest date for which an occurrence could trigger coverage under a Claims Made
policy.
POLICY INFORMATION
Current Retroactive Date
Enter date: The current retroactive date should be shown if the Umbrella is over a Claims Made
primary policy. If the current retroactive date is different from the proposed retroactive date, an
explanation must be provided.
POLICY INFORMATION
Limit of Liability - Each
Occurrence
Enter limit: The excess umbrella liability each occurrence limit.
POLICY INFORMATION
Limit of Liability
Enter limit: The excess umbrella liability limit other coverage limit should be listed as a whole
dollar amount, as found on the policy declarations page. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
POLICY INFORMATION
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
POLICY INFORMATION
Limit of Liability
Enter limit: The excess umbrella liability limit other coverage limit should be listed as a whole
dollar amount, as found on the policy declarations page. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
POLICY INFORMATION
Enter text: The description of other coverage (not the limit) on the excess umbrella liability
policy. Any questions about appropriate limits or applicable policy coverage(s) should be
answered by the issuing insurer(s).
POLICY INFORMATION
Retained Limit
Enter deductible: The excess or umbrella liability deductible or retention amount.
POLICY INFORMATION
First Dollar Defense
Enter Y for a Yes response. Input N for No response. Indicates that first dollar defense
coverage is requested.
EMPLOYEE BENEFITS
LIABILITY
Limit of Insurance (ea
Employee)
Enter limit: The each employee limit for employee benefits coverage.
EMPLOYEE BENEFITS
LIABILITY
Aggregate Limit for EBL
Enter limit: The aggregate limit for employee benefits coverage.
ACORD 131 (2013/12)
Page 2 of 25
EMPLOYEE BENEFITS
LIABILITY
Retained Limit for EBL
Enter amount: The retention amount for employee benefits coverage.
EMPLOYEE BENEFITS
LIABILITY
Retroactive Date for EBL
Enter date: The retroactive date for employee benefits coverage.
EMPLOYEE BENEFITS
LIABILITY
Name of Benefit Program
Enter text: The full name of the benefit program.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
ACORD 131 (2013/12)
Page 3 of 25
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
ACORD 131 (2013/12)
Page 4 of 25
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
ACORD 131 (2013/12)
Page 5 of 25
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
PRIMARY LOCATION AND
SUBSIDIARIES
Number (#)
Enter number: The location number for the premises.
PRIMARY LOCATION AND
SUBSIDIARIES
Name
Enter text: The name of the location. For commercial policies, this may be a company name.
PRIMARY LOCATION AND
SUBSIDIARIES
Location
Enter text: The first address line of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter text: The city of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The state of the commercial structure.
PRIMARY LOCATION AND
SUBSIDIARIES
Enter code: The postal code of the commercial structure.
ACORD 131 (2013/12)
Page 6 of 25
PRIMARY LOCATION AND
SUBSIDIARIES
Description
Enter text: The description of the operations of this risk. A restatement of the products
classification wording is often not sufficient (e.g., Metal Goods Manufacturing NOC could
include anything from paper clips to bridge girders).
PRIMARY LOCATION AND
SUBSIDIARIES
Annual Payroll
Enter amount: The total annual payroll of the business in whole dollars.
PRIMARY LOCATION AND
SUBSIDIARIES
Ann. Gross Sales
Enter amount: The total annual gross sales or receipts.
PRIMARY LOCATION AND
SUBSIDIARIES
Foreign Sales
Enter amount: The estimated annual foreign gross sales.
PRIMARY LOCATION AND
SUBSIDIARIES
# Empl.
Enter number: The number of employees.
UNDERLYING INSURANCE
Carrier / Policy Number
Enter text: The full name of the insurer of the underlying automobile policy.
UNDERLYING INSURANCE
Enter identifier: The policy number of the underlying automobile policy.
UNDERLYING INSURANCE
Policy Effective Date
Enter date: The effective date of the underlying automobile policy.
UNDERLYING INSURANCE
Policy Expiration Date
Enter date: The expiration date of the underlying automobile policy.
UNDERLYING INSURANCE
Limits - CSL Ea Acc
Enter limit: The vehicle combined single limit liability each accident amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, this is on the underlying automobile policy.
UNDERLYING INSURANCE
BI Ea Acc
Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, this is on the underlying automobile policy.
UNDERLYING INSURANCE
BI Ea Per
Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, this is on the underlying automobile policy.
UNDERLYING INSURANCE
PD Ea Acc
Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, this is on the underlying automobile policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The combined single limit premium on the underlying automobile policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The bodily injury premium amount on the underlying automobile policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The property damage premium amount on the underlying automobile policy.
