ACORD 139 (2014/09) - STATEMENT OF VALUES
ACORD 139 (2014/09) - STATEMENT OF VALUES
ACORD 139, Statement of Values was developed to assist in the collection of information when multiple locations owned or operated by the same
insured will be included in an average or blanket rated property insurance policy. This form is not intended to replace specific ACORD applications,
such as ACORD 140, Property Section, or ACORD 160, Business Owners Application. Note: Use ACORD 159, Schedule of Insurance, when an
average or blanket rate does not apply, but multiple locations owned or operated by the same insured will be covered under a single policy, with
separate limits applying to each location.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer / agency.
IDENTIFICATION SECTION
Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION
Phone No.
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax No.
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
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.
ACORD 139 (2014/09) rev. 11-26-2013
Page 1 of 18
IDENTIFICATION SECTION
Page ____ of
Enter number: The page number applicable to this page.
IDENTIFICATION SECTION
Field Box
Enter number: The total number of pages applicable to this form (e.g., Page 1 of 4). If only one
page, indicate Page 1 of 1.
IDENTIFICATION SECTION
Applicant/Named Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Policy #
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
IDENTIFICATION SECTION
Headquarters Address
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION
Coins % 80%
Check the box (if applicable): Indicates that 80% coinsurance is applicable.
IDENTIFICATION SECTION
Coins % 90%
Check the box (if applicable): Indicates that 90% coinsurance is applicable.
IDENTIFICATION SECTION
Coins % 100%
Check the box (if applicable): Indicates that 100% coinsurance is applicable.
IDENTIFICATION SECTION
Check Box Other
Check the box (if applicable): Indicates that a coinsurance percentage other than those listed is
applicable.
IDENTIFICATION SECTION
Other Description
Enter percentage: The coinsurance percentage.
IDENTIFICATION SECTION
Applicable Cause of Loss
Basic
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is basic.
IDENTIFICATION SECTION
Broad
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is broad.
IDENTIFICATION SECTION
Special
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is special.
IDENTIFICATION SECTION
Other
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is other
than those listed.
IDENTIFICATION SECTION
Other Description
Enter text: The cause of loss for the subject of insurance.
IDENTIFICATION SECTION
Earthquake Cov
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is
earthquake.
IDENTIFICATION SECTION
Flood
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is flood.
IDENTIFICATION SECTION
Sprinkler Leakage Excl
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is sprinkler
leakage exclusion.
ACORD 139 (2014/09) rev. 11-26-2013
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IDENTIFICATION SECTION
Vandalism Excl
Check the box (if applicable): Indicates the cause of loss for the subject of insurance is
vandalism exclusion.
IDENTIFICATION SECTION
Specific Average Rate
Check the box (if applicable): Indicates the a specific average rate is being requested.
IDENTIFICATION SECTION
Blanket Rate
Check the box (if applicable): Indicates that a blanket rate is being requested.
IDENTIFICATION SECTION
Other
Check the box (if applicable): Indicates that a rate other than specific average or blanket is
being requested.
IDENTIFICATION SECTION
Other Description
Enter text: The rate that is being requested.
IDENTIFICATION SECTION
Applicable Form Numbers
Enter text: The form numbers, endorsements, options, and any information affecting rates or
loss costs that cannot be shown in the schedule on the form.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
ACORD 139 (2014/09) rev. 11-26-2013
Page 3 of 18
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
ACORD 139 (2014/09) rev. 11-26-2013
Page 4 of 18
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ACORD 139 (2014/09) rev. 11-26-2013
Page 5 of 18
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
ACORD 139 (2014/09) rev. 11-26-2013
Page 6 of 18
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
ACORD 139 (2014/09) rev. 11-26-2013
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STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
ACORD 139 (2014/09) rev. 11-26-2013
Page 8 of 18
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
ACORD 139 (2014/09) rev. 11-26-2013
Page 9 of 18
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ACORD 139 (2014/09) rev. 11-26-2013
Page 10 of 18
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
ACORD 139 (2014/09) rev. 11-26-2013
Page 11 of 18
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
ACORD 139 (2014/09) rev. 11-26-2013
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STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
ACORD 139 (2014/09) rev. 11-26-2013
Page 13 of 18
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
ACORD 139 (2014/09) rev. 11-26-2013
Page 14 of 18
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
ACORD 139 (2014/09) rev. 11-26-2013
Page 15 of 18
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Class Code
Enter code: The Class Code for the exposure described by this Group. This code is derived
from Insurance Services Office or company code list.
STATEMENT OF VALUES
Location #
Enter number: The location number for the premises.
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STATEMENT OF VALUES
Bldg #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
STATEMENT OF VALUES
Description
Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from
other sublocations at a given location. An example might be 3 story blue structure on the left of
the main building.
STATEMENT OF VALUES
Address Of Property
Enter text: The first address line of the commercial structure.
STATEMENT OF VALUES
Enter text: The city of the commercial structure.
STATEMENT OF VALUES
Enter code: The state of the commercial structure.
STATEMENT OF VALUES
Enter code: The postal code of the commercial structure.
STATEMENT OF VALUES
Valuation
Enter code: Indicate the method which will be used to determine the amount paid on a claim. If
other valuation basis applies, provide necessary information.
Example valuation methods are:
A - Actual Cash Value
R - Replacement Cost
V - Agreed Amount
M - Market Value
STATEMENT OF VALUES
Subject
Enter code: The code designating all unit at risk / coverages that are to be insured at this
particular location number / building number combination.
Examples:
B - Building
BUSIN - Business Income with Extra Expense
BUSER - Business Income with Extra Expense and Rental Value
BUSRN - Business Income with Rental Value without Extra Expense
BPP - Business Personal Property
EE - Extra Expense
FF - Furniture & Fixtures
LBI - Loss of Business Income
MACEQ - Machinery, Equipment
PP - Personal Property
POTOP - Property of Others
STK - Stock
STATEMENT OF VALUES
100% Values
Enter amount: The value for each property in accordance with the valuation method and the
subject of insurance. As used here, this is the 100% value.
STATEMENT OF VALUES
Rate or Loss Cost
Enter rate: The class rate information or equivalent information for each location for class rated
property. For specifically rated property, attach specific rate or loss cost information if known.
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STATEMENT OF VALUES
Premium
Enter amount: The premium for this property.
STATEMENT OF VALUES
Total $ Field Box
Enter amount: The total value for all properties in accordance with the valuation method and the
subject of insurance.
STATEMENT OF VALUES
Total $ Field Box
Enter amount: The total premium for all properties.
SIGNATURE SECTION
Insured's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Title
Enter text: The title of the individual in the organization or his relationship to the organization.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured.
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