ACORD 82 (2013/09) - WATERCRAFT APPLICATION

ACORD 82 (2013/09) - WATERCRAFT APPLICATION
ACORD 82, Watercraft Application, is used when insurances is desired for watercraft. The underwriting process for any
personal lines policy begins with the submission of a completed application. The following will provide assistance in completing ACORD 82,
Watercraft Application.
This form can be used for a standalone watercraft policy, or as a supplement to the Homeowners Application (ACORD 80) if physical damage on
watercraft is being written under the Homeowners policy. Check with the company to determine whether physical damage can be written on the
Homeowners policy.
If coverage will be provided under a yacht policy, do not use this form. Use ACORD 210, Yacht Section.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Boat Hull No.
Enter number: The producer assigned number for the watercraft.
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
Agency Address Line 1
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Agency Address Line 2
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
Agency City
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
Agency State
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Agency Zip
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
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
ACORD 82 (2013/09) rev. 07-31-2013 P age 1 of 39
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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
Plan
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION
Facility Code
Enter identifier: The identification code used by assigned risk plans, FAIR plans and other
associations (only applicable in a few states). When using this field, also enter the name of the
facility in the company or plan field.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant's Name and
Mailing Address (Include
county & zip+4)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Address Line 1
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Address Line 2
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
County
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Zip + 4
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION
Date at Current Residence
Enter date: The date insured moved into their current residence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Primary Phone #
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION
Home (checkbox)
Check the box (if applicable): Indicates the primary phone number is for a home phone.
IDENTIFICATION SECTION
Bus (checkbox)
Check the box (if applicable): Indicates the primary phone number is for a business phone.
IDENTIFICATION SECTION
Cell (checkbox)
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
IDENTIFICATION SECTION
Secondary Phone #
Enter number: The named insured's secondary phone number.
ACORD 82 (2013/09)
Page 2 of 39
IDENTIFICATION SECTION
Home (checkbox)
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
IDENTIFICATION SECTION
Bus (checkbox)
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
IDENTIFICATION SECTION
Cell (checkbox)
Check the box (if applicable): Indicates the phone number is for a cell phone.
IDENTIFICATION SECTION
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
IDENTIFICATION SECTION
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
IDENTIFICATION SECTION
Birth Date
Enter date: The date of birth of the insured.
IDENTIFICATION SECTION
Marital Status / Civil Union
(if applicable)
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* F Fianc or Fiance
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union/ Registered Domestic Partner
* U Unknown
* O Other
IDENTIFICATION SECTION
Applicant's Occupation
Enter text: The named insured's primary occupation or business activity.
IDENTIFICATION SECTION
Co-Applicant's Occupation
Enter text: The named insured's primary occupation or business activity.
COVERAGES / LIMITS OF
LIABILITY
Hull - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Hull - Limit
Enter limit: The limit for boat (hull) coverage. This may include collision liability.
COVERAGES / LIMITS OF
LIABILITY
ACV (checkbox)
Check the box (if applicable): Indicates the loss settlement basis is the actual cash value of the
item.
COVERAGES / LIMITS OF
LIABILITY
RC (checkbox)
Check the box (if applicable): Indicates the loss settlement basis is the replacement cost of the
item.
COVERAGES / LIMITS OF
LIABILITY
AA (checkbox)
Check the box (if applicable): Indicates the loss settlement basis for the item is the agreed
amount.
COVERAGES / LIMITS OF
LIABILITY
Hull - Deductible
Enter deductible: The deductible for boat (hull) coverage.
COVERAGES / LIMITS OF
LIABILITY
Hull - Form Number
Enter identifier: The number used by the insurer for this form.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Hull - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Hull - Premium
Enter amount: The premium for boat (hull) coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Limit
Enter limit: The limit for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Deductible
Enter deductible: The deductible for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Premium
Enter amount: The premium for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Limit
Enter limit: The limit for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Deductible
Enter deductible: The deductible for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Outboard Motor - Premium
Enter amount: The premium for outboard motor coverage.
COVERAGES / LIMITS OF
LIABILITY
Portable Accessories - Unit
#
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Portable Accessories - Limit
Enter limit: The limit for portable accessories (equipment not permanently attached to the boat)
coverage.