UNDERLYING INSURANCE
Rating Mod
Enter rate: The combined rating modification and experience modification debit or credit as they
apply.
UNDERLYING INSURANCE
General Liability - Occur
Check the box (if applicable): Indicates the general liability policy, occurrence basis applies. As
used here, this is on the underlying general liability policy.
ACORD 131 (2013/12)
Page 7 of 25
UNDERLYING INSURANCE
Claims Made
Check the box (if applicable): Indicates the claims made option applies on the general liability
policy. As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Carrier / Policy Number
Enter text: The full name of the insurer of the underlying general liability policy.
UNDERLYING INSURANCE
Enter identifier: The policy number of the underlying general liability policy.
UNDERLYING INSURANCE
Policy Effective Date
Enter date: The effective date of the underlying general liability policy.
UNDERLYING INSURANCE
Policy Expiration Date
Enter date: The expiration date of the underlying general liability policy.
UNDERLYING INSURANCE
Each Occurrence
Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate
limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used
here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
General Aggr
Enter limit: The general liability, general aggregate limit amount. Any questions about
appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Prod & Comp Ops
Aggregate
Enter limit: The general liability, products and completed operations aggregate limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s). As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Personal & Adv Injury
Enter limit: The general liability, personal and advertising injury limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s). As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Damage To Rented
Premises
Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any
questions about appropriate limits or applicable policy coverage(s) should be answered by the
issuing insurer(s). As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Medical Expense
Enter limit: The general liability, medical expense each person limit amount. Any questions
about appropriate limits or applicable policy coverage(s) should be answered by the issuing
insurer(s). As used here, this is on the underlying general liability policy.
UNDERLYING INSURANCE
Prem / Ops
Enter amount: The premises operations premium amount on the underlying general liability
policy.
UNDERLYING INSURANCE
Products
Enter amount: The products premium on the underlying general liability policy.
UNDERLYING INSURANCE
Other
Enter amount: The premium associated with other coverages on the underlying general liability
policy.
UNDERLYING INSURANCE
Rating Mod
Enter rate: The combined rating modification and experience modification debit or credit as they
apply.
UNDERLYING INSURANCE
Employers Liability -
Carrier/Policy Number
Enter text: The full name of the insurer of the underlying employers liability policy.
UNDERLYING INSURANCE
Enter identifier: The policy number of the underlying employers liability policy.
ACORD 131 (2013/12)
Page 8 of 25
UNDERLYING INSURANCE
Policy Effective Date
Enter date: The effective date of the underlying employers liability policy.
UNDERLYING INSURANCE
Policy Expiration Date
Enter date: The expiration date of the underlying employers liability policy.
UNDERLYING INSURANCE
Each Accident
Enter limit: The workers compensation and employers liability policy, employers liability each
accident limit amount. Any questions about appropriate limits or applicable policy coverage(s)
should be answered by the issuing insurer(s). As used here, this is on the underlying employers
liability policy.
UNDERLYING INSURANCE
Disease Each Employee
Enter limit: The workers compensation and employers liability policy, employers liability disease
each employee limit amount. Any questions about appropriate limits or applicable policy
coverage(s) should be answered by the issuing insurer(s). As used here, this is on the
underlying employers liability policy.
UNDERLYING INSURANCE
Disease Policy Limit
Enter limit: The workers compensation and employers liability policy, employers liability disease
policy limit amount. Any questions about appropriate limits or applicable policy coverage(s)
should be answered by the issuing insurer(s). As used here, this is on the underlying employers
liability policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The premium amount on the underlying employers liability policy.
UNDERLYING INSURANCE
Rating Mod
Enter rate: The combined rating modification and experience modification debit or credit as they
apply.
UNDERLYING INSURANCE
Blank Space - Type
Enter text: The description of the underlying policy type.
UNDERLYING INSURANCE
Carrier
Enter text: The full name of the insurer of the underlying policy.
UNDERLYING INSURANCE
Policy Number
Enter identifier: The policy number of the underlying policy.
UNDERLYING INSURANCE
Policy Effective Date
Enter date: The effective date of the underlying policy.
UNDERLYING INSURANCE
Policy Expiration Date
Enter date: The expiration date of the underlying policy.
UNDERLYING INSURANCE
Limits
Enter text: The description of the coverage.
UNDERLYING INSURANCE
Enter limit: The combined single or total limit on the underlying policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The premium amount on the underlying policy.
UNDERLYING INSURANCE
Rating Mod
Enter rate: The combined rating modification and experience modification debit or credit as they
apply.
UNDERLYING INSURANCE
Type
Enter text: The description of the underlying policy type.
