Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 190 (2013/09)
Supplemental Property Application
ACORD 190, Supplemental Property Application, is used to collect
additional detailed underwriting information on property risks which are susceptible to
arson or other fraudulent losses. This application may be used in conjunction with
ACORD 140, Property Section; ACORD 160, Business Owners Section; ACORD 402,
Agriculture Property Section; ACORD 80, Homeowners Application and ACORD 89,
Residential Section.
The Supplemental Property Application is a uniquely designed ACORD application. Yes
responses to the underwriting questions on page 1 should be explained in detail in
corresponding sections on the application.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
LOC #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
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.
LOCATION OF PROPERTY
Street
Enter text: The first address line of the physical location.
LOCATION OF PROPERTY
Enter text: The city of the physical location.
LOCATION OF PROPERTY
Enter text: The county of the location.
LOCATION OF PROPERTY
Enter code: The state or province of the physical location.
LOCATION OF PROPERTY
Enter code: The postal code of the physical location.
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Section Name
Field Name
Field and/or Section Description
UNDERWRITING
INFORMATION
Is the applicant other than an
individual or a sole
proprietorship?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the applicant other than an individual or a sole proprietorship?. As used
here, if Yes, complete section (A) on page 2.
UNDERWRITING
INFORMATION
Are mortgage payments overdue
by three months or more?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are mortgage payments overdue by three months or more?. As used here, if
Yes, complete section (B) on page 2.
UNDERWRITING
INFORMATION
Are tax liens against this property
or business taxes unpaid or
overdue for one year or more?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are tax liens against this property or business taxes unpaid or overdue for one
year or more?. As used here, if Yes, complete section (B) on page 2.
UNDERWRITING
INFORMATION
Are there any current violations of
fire, safety, health, building or
construction codes at any listed
locations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are there any current violations of fire, safety, health, building or construction
codes at any listed locations?. As used here, if Yes, complete section (C) on page 2.
UNDERWRITING
INFORMATION
During the last ten years, has
anyone with a financial interest in
this property including the
mortgagee been convicted of any
degree of arson, fraud, or other
crime related to loss on this or any
other property?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, During the last 10 years, has anyone with a financial interest in this property
including the mortgagee (if other than a federally or state chartered lending institution)
been convicted of any degree of arson, fraud, or other crime related to loss on this or any
other property? (In RI, failure to disclose the existence of an arson conviction is a
misdemeanor punishable by a sentence of up to one year of imprisonment.). As used
here, if Yes, complete section (D) on page 2.
UNDERWRITING
INFORMATION
During the last ten years, has
anyone with a financial interest in
this property including the
mortgagee had any fire or
explosion losses exceeding $1,000
on this or any other property?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, During the last 10 years, has anyone with a financial interest in this property
including the mortgagee (if other than a federally or state chartered lending institution) had
any fire or explosion losses exceeding $1,000 on this or any other property?. As used
here, if Yes, complete section (D) on page 2.
UNDERWRITING
INFORMATION
Is the lender other than a federally
or state chartered lending
institution?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the lender other than a federally or state chartered lending institution?. As
used here, if Yes, complete section (E) on page 2.
UNDERWRITING
INFORMATION
Is any portion of the building
vacant, unoccupied or seasonal?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is any portion of the building vacant, unoccupied or seasonal?. As used here, if
Yes, complete section (F) on page 2.
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Section Name
Field Name
Field and/or Section Description
UNDERWRITING
INFORMATION
If an apartment, are more than
10% of the rental units
unoccupied?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, If an apartment, are more than 10% of the rental units unoccupied? As used
here, if Yes, complete section (F) on page 2.
UNDERWRITING
INFORMATION
Is there any other insurance in
force or to be secured on this
property?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there any other insurance in force or to be secured on this property?. As
used here, if Yes, complete section (G) on page 2.
BUILDING INFORMATION
H. Purchase Date
Enter date: The date the property was purchased, (MM/DD/YYYY). As used here, if within
the last 3 years, complete Real Estate Transactions information, section (H), on page 2.
BUILDING INFORMATION
Purchase Price
Enter amount: The amount the insured paid for the property.
BUILDING INFORMATION
Rental Income
Enter amount: The expected annual rental income amount.