COVERAGES / LIMITS OF
LIABILITY
Portable Accessories - Form
Number
Enter identifier: The number used by the insurer for this form.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Portable Accessories - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Portable Accessories -
Premium
Enter amount: The premium for portable accessories (equipment not permanently attached to
the boat) coverage.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Limit
Enter limit: The limit for trailer coverage.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Deductible
Enter deductible: The deductible for trailer coverage.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Trailer - Premium
Enter amount: The premium for trailer coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects - Limit
Enter limit: The limit for personal effects coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects -
Deductible
Enter deductible: The deductible for personal effects coverage.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Personal Effects - Premium
Enter amount: The premium for personal effects coverage.
COVERAGES / LIMITS OF
LIABILITY
Towing - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Towing - Limit
Enter limit: The limit for towing coverage.
COVERAGES / LIMITS OF
LIABILITY
Towing - Deductible
Enter deductible: The deductible for towing coverage.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Towing - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Towing - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Towing - Premium
Enter amount: The premium for towing coverage.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out - Limit
Enter limit: The limit for hurricane haul out coverage.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out -
Deductible
Enter deductible: The deductible for hurricane haul out coverage.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Hurricane Haul-Out -
Premium
Enter amount: The premium for hurricane haul out coverage.
COVERAGES / LIMITS OF
LIABILITY
Liability - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Liability - Limit CSL / BI ea
pers
Enter limit: The bodily injury each person limit for boat (hull) damage.
COVERAGES / LIMITS OF
LIABILITY
Liability - Limit CSL / BI ea
Acc
Enter limit: The limit amount for combined single limit liability (may be called protection and
indemnity).
COVERAGES / LIMITS OF
LIABILITY
Liability CSL / BI -
Deductible
Enter deductible: The deductible for combined single limit boat (hull) coverage.
COVERAGES / LIMITS OF
LIABILITY
Liability CSL / BI - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Liability CSL / BI - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Liability CSL / BI - Premium
Enter amount: The premium for combined single limit boat (hull) coverage.
COVERAGES / LIMITS OF
LIABILITY
Liability - Limit PD ea Acc
Enter limit: The limit for property damage coverage.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Liability PD - Deductible
Enter deductible: The deductible for property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Liability PD - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Liability PD - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Liability PD - Premium
Enter amount: The premium for property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments - Limit
Enter limit: The limit for medical payments for bodily injury to occupants of the boat coverage.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Medical Payments -
Premium
Enter amount: The premium for medical payments coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability -
Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Limit ea Pers
Enter limit: The each person limit for uninsured boaters bodily injury coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Limit ea acc
Enter limit: The each accident limit for uninsured boaters coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Deductible
Enter deductible: The deductible for uninsured boaters combined single limit coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
CSL / BI - Premium
Enter amount: The premium for uninsured boaters combined single limit coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
PD - Limit
Enter limit: The limit for uninsured boaters property damage coverage.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
PD - Deductible
Enter deductible: The deductible for uninsured boaters property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
PD - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
PD - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Uninsured Boaters Liability
PD - Premium
Enter amount: The premium for uninsured boaters property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability - Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability CSL / BI - Limit ea
pers
Enter limit: The each person limit for underinsured boaters bodily injury coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability CSL / BI - Limit ea
acc
Enter limit: The each accident limit for underinsured boaters coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability CSL / BI -
Deductible
Enter deductible: The deductible for underinsured boaters combined single limit coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability CSL / BI - Form
Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability CSL / BI - Form
Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters CSL /
BI Liability - Premium
Enter amount: The premium for underinsured boaters combined single limit coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability PD - Limit
Enter limit: The limit for underinsured boaters property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability PD - Deductible
Enter deductible: The deductible for underinsured boaters property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability PD - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability PD - Form Date
Enter date: The edition date of the form.
ACORD 82 (2013/09)
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COVERAGES / LIMITS OF
LIABILITY
Underinsured Boaters
Liability PD - Premium
Enter amount: The premium for underinsured boaters property damage coverage.
COVERAGES / LIMITS OF
LIABILITY
Code
Enter code: The code for the coverage.
COVERAGES / LIMITS OF
LIABILITY
Coverage
Enter text: The description of the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Deductible
Enter deductible: The deductible for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Premium
Enter amount: The premium for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Code
Enter code: The code for the coverage.
COVERAGES / LIMITS OF
LIABILITY
Coverage
Enter text: The description of the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
ACORD 82 (2013/09)
Page 9 of 39
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Deductible
Enter deductible: The deductible for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Premium
Enter amount: The premium for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Code
Enter code: The code for the coverage.
COVERAGES / LIMITS OF
LIABILITY
Coverage
Enter text: The description of the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Deductible
Enter deductible: The deductible for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Premium
Enter amount: The premium for the coverage or adjustment.