UNDERLYING INSURANCE
Carrier
Enter text: The full name of the insurer of the underlying policy.
UNDERLYING INSURANCE
Policy Number
Enter identifier: The policy number of the underlying policy.
UNDERLYING INSURANCE
Policy Effective Date
Enter date: The effective date of the underlying policy.
ACORD 131 (2013/12)
Page 9 of 25
UNDERLYING INSURANCE
Policy Expiration Date
Enter date: The expiration date of the underlying policy.
UNDERLYING INSURANCE
Limits
Enter text: The description of the coverage.
UNDERLYING INSURANCE
Enter limit: The combined single or total limit on the underlying policy.
UNDERLYING INSURANCE
Annual Renewal Premium
Enter amount: The premium amount on the underlying policy.
UNDERLYING INSURANCE
Rating Mod
Enter rate: The combined rating modification and experience modification debit or credit as they
apply.
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).
UNDERLYING INSURANCE
(continued)
1. Are defense costs - Within
Aggregate Limits?
Check the box (if applicable): Indicates defense costs are within aggregate limits.
UNDERLYING INSURANCE
(continued)
A Separate Limit?
Check the box (if applicable): Indicates defense costs a separate limit?
UNDERLYING INSURANCE
(continued)
Unlimited?
Check the box (if applicable): Indicates defense costs are unlimited.
UNDERLYING INSURANCE
(continued)
2. Indicate the edition date
of the ISO form or similar
filing for the
underlying coverage
Enter date: The edition date of the underlying general liability coverage form. Policy coverage
may vary depending on the edition date of the policy paper. The underlying general liability
coverage forms issued by Insurances Services Office (ISO) vary if they are based on the rules
of 86 or the rules of 88.
UNDERLYING INSURANCE
(continued)
3. Has any product, work,
accident, or location been
excluded, uninsured or
self insured from any
previous coverage?
Enter Y for a Yes response. Input N for No response. The response to the question, Has any
product, work, accident, or location been excluded, uninsured or self insured from any previous
coverage?.
UNDERLYING INSURANCE
(continued)
Remarks
Enter text: An explanation as to whether any product, work, accident or location has been
excluded, uninsured or self-insured from any previous coverage.
UNDERLYING INSURANCE
(continued)
4. For Claims Made, indicate
the retroactive date of
current underlying
policy
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
ACORD 131 (2013/12)
Page 10 of 25
UNDERLYING INSURANCE
(continued)
5. For Claims Made, indicate
entry date into
uninterrupted Claims Made
coverage
Enter date: The retroactive date shown on the applicant's first Claims Made policy. If this is the
first such policy, the date will be the same as the proposed retroactive date shown on the
preceding field. If this is a renewal, it is the effective date of the first policy issued in the
sequence of uninterrupted Claims Made policies.
UNDERLYING INSURANCE
(continued)
6. For Claims Made, was
tail coverage purchased
for any previous primary or
excess policy?
Enter Y for a Yes response. Input N for No response. The response to the question, For
Claims made, was tail coverage purchased for any previous primary or excess policy?.
UNDERLYING INSURANCE
(continued)
Effective Date
Enter date: The effective date of the tail coverage. The proposed retroactive date for the policy
being applied for should not be earlier than the effective date of the tail coverage.
UNDERLYING INSURANCE
(continued)
Remarks
Enter text: An explanation as to whether tail coverage was purchased for any previous primary
or excess policy.
UNDERLYING INSURANCE
(continued)
Coverage/Exposure - Any
Auto - Coverage
Check the box (if applicable): Indicates the underlying policy coverage any automobile (symbol
1).
UNDERLYING INSURANCE
(continued)
CGL - Claims Made -
Coverage
Check the box (if applicable): Indicates the underlying general liability policy is a claims made
policy.
UNDERLYING INSURANCE
(continued)
CGL - Occurrence -
Coverage
Check the box (if applicable): Indicates the underlying general liability policy is an occurrence
policy.
UNDERLYING INSURANCE
(continued)
Aircraft Liability - Coverage
Check the box (if applicable): Indicates the underlying policy includes aircraft liability coverage.
UNDERLYING INSURANCE
(continued)
Aircraft Liability - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for aircraft liability coverage.
UNDERLYING INSURANCE
(continued)
Aircraft Passenger Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes aircraft passenger liability
coverage.
UNDERLYING INSURANCE
(continued)
Aircraft Passenger Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for aircraft passenger liability
coverage.
UNDERLYING INSURANCE
(continued)
Additional Interests -
Coverage
Check the box (if applicable): Indicates the underlying policy includes additional interests
coverage.