BUILDING INFORMATION
Approximate Cost of Subsequent
Improvements
Enter amount: The approximate cost of subsequent improvements to the property.
BUILDING INFORMATION
Approximate Replacement Costs
Enter amount: The estimated total dollar amount required to rebuild the building, without
depreciation, in case of total loss.
BUILDING INFORMATION
Approximate Fair Market Value
(Exclusive of Land)
Enter amount: The current market value for which the building could be sold (exclusive of
land).
BUILDING INFORMATION
Indicate the value used to
determine the amount of:
Purchase Price
Check the box (if applicable): Indicates the purchase prices was used to determine the
amount of insurance.
BUILDING INFORMATION
Replace Cost
Check the box (if applicable): Indicates the replacement cost was used to determine the
amount of insurance.
BUILDING INFORMATION
Fair Mkt Value
Check the box (if applicable): Indicates the fair market value was used to determine the
amount of insurance. As used here in the state of Missouri, ACV, (Actual Cash Value) is
used instead of Fair Market Value.
BUILDING INFORMATION
How was the value determined?
(check all that apply) Professional
Appraiser
Check the box (if applicable): Indicates the insurance value was determined by a
professional appraiser.
BUILDING INFORMATION
By Applicant / Insured
Check the box (if applicable): Indicates the insurance value was determined by the
applicant / insured.
BUILDING INFORMATION
By Agent / Broker
Check the box (if applicable): Indicates the insurance value was determined by the agent /
broker.
BUILDING INFORMATION
Company Appraisal Guide
Check the box (if applicable): Indicates the insurance value was determined by the
company appraisal guide.
BUILDING INFORMATION
Name of Company:
Enter text: The name of the company providing the appraisal guide.
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Section Name
Field Name
Field and/or Section Description
BUILDING INFORMATION
Other Checkbox
Check the box (if applicable): Indicates the insurance value was determined by a means
other than those listed.
BUILDING INFORMATION
Other Description
Enter text: The description of how the insurance value was determined.
REMARKS
Remarks
Enter text: The remarks associated with the supplemental property application.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
LOC #
Enter number: The location number for the premises.
(A) OWNERSHIP
INFORMATION
Name One
Enter text: The additional interest's full name.
(A) OWNERSHIP
INFORMATION
Address One
Enter text: The additional interest's mailing address line one.
(A) OWNERSHIP
INFORMATION
Enter text: The additional interest's mailing address city name.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address state or province code.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address postal code.
(A) OWNERSHIP
INFORMATION
Position One
Enter text: The title of the additional interest's authorized representative.
(A) OWNERSHIP
INFORMATION
Interest % One
Enter percentage: The percentage of ownership the additional interest has in the item.
(A) OWNERSHIP
INFORMATION
Name Two
Enter text: The additional interest's full name.
(A) OWNERSHIP
INFORMATION
Address Two
Enter text: The additional interest's mailing address line one.
(A) OWNERSHIP
INFORMATION
Enter text: The additional interest's mailing address city name.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address state or province code.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address postal code.
(A) OWNERSHIP
INFORMATION
Position Two
Enter text: The title of the additional interest's authorized representative.
(A) OWNERSHIP
INFORMATION
Interest % Two
Enter percentage: The percentage of ownership the additional interest has in the item.
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Section Name
Field Name
Field and/or Section Description
(A) OWNERSHIP
INFORMATION
Name Three
Enter text: The additional interest's full name.
(A) OWNERSHIP
INFORMATION
Address Three
Enter text: The additional interest's mailing address line one.
(A) OWNERSHIP
INFORMATION
Enter text: The additional interest's mailing address city name.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address state or province code.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address postal code.
(A) OWNERSHIP
INFORMATION
Position Three
Enter text: The title of the additional interest's authorized representative.
(A) OWNERSHIP
INFORMATION
Interest % Three
Enter percentage: The percentage of ownership the additional interest has in the item.
(A) OWNERSHIP
INFORMATION
Name Four
Enter text: The additional interest's full name.
(A) OWNERSHIP
INFORMATION
Address Four
Enter text: The additional interest's mailing address line one.
(A) OWNERSHIP
INFORMATION
Enter text: The additional interest's mailing address city name.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address state or province code.