ACORD 82 (2013/09)
Page 10 of 39
COVERAGES / LIMITS OF
LIABILITY
Code
Enter code: The code for the coverage.
COVERAGES / LIMITS OF
LIABILITY
Coverage
Enter text: The description of the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Unit #
Enter number: The producer assigned number for the unit being covered.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Limit
Enter limit: The limit for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Applies To
Enter code: The code identifying what the limit applies to (i.e. per occurrence).
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Deductible
Enter deductible: The deductible for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Number
Enter identifier: The number used by the insurer for this form.
COVERAGES / LIMITS OF
LIABILITY
Blank - Form Date
Enter date: The edition date of the form.
COVERAGES / LIMITS OF
LIABILITY
Blank Space - Premium
Enter amount: The premium for the coverage or adjustment.
COVERAGES / LIMITS OF
LIABILITY
Total
Enter amount: The total premium amount for the watercraft.
RATING / UNDERWRITING
Bilge Pumps
Enter Y for a Yes response. Input N for No response. Indicate if the watercraft has a bilge
pump. A bilge pump is a manually operated or automatically activated device used for pumping
water from the inner part of the ship's hull. Using the same principle as the manual pump, the
automatic pump is activated by the rise of water within the hull. Specify the manufacturer and
the model (e.g., Dynaflow Pump 304) in the Remarks section.
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Fume Detector
Enter Y for a Yes response. Input N for No response. Indicates if there is a fume detector on
the watercraft. A fume detector is a device used for detecting the presence of fuel vapors below
deck. Specify the manufacturer and model (e.g., Sniffer 203) in the Remarks section.
ACORD 82 (2013/09)
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RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Depth Sounder
Enter Y for a Yes response. Input N for No response. Indicates if there is a depth sounder on
the watercraft. An electronic device for determining the depth of the water beneath the boat.
Use the Remarks section to indicate the manufacturer and model (e.g., Moran 6 - 150/SV-300).
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Radar
Enter Y for a Yes response. Input N for No response. Indicates if the watercraft has a radar
system. A radar system is a device for detecting distant objects and determining their position.
Specify the manufacturer and model in the Remarks section.
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Radio Direction Finder
Enter Y for a Yes response. Input N for No response. Indicates if the watercraft has a radio
direction finder used as a navigational aid employing a radio signal. Enter the manufacturer and
model (e.g., Loran, GSP) in the Remarks section.
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
CO2/ Chemical System
Enter Y for a Yes response. Input N for No response. Indicates if there is a carbon dioxide
(CO2)/chemical system on the watercraft. A CO2 or chemical system is a built-in fire
extinguishing device. Use the Remarks section to Indicate if it is manual or automatic and
identify the spaces protected. Include the manufacturer and model.
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Automatic
Enter Y for a Yes response. Input N for No response. Indicates if the CO2 / chemical system
is triggered automatically.
RATING / UNDERWRITING
Spaces Protected
Enter text: The description of the spaces protected by the CO2 / chemical system in the boat.
RATING / UNDERWRITING
Cooking Stove
Enter Y for a Yes response. Input N for No response. Indicates if there is a cooking stove in
the watercraft. Use the Remarks section to indicate the manufacturer, model, fuel type and the
number of stoves.
RATING / UNDERWRITING
Manufacturer
Enter text: The name of the manufacturer of the equipment.
RATING / UNDERWRITING
Model
Enter text: The manufacturer's model name for the equipment.
RATING / UNDERWRITING
Fuel Type
Enter text: The description of the type of fuel used for cooking.
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RATING / UNDERWRITING
# of Stoves
Enter number: The number of cooking stoves.,
RATING / UNDERWRITING
Fire Extinguishers
Enter Y for a Yes response. Input N for No response. Indicates if there is a fire extinguisher
on the watercraft. Use the Remarks section to indicate the number of fire extinguishers, the
type, size, and the date last weighed, if available.
RATING / UNDERWRITING
Type
Enter text: The description of the type of fire extinguisher,
RATING / UNDERWRITING
Size
Enter text: The size of the fire extinguisher.
RATING / UNDERWRITING
Date Last Weighed
Enter date: The date the fire extinguishers were last weighed.
RATING / UNDERWRITING
# of Extinguishers
Enter number: The number of fire extinguishers.