UNDERLYING INSURANCE
(continued)
Additional Interests -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for additional interests coverage.
UNDERLYING INSURANCE
(continued)
Care, Custody, Control -
Coverage
Check the box (if applicable): Indicates the underlying policy includes care, custody and control
coverage.
ACORD 131 (2013/12)
Page 11 of 25
UNDERLYING INSURANCE
(continued)
Care, Custody, Control -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for care, custody and control
coverage.
UNDERLYING INSURANCE
(continued)
Employee Benefit Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes employee benefits liability
coverage.
UNDERLYING INSURANCE
(continued)
Employee Benefit Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for employee benefits liability
coverage.
UNDERLYING INSURANCE
(continued)
Foreign Liability / Travel -
Coverage
Check the box (if applicable): Indicates the underlying policy includes foreign liability/travel
coverage.
UNDERLYING INSURANCE
(continued)
Foreign Liability / Travel -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for foreign liability/travel coverage.
UNDERLYING INSURANCE
(continued)
Garage Keepers Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes garage keepers liability
coverage.
UNDERLYING INSURANCE
(continued)
Garage Keepers Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for garage keepers liability
coverage.
UNDERLYING INSURANCE
(continued)
Incidental Medical
Malpractice - Coverage
Check the box (if applicable): Indicates the underlying policy includes incidental medical
malpractice coverage.
UNDERLYING INSURANCE
(continued)
Incidental Medical
Malpractice - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for incidental medical malpractice
coverage.
UNDERLYING INSURANCE
(continued)
Liquor Liability - Coverage
Check the box (if applicable): Indicates the underlying policy includes liquor liability coverage.
UNDERLYING INSURANCE
(continued)
Liquor Liability - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for liquor liability coverage.
UNDERLYING INSURANCE
(continued)
Pollution Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes pollution liability coverage.
UNDERLYING INSURANCE
(continued)
Pollution Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for pollution liability coverage.
UNDERLYING INSURANCE
(continued)
Professional Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes professional liability (errors
and omissions) coverage.
UNDERLYING INSURANCE
(continued)
Professional Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for professional liability (errors and
omissions) coverage.
ACORD 131 (2013/12)
Page 12 of 25
UNDERLYING INSURANCE
(continued)
Vendor Liability - Coverage
Check the box (if applicable): Indicates the underlying policy includes vendors liability coverage.
UNDERLYING INSURANCE
(continued)
Vendor Liability - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for vendors liability coverage.
UNDERLYING INSURANCE
(continued)
Watercraft Liability -
Coverage
Check the box (if applicable): Indicates the underlying policy includes watercraft liability
coverage.
UNDERLYING INSURANCE
(continued)
Watercraft Liability -
Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for watercraft liability coverage.
UNDERLYING INSURANCE
(continued)
Other - Coverage
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed.
UNDERLYING INSURANCE
(continued)
Other - Description
Enter text: The description of the coverage.
UNDERLYING INSURANCE
(continued)
Other - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for the coverage described.
UNDERLYING INSURANCE
(continued)
Other - Coverage
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed.
UNDERLYING INSURANCE
(continued)
Other - Description
Enter text: The description of the coverage.
UNDERLYING INSURANCE
(continued)
Other - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for the coverage described.
UNDERLYING INSURANCE
(continued)
Other - Coverage
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed.
UNDERLYING INSURANCE
(continued)
Other - Description
Enter text: The description of the coverage.
UNDERLYING INSURANCE
(continued)
Other - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for the coverage described.
UNDERLYING INSURANCE
(continued)
Other - Coverage
Check the box (if applicable): Indicates the underlying policy includes a coverage not listed.
UNDERLYING INSURANCE
(continued)
Other - Description
Enter text: The description of the coverage.
UNDERLYING INSURANCE
(continued)
Other - Exposure
Check the box (if applicable): Indicates the limits are less than those shown on the underlying
insurance section of the form causing an exposure to exists for the coverage described.
UNDERLYING INSURANCE
(continued)
Underlying Insurance
Coverage Information
Enter text: The description of underlying insurance coverage information including all restrictions
(e.g. laser endorsements, discrimination, subrogation waivers) or extensions of coverage.
ACORD 131 (2013/12)
Page 13 of 25
UNDERLYING INSURANCE
(continued)
Previous Experience
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
ACORD 131 (2013/12)
Page 14 of 25
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
Enter date: The date the claim was filed.
UNDERLYING INSURANCE
(continued)
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
UNDERLYING INSURANCE
(continued)
Enter text: A brief description of the loss.
UNDERLYING INSURANCE
(continued)
Enter amount: The amount that has been paid on this claim to date.