(A) OWNERSHIP
INFORMATION
Enter code: The additional interest's mailing address postal code.
(A) OWNERSHIP
INFORMATION
Position Four
Enter text: The title of the additional interest's authorized representative.
(A) OWNERSHIP
INFORMATION
Interest % Four
Enter percentage: The percentage of ownership the additional interest has in the item.
(B) MORTGAGE PAYMENT
Mortgagee
Enter text: The additional interest's full name.
(B) MORTGAGE PAYMENT
Enter text: The additional interest's mailing address line one.
(B) MORTGAGE PAYMENT
Enter text: The additional interest's mailing address city name.
(B) MORTGAGE PAYMENT
Enter code: The additional interest's mailing address state or province code.
(B) MORTGAGE PAYMENT
Enter code: The additional interest's mailing address postal code.
(B) MORTGAGE PAYMENT
Date Due
Enter date: The date the payment is due. As used here, the date the late payment was
due.
(B) MORTGAGE PAYMENT
Amount Due
Enter amount: The amount due. As used here, the amount of the late payment.
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Section Name
Field Name
Field and/or Section Description
(B) MORTGAGE PAYMENT
Other Encumbrances
Enter text: The description of any other encumbrances that may be on the property.
(B) TAX LIENS / OVERDUE
TAXES
Tax Lien One
Check the box (if applicable): Indicates there is a tax lien on the property.
(B) TAX LIENS / OVERDUE
TAXES
Overdue Tax One
Check the box (if applicable): Indicates there is overdue tax on the property.
(B) TAX LIENS / OVERDUE
TAXES
Date Due One
Enter date: The date the tax is / was due.
(B) TAX LIENS / OVERDUE
TAXES
Amount Due One
Enter amount: The amount of tax due.
(B) TAX LIENS / OVERDUE
TAXES
Tax Lien Two
Check the box (if applicable): Indicates there is a tax lien on the property.
(B) TAX LIENS / OVERDUE
TAXES
Overdue Tax Two
Check the box (if applicable): Indicates there is overdue tax on the property.
(B) TAX LIENS / OVERDUE
TAXES
Date Due Two
Enter date: The date the tax is / was due.
(B) TAX LIENS / OVERDUE
TAXES
Amount Due Two
Enter amount: The amount of tax due.
( C ) CODE VIOLATION
Code Violations Date One
Enter date: The date the violation was issued.
( C ) CODE VIOLATION
Code Violations Description One
Enter text: The description of the violation.
( C ) CODE VIOLATION
Code Violations Date Two
Enter date: The date the violation was issued.
( C ) CODE VIOLATION
Code Violations Description Two
Enter text: The description of the violation.
(D) CONVICTIONS
Convictions Date One
Enter date: The date of the conviction. As used here, the date of the conviction of arson,
fraud or property related crime.
(D) CONVICTIONS
Convictions Description One
Enter text: The description of the conviction. As used here, the description of the
conviction of arson, fraud or property related crime.
(D) CONVICTIONS
Convictions Individual One
Enter text: The full name of the individual convicted. As used here, the name of the
individual convicted of arson, fraud or property related crime.
(D) CONVICTIONS
Convictions Date Two
Enter date: The date of the conviction. As used here, the date of the conviction of arson,
fraud or property related crime.
(D) CONVICTIONS
Convictions Description Two
Enter text: The description of the conviction. As used here, the description of the
conviction of arson, fraud or property related crime.
(D) CONVICTIONS
Convictions Individual Two
Enter text: The full name of the individual convicted. As used here, the name of the
individual convicted of arson, fraud or property related crime.
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Section Name
Field Name
Field and/or Section Description
(D) LOSSES
Losses Date One
Enter date: The date that the loss occurred. As used here, describes fire or explosion
losses exceeding $1,000.
(D) LOSSES
Losses Amount One
Enter amount: The estimated dollar amount which may be paid on all claims arising from
this incident. If no dollar estimate is available, provide a description such as small or
substantial. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES
Losses Location One
Enter text: The first address line of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter text: The city of the physical location. As used here, describes fire or explosion
losses exceeding $1,000.
(D) LOSSES
Enter code: The state or province of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter code: The postal code of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Losses Description One
Enter text: The description of the incident resulting in a potential loss to the insured. As
used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES
Losses Date Two
Enter date: The date that the loss occurred. As used here, describes fire or explosion
losses exceeding $1,000.
(D) LOSSES
Losses Amount Two
Enter amount: The estimated dollar amount which may be paid on all claims arising from
this incident. If no dollar estimate is available, provide a description such as small or
substantial. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES
Losses Location Two
Enter text: The first address line of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter text: The city of the physical location. As used here, describes fire or explosion
losses exceeding $1,000.
(D) LOSSES
Enter code: The state or province of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter code: The postal code of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Losses Description Two
Enter text: The description of the incident resulting in a potential loss to the insured. As
used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES
Losses Date Three
Enter date: The date that the loss occurred. As used here, describes fire or explosion
losses exceeding $1,000.
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Section Name
Field Name
Field and/or Section Description
(D) LOSSES
Losses Amount Three
Enter amount: The estimated dollar amount which may be paid on all claims arising from
this incident. If no dollar estimate is available, provide a description such as small or
substantial. As used here, describes fire or explosion losses exceeding $1,000.
(D) LOSSES
Losses Location Three
Enter text: The first address line of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter text: The city of the physical location. As used here, describes fire or explosion
losses exceeding $1,000.
(D) LOSSES
Enter code: The state or province of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Enter code: The postal code of the physical location. As used here, describes fire or
explosion losses exceeding $1,000.
(D) LOSSES
Losses Description Three
Enter text: The description of the incident resulting in a potential loss to the insured. As
used here, describes fire or explosion losses exceeding $1,000.
(E) LENDER
Name
Enter text: The additional interest's full name.
(E) LENDER
Explanation
Enter code: The relationship of the additional interest to the named insured.
(F) VACANCY /
UNOCCUPANCY
Season When Unused - Start Date
Enter date: The dates when the property is not in use. For seasonal property and risks
when vacancy or unoccupancy is planned, enter the start and end dates of the vacancy or
unoccupancy.
(F) VACANCY /
UNOCCUPANCY
End Date
Enter date: The dates when the property is not in use. For seasonal property and risks
when vacancy or unoccupancy is planned, enter the start and end dates of the vacancy or
unoccupancy.
(F) VACANCY /
UNOCCUPANCY
Total # of Apartment Units
Enter number: The number of separate living units in structure.
(F) VACANCY /
UNOCCUPANCY
# of Unoccupied Apartment Units
Enter number: The number of unoccupied apartments in structure.
(F) VACANCY /
UNOCCUPANCY
Other Buildings, % Vacant
Enter percentage: The percentage of the building, excluding apartments, that is vacant
(unoccupied and no furniture).
(F) VACANCY /
UNOCCUPANCY
Other Buildings, % Unoccupied
Enter percentage: The percentage of the building, excluding apartments, that is
unoccupied (furnished, but no residents).
(F) VACANCY /
UNOCCUPANCY
Anticipated Date of Occupancy
Enter date: The anticipated date of occupancy for tenants that are scheduled to occupy the
building.
(F) VACANCY /
UNOCCUPANCY
Reason for Vacancy /
Unoccupancy
Enter text: The reasons for the vacancy or unoccupancy, such as seasonal rental property
or building renovation.
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Section Name
Field Name
Field and/or Section Description
(F) VACANCY /
UNOCCUPANCY
How is Building Protected from
Entry?
Enter text: The description of other protective measures or devices (e.g., if windows have
steel grates and are connected to an alarm). Indicate if the building has skylights and if
windows are visible from the street. As used here, list any security measures to protect the
building from unlawful entry.
(F) VACANCY /
UNOCCUPANCY
Is there a government order to
vacate or destroy the building, or
has the building been classified as
uninhabitable or structurally
unsafe?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a government order to vacate or destroy the building, or has the
building been classified as uninhabitable or structurally unsafe?.
(F) VACANCY /
UNOCCUPANCY
Are any utilities out of service?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are any utilities out of service?.
(F) VACANCY /
UNOCCUPANCY
Explain
Enter text: An explanation as to whether any utilities on the property are out of service.