UNDERLYING INSURANCE
(continued)
Enter amount: The reserve amount the previous carrier is holding open for this claim.
UNDERLYING INSURANCE
(continued)
No Such Claims
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. As used here, also indicates there were no
claims exceeding $10,000.
CARE, CUSTODY,
CONTROL
Loc
Enter number: The producer assigned number for the location if applicable to the ACORD 125.
CARE, CUSTODY,
CONTROL
Real Property/Personal
Property
Check the box (if applicable): Indicates the property in the care, custody and control of the
insured is real property.
ACORD 131 (2013/12)
Page 15 of 25
CARE, CUSTODY,
CONTROL
Personal Property
Check the box (if applicable): Indicates the property in the care, custody and control of the
insured is personal property.
CARE, CUSTODY,
CONTROL
Value
Enter amount: The value of the entire building, not just the portion occupied, for real property or
the value of the personal property.
CARE, CUSTODY,
CONTROL
A, B, C, D
Check the box (if applicable): Indicates the insured is held harmless in the lease.
CARE, CUSTODY,
CONTROL
B
Check the box (if applicable): Indicates the insured has a waiver of subrogation.
CARE, CUSTODY,
CONTROL
C
Check the box (if applicable): Indicates the insured is a named insured on the fire policy.
CARE, CUSTODY,
CONTROL
D
Enter text: The description of the insured's liability for the described premises when other than
those listed.
CARE, CUSTODY,
CONTROL
Sq Ft of Bldg Occ
Enter number: The total square footage of the premises occupied by the applicant.
CARE, CUSTODY,
CONTROL
Occupancy / Description of
Personal Property
Enter text: The description of the building occupancy or of the property held by the insured in his
care, custody and control.
VEHICLES
# Owned
Enter number: The number of owned private passenger vehicles.
VEHICLES
# Non-owned
Enter number: The number of non-owned private passenger vehicles.
VEHICLES
# Leased
Enter number: The number of leased private passenger vehicles.
VEHICLES
Property Hauled
Enter text: The description of property hauled in private passenger vehicles.
VEHICLES
Local
Enter number: The number of private passenger vehicles that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local..
VEHICLES
Intermediate
Enter number: The number of private passenger vehicles that fall within the category of
intermediate radius/distance in accordance with a company's rating rules. The Insurance
Services Office maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of private passenger vehicles that fall within the category of long
distance radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned light weight trucks.
VEHICLES
# Non-owned
Enter number: The number of non-owned light weight trucks.
VEHICLES
# Leased
Enter number: The number of leased light weight trucks.
VEHICLES
Property Hauled
Enter text: The description of property hauled in light weight trucks.
ACORD 131 (2013/12)
Page 16 of 25
VEHICLES
Local
Enter number: The number of light weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local.
VEHICLES
Intermediate
Enter number: The number of light weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of light weight trucks that fall within the category of long distance
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned medium weight trucks.
VEHICLES
# Non-owned
Enter number: The number of non-owned medium weight trucks.
VEHICLES
# Leased
Enter number: The number of leased medium weight trucks.
VEHICLES
Property Hauled
Enter text: The description of property hauled in medium weight trucks.
VEHICLES
Local
Enter number: The number of medium weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local.
VEHICLES
Intermediate
Enter number: The number of medium weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of medium weight trucks that fall within the category of long distance
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned heavy weight trucks.
VEHICLES
# Non-owned
Enter number: The number of non-owned heavy weight trucks.
VEHICLES
# Leased
Enter number: The number of leased heavy weight trucks.
VEHICLES
Property Hauled
Enter text: The description of property hauled in heavy weight trucks.
VEHICLES
Local
Enter number: The number of heavy weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local.
VEHICLES
Intermediate
Enter number: The number of heavy weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of heavy weight trucks that fall within the category of long distance
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of long distance.
ACORD 131 (2013/12)
Page 17 of 25
VEHICLES
# Owned
Enter number: The number of owned extra heavy weight trucks.
VEHICLES
# Non-owned
Enter number: The number of non-owned extra heavy weight trucks.
VEHICLES
# Leased
Enter number: The number of leased extra heavy weight trucks.
VEHICLES
Property Hauled
Enter text: The description of property hauled in extra heavy weight trucks.
VEHICLES
Local
Enter number: The number of extra heavy weight trucks that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local.
VEHICLES
Intermediate
Enter number: The number of extra heavy weight trucks. that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of extra heavy weight trucks that fall within the category of long
distance radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned heavy weight truck tractors.
VEHICLES
# Non-owned
Enter number: The number of non-owned heavy weight truck tractors.
VEHICLES
# Leased
Enter number: The number of leased heavy weight truck tractors.
VEHICLES
Property Hauled
Enter text: The description of property hauled in heavy weight truck tractors.
VEHICLES
Local
Enter number: The number of heavy weight truck tractors that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of local.
VEHICLES
Intermediate
Enter number: The number of heavy weight truck tractors that fall within the category of local
radius/distance in accordance with a company's rating rules. The Insurance Services Office
maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of heavy weight truck tractors that fall within the category of long
distance radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned extra heavy weight truck tractors.
VEHICLES
# Non-owned
Enter number: The number of non-owned extra heavy weight truck tractors.
VEHICLES
# Leased
Enter number: The number of leased extra heavy weight truck tractors.
VEHICLES
Property Hauled
Enter text: The description of property hauled in extra heavy weight truck tractors.
VEHICLES
Local
Enter number: The number of extra heavy weight truck tractors that fall within the category of
local radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of local.
ACORD 131 (2013/12)
Page 18 of 25
VEHICLES
Intermediate
Enter number: The number of extra heavy weight truck tractors that fall within the category of
local radius/distance in accordance with a company's rating rules. The Insurance Services
Office maintains the definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of extra heavy weight truck tractors that fall within the category of
long distance radius/distance in accordance with a company's rating rules. The Insurance
Services Office maintains the definition of long distance.
VEHICLES
# Owned
Enter number: The number of owned buses.
VEHICLES
# Non-owned
Enter number: The number of non-owned buses.
VEHICLES
# Leased
Enter number: The number of leased buses.
VEHICLES
Property Hauled
Enter text: The description of property hauled in buses.
VEHICLES
Local
Enter number: The number of buses that fall within the category of local radius/distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of local.
VEHICLES
Intermediate
Enter number: The number of buses that fall within the category of local radius/distance in
accordance with a company's rating rules. The Insurance Services Office maintains the
definition of intermediate.
VEHICLES
Long Distance
Enter number: The number of buses that fall within the category of long distance radius/distance
in accordance with a company's rating rules. The Insurance Services Office maintains the
definition of long distance.
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).
ADDITIONAL EXPOSURES
1. Media used, annual costs
Enter code: The type of advertising media used (e.g. Print, Television, Radio, etc.)
ADDITIONAL EXPOSURES
Annual Cost
Enter amount: The annual cost of the advertising media used.
ADDITIONAL EXPOSURES
2. Services of advertising
agency used?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
services of an Advertising Agency used?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any services from an advertising agency have been
used.
ADDITIONAL EXPOSURES
3. Any coverage provided
under agency's policy?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
coverage provided under agency's policy?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any coverage has been provided under the agency's
policy.
ACORD 131 (2013/12)
Page 19 of 25
ADDITIONAL EXPOSURES
4. Does applicant own, lease
or operate aircraft?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant own/lease/operate aircraft?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether the applicant owns/leases or operates aircraft.
ADDITIONAL EXPOSURES
5. Are explosives, caustics,
flammables or other
dangerous cargo hauled?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
explosives, caustics, flammables or other dangerous cargo hauled?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any explosives, caustics, flammable or other
dangerous cargo is hauled.
ADDITIONAL EXPOSURES
6. Are passengers carried
for a fee?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
passengers carried for a fee?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any passengers are carried for a fee.
ADDITIONAL EXPOSURES
7. Any units not insured by
underlying policies?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
units not insured by underlying policies?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any units are not insured by underlying policies.
ADDITIONAL EXPOSURES
8. Are any vehicles leased or
rented to others?
Enter Y for a Yes response. Input N for No response. The response to the question, Are any
vehicles leased or rented to others?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any vehicles are leased or rented to others.
ADDITIONAL EXPOSURES
9. Is Hired and Non-Owned
coverage provided?
Enter Y for a Yes response. Input N for No response. The response to the question, Is hired
and non-owned coverage provided?
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any hired and non-owned coverages are provided.
ADDITIONAL EXPOSURES
10. Is bridge, dam or marine
work performed?
Enter Y for a Yes response. Input N for No response. The response to the question, Is
bridge, dam or marine work performed?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether any bridge, dam, or marine work is performed.
ADDITIONAL EXPOSURES
11. Describe typical jobs
performed
Enter text: The description of work performed by the insured. ACORD 101, Additional Remarks
Schedule, may be attached if more space is required.
ADDITIONAL EXPOSURES
12. Describe agreement
Enter text: The description of the contractual agreement(s) pertaining to the work performed.
ACORD 101, Additional Remarks Schedule, may be attached if more space is required.