(F) VACANCY /
UNOCCUPANCY
Is there unrepaired damage or
have items been stripped from
building?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there unrepaired damage or have items been stripped from building?.
(F) VACANCY /
UNOCCUPANCY
Describe
Enter text: An explanation as to whether there is any unrepaired damage on premises or if
any items have been stripped from the building.
(F) VACANCY /
UNOCCUPANCY
Is the building up for sale?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the building up for sale?.
(F) VACANCY /
UNOCCUPANCY
Date Listed For Sale
(MM/DD/YYYY)
Enter date: The date the building was listed for sale.
(G) OTHER INSURANCE
Other Insurance Status One
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE
Other Insurance Effective Date
One
Enter date: The date on which the terms and conditions of the other policy commence.
(G) OTHER INSURANCE
Other Insurance Expiration Date
One
Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE
Other Insurance Amount of
Insurance One
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE
Other Insurance Carrier One
Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE
Other Insurance Policy Number
One
Enter identifier: The policy number on any other applicable insurance.
(G) OTHER INSURANCE
Other Insurance Status Two
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE
Other Insurance Effective Date
Two
Enter date: The date on which the terms and conditions of the other policy commence.
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Section Name
Field Name
Field and/or Section Description
(G) OTHER INSURANCE
Other Insurance Expiration Date
Two
Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE
Other Insurance Amount of
Insurance Two
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE
Other Insurance Carrier Two
Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE
Other Insurance Policy Number
Two
Enter identifier: The policy number on any other applicable insurance.
(G) OTHER INSURANCE
Other Insurance Status Three
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
(G) OTHER INSURANCE
Other Insurance Effective Date
Three
Enter date: The date on which the terms and conditions of the other policy commence.
(G) OTHER INSURANCE
Other Insurance Expiration Date
Three
Enter date: The date on which the terms and conditions of the other policy expires.
(G) OTHER INSURANCE
Other Insurance Amount of
Insurance Three
Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits
or applicable policy coverage(s) should be answered by the issuing insurer(s).
(G) OTHER INSURANCE
Other Insurance Carrier Three
Enter text: The insurer name on any other applicable insurance.
(G) OTHER INSURANCE
Other Insurance Policy Number
Three
Enter identifier: The policy number on any other applicable insurance.
(H) REAL ESTATE
TRANSACTIONS
Date One
Enter date: The date of the real estate transaction. As used here, list all real estate
transactions over the past three years.
(H) REAL ESTATE
TRANSACTIONS
Name of Seller One
Enter text: The name of seller of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Selling Price One
Enter amount: The selling price of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Mortgage Amount One
Enter amount: The mortgage amount of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Mortgagee One
Enter Text: The mortgagee of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Date Two
Enter date: The date of the real estate transaction. As used here, list all real estate
transactions over the past three years.
(H) REAL ESTATE
TRANSACTIONS
Name of Seller Two
Enter text: The name of seller of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Selling Price Two
Enter amount: The selling price of the real estate transaction.
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Section Name
Field Name
Field and/or Section Description
(H) REAL ESTATE
TRANSACTIONS
Mortgage Amount Two
Enter amount: The mortgage amount of the real estate transaction.
(H) REAL ESTATE
TRANSACTIONS
Mortgagee Two
Enter Text: The mortgagee of the real estate transaction.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
LOC #
Enter number: The location number for the premises.
REMARKS
Remarks
Enter text: The remarks associated with the supplemental property application.
STATEMENT / SIGNATURE (Privacy) checkbox
Notice of Information Practices
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific
38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition,
ACORD 38 contains CA and MA state specific language.
STATEMENT / SIGNATURE Applicant's Initials
Initial here: The named insured's initials.
STATEMENT / SIGNATURE Signature of Agent / Broker
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. As used here, the agent / broker signature is not required in New York.
STATEMENT / SIGNATURE Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
STATEMENT / SIGNATURE State Producer License No
Enter identifier: The State License Number of the producer.
STATEMENT / SIGNATURE Signature of Insured /Applicant
Sign here: Accommodates the signature of the applicant or named insured.
STATEMENT / SIGNATURE Title of Insured / Applicant
Enter number: The title of the contact for the named insured.
STATEMENT / 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.
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
ACORD 190 (2013/09) rev. 06-28-2013
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