ADDITIONAL EXPOSURES
13. Does applicant own,
rent, or otherwise use
cranes?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant own, rent or otherwise use cranes?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether the applicant owns, rents or uses cranes.
ACORD 131 (2013/12)
Page 20 of 25
ADDITIONAL EXPOSURES
14. Do subcontractors carry
coverages or limits less
than applicant?
Enter Y for a Yes response. Input N for No response. The response to the question, Do
subcontractors carry coverages or limits less than applicant?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether subcontractors carry coverages or limits less than
applicant.
ADDITIONAL EXPOSURES
15. Is applicant self-insured
in any state?
Enter Y for a Yes response. Input N for No response. The response to the question, Is
applicant self-insured in any state?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether the applicant is self-insured in any state.
ADDITIONAL EXPOSURES
16. Regulation: - Jones Act
Check the box (if applicable): Indicates the employee/self-insured is subject to the Jones Act.
ADDITIONAL EXPOSURES
FELA
Check the box (if applicable): Indicates the employee/self-insured is subject to the Federal
Employers Liability Act.
ADDITIONAL EXPOSURES
Stop Gap
Check the box (if applicable): Indicates the employee/self-insured is subject to Stop Gap.
ADDITIONAL EXPOSURES
Other
Check the box (if applicable): Indicates the employee/self-insured is subject to regulations not
listed.
ADDITIONAL EXPOSURES
Other Description
Enter text: The description of the regulations the employee/self-insured is subject to.
ADDITIONAL EXPOSURES
17. Hospital or first aid
facility maintained?
Enter Y for a Yes response. Input N for No response. The response to the question, Hospital
or first aid facility maintained?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether a hospital or first aid facility is maintained.
ADDITIONAL EXPOSURES
18. Coverage provided for
doctors/nurses?
Enter Y for a Yes response. Input N for No response. The response to the question,
Coverage provided for doctors/nurses?.
ADDITIONAL EXPOSURES
Remarks
Enter text: An explanation as to whether coverages are provided for doctors/nurses.
ADDITIONAL EXPOSURES
19. Indicate # of doctors,
nurses, beds.
Enter number: The number of doctors.
ADDITIONAL EXPOSURES
Nurses
Enter number: The number of nurses.
ADDITIONAL EXPOSURES
Beds
Enter number: The number of beds/bunks.
Form Page 4
Section Name
Field Name
Description
ADDITIONAL EXPOSURES
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ADDITIONAL EXPOSURES
(continued)
EPA #
Enter identifier: The number assigned to the insured by the Environmental Protection Agency.
ACORD 131 (2013/12)
Page 21 of 25
ADDITIONAL EXPOSURES
(continued)
20. Do current or past
products, or their
components, contain
hazardous materials that
may require special disposal
methods?
Enter Y for a Yes response. Input N for No response. The response to the question, Do
current or past products, or their components, contain hazardous materials that may require
special disposal methods?.
ADDITIONAL EXPOSURES
(continued)
Remarks
Enter text: An explanation as to whether current or past products, or their components, contain
hazardous materials that may require special disposal methods.
ADDITIONAL EXPOSURES
(continued)
21. Indicate the coverages
carried: - GL with Standard
ISO Pollution Exclusion
Check the box (if applicable): Indicates the insured carries a general liability policy with standard
Insurance Services Office pollution exclusion coverage.
ADDITIONAL EXPOSURES
(continued)
GL with Standard Sudden &
Accidental Only
Check the box (if applicable): Indicates the insured carries a general liability policy with standard
sudden and accidental only coverage.
ADDITIONAL EXPOSURES
(continued)
GL with Pollution Coverage
Endorsement
Check the box (if applicable): Indicates the insured carries a general liability policy with a
pollution coverage endorsement.
ADDITIONAL EXPOSURES
(continued)
Separate Pollution Coverage
Check the box (if applicable): Indicates the insured carries separate pollution coverage.
ADDITIONAL EXPOSURES
(continued)
22. Are missiles, engines,
guidance systems, frames
or any other product
used/installed in aircraft?
Enter Y for a Yes response. Input N for No response. The response to the question, Are
missiles, engines, guidance systems, frames or any other product used/installed in aircraft?.
ADDITIONAL EXPOSURES
(continued)
Remarks
Enter text: An explanation as to whether missiles, engines, guidance systems, frames or any
other product is used/installed in an aircraft.
ADDITIONAL EXPOSURES
(continued)
23. Any foreign operations,
foreign products distributed
in the USA or US products
sold / distributed in foreign
countries? (If YES, Attach
ACORD 815)
Enter Y for a Yes response. Input N for No response. The response to the question, Any
foreign operations, foreign products distributed in USA, or US products sold / distributed in
foreign countries?.
ADDITIONAL EXPOSURES
(continued)
24. Product liability loss in
past three (3) years?
Enter Y for a Yes response. Input N for No response. The response to the question, Any
product liability loss in past specified number of years?.
ADDITIONAL EXPOSURES
(continued)
Remarks
Enter text: An explanation of any product liability loss in the past three (3) years.
ADDITIONAL EXPOSURES
(continued)
25. Gross sales from each of
the last three (3) years.
Enter amount: The gross sales or receipts amount.
ACORD 131 (2013/12)
Page 22 of 25
ADDITIONAL EXPOSURES
(continued)
Gross Sales
Enter amount: The gross sales or receipts amount.
ADDITIONAL EXPOSURES
(continued)
Gross Sales
Enter amount: The gross sales or receipts amount.
ADDITIONAL EXPOSURES
(continued)
26. Describe independent
contractors
Enter text: The description of independent contractors. ACORD 101, Additional Remarks
Schedule, may be attached if more space is required.
ADDITIONAL EXPOSURES
(continued)
27. Does applicant own or
lease watercraft?
Enter Y for a Yes response. Input N for No response. The response to the question, Does
applicant own or lease watercraft?.
ADDITIONAL EXPOSURES
(continued)
Loc #
Enter number: The location number for the premises.
ADDITIONAL EXPOSURES
(continued)
# Owned
Enter number: The number of watercraft owned. As used here, the number of watercraft owned
of the same type.
ADDITIONAL EXPOSURES
(continued)
Length
Enter number: The length of the watercraft expressed in feet.
ADDITIONAL EXPOSURES
(continued)
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.
ADDITIONAL EXPOSURES
(continued)
Loc #
Enter number: The location number for the premises.
ADDITIONAL EXPOSURES
(continued)
# Owned
Enter number: The number of watercraft owned. As used here, the number of watercraft owned
of the same type.
ADDITIONAL EXPOSURES
(continued)
Length
Enter number: The length of the watercraft expressed in feet.
ADDITIONAL EXPOSURES
(continued)
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.
ADDITIONAL EXPOSURES
(continued)
Loc #
Enter number: The location number for the premises.
ADDITIONAL EXPOSURES
(continued)
# Stories
Enter number: The number of stories, counting the ground floor as one, which this building has.
ADDITIONAL EXPOSURES
(continued)
# Units
Enter number: The number of separate living units in the structure.
ADDITIONAL EXPOSURES
(continued)
# Swimming Pools
Enter number: The number of swimming pools on the premises.
ACORD 131 (2013/12)
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ADDITIONAL EXPOSURES
(continued)
# Diving Boards
Enter number: The number of diving boards on the premises.
ADDITIONAL EXPOSURES
(continued)
Loc #
Enter number: The location number for the premises.
ADDITIONAL EXPOSURES
(continued)
# Stories
Enter number: The number of stories, counting the ground floor as one, which this building has.
ADDITIONAL EXPOSURES
(continued)
# Units
Enter number: The number of separate living units in the structure.
ADDITIONAL EXPOSURES
(continued)
# Swimming Pools
Enter number: The number of swimming pools on the premises.
ADDITIONAL EXPOSURES
(continued)
# Diving Boards
Enter number: The number of diving boards on the premises.
REMARKS
Remarks
Enter text: The remarks associated with the commercial umbrella line of business. ACORD
101, Additional Remarks Schedule, may be attached if more space is required.
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).
SIGNATURE
Uninsured Motorists (UM)
Coverage
Enter limit: The limit for commercial umbrella / excess uninsured motorists coverage (if
applicable in your states).
SIGNATURE
Underinsured Motorists
(UIM) Coverage
Enter limit: The limit for commercial umbrella / excess underinsured motorists coverage (if
applicable in your state).
SIGNATURE
Medical Payments Coverage
Enter limit: The limit for commercial umbrella / excess medical payments coverage (if applicable
in your states).
SIGNATURE
Applicable Only in Louisiana
- 1. I Select UM Limits
Initial here: The named insured's initials. As used here, applicable in Louisiana.
SIGNATURE
2. I Reject UM Coverage
Initial here: The named insured's initials. As used here, applicable in Louisiana.
SIGNATURE
Applicable Only in New
Hampshire - 1. I Select UM
Limits
Initial here: The named insured's initials. As used here, applicable in New Hampshire.
SIGNATURE
2. I Reject UM Coverage
Initial here: The named insured's initials. As used here, applicable in New Hampshire.
ACORD 131 (2013/12)
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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.
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer. As used here, this is required in
Florida.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 131 (2013/12)
Page 25 of 25