RATING / UNDERWRITING
Ship to Shore Radio
Enter Y for a Yes response. Input N for No response. Indicates if the watercraft has a ship to
shore radio. Use the Remarks section to indicate the type of radio. Examples:
* SSB-Single Side Band
* VHF-FM-Very High Frequency - Frequency Modulation
* CB -Citizens Band
* Cellular Phones
* Marine Radio
RATING / UNDERWRITING
Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
RATING / UNDERWRITING
Anti-Theft Devices
Enter Y for a Yes response. Input N for No response. Indicates if the watercraft has an
anti-theft device. Special locks, burglar alarms or engine cut-out devices may be employed by
the applicant. Marina security may be noted as well using the Remarks section.
RATING / UNDERWRITING
Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
RATING / UNDERWRITING
Heating
Enter Y for a Yes response. Input N for No response. Indicates if the watercraft has a heating
system.
RATING / UNDERWRITING
Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
RATING / UNDERWRITING
Other Equipment Type
Enter text: The description of the equipment on the watercraft.
RATING / UNDERWRITING
Other
Enter Y for a Yes response. Input N for No response. Indicates there is equipment other than
those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
RATING / UNDERWRITING
Other Equipment Type
Enter text: The description of the equipment on the watercraft.
RATING / UNDERWRITING
Other
Enter Y for a Yes response. Input N for No response. Indicates there is equipment other than
those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
RATING / UNDERWRITING
Other Equipment Type
Enter text: The description of the equipment on the watercraft.
ACORD 82 (2013/09)
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RATING / UNDERWRITING
Other
Enter Y for a Yes response. Input N for No response. Indicates there is equipment other than
those listed.
RATING / UNDERWRITING
Other Description
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Equipment
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Year
Enter year: The model year of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Manufacturer
Enter text: The name of the manufacturer of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Model
Enter text: The manufacturer's model name for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Serial Number
Enter identifier: The serial number for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Limit
Enter amount: The limit amount required for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Equipment
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Year
Enter year: The model year of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Manufacturer
Enter text: The name of the manufacturer of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Model
Enter text: The manufacturer's model name for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Serial Number
Enter identifier: The serial number for the equipment.
ACORD 82 (2013/09)
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PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Limit
Enter amount: The limit amount required for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Equipment
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Year
Enter year: The model year of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Manufacturer
Enter text: The name of the manufacturer of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Model
Enter text: The manufacturer's model name for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Serial Number
Enter identifier: The serial number for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Limit
Enter amount: The limit amount required for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Equipment
Enter text: The description of the equipment (ex. lifeboat, tender, etc.).
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Year
Enter year: The model year of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Manufacturer
Enter text: The name of the manufacturer of the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Model
Enter text: The manufacturer's model name for the equipment.
PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Serial Number
Enter identifier: The serial number for the equipment.
ACORD 82 (2013/09)
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PORTABLE ACCESSORIES
AND LIFEBOATS /
TENDERS
Limit
Enter amount: The limit amount required for the equipment.
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).
IDENTIFICATION SECTION
Boat Hull No.
Enter number: The producer assigned number for the watercraft.
BOAT HULL
Power - Inboard
Check the box (if applicable): Indicates the watercraft is propelled by an inboard motor.
BOAT HULL
Outboard
Check the box (if applicable): Indicates the watercraft is propelled by an outboard motor.
BOAT HULL
Inboard/Outdrive
Check the box (if applicable): Indicates the watercraft is propelled by an inboard/out drive motor.
BOAT HULL
Waterjet
Check the box (if applicable): Indicates the watercraft is propelled by a water jet.
BOAT HULL
Sail
Check the box (if applicable): Indicates the watercraft is propelled by a sail.
BOAT HULL
Other
Check the box (if applicable): Indicates the watercraft is propelled by a method other than those
listed.
BOAT HULL
Other Description
Enter text: The method of propulsion of the watercraft.
BOAT HULL
Type of Hull - Cabin Cruiser
Check the box (if applicable): Indicates the watercraft type is a cabin cruiser.
BOAT HULL
Open Cockpit
Check the box (if applicable): Indicates the watercraft type is an open cockpit.
BOAT HULL
Sailboat
Check the box (if applicable): Indicates the watercraft type is a sailboat.
BOAT HULL
Pontoon
Check the box (if applicable): Indicates the watercraft type is a pontoon boat.
BOAT HULL
Bass
Check the box (if applicable): Indicates the watercraft type is a bass boat.
BOAT HULL
Personal WC
Check the box (if applicable): Indicates the watercraft type is a personal watercraft.
BOAT HULL
Ski
Check the box (if applicable): Indicates the watercraft type is a ski boat.
BOAT HULL
Other
Check the box (if applicable): Indicates the watercraft type is other than those listed.
BOAT HULL
Other Description
Enter text: The description of the watercraft type.
BOAT HULL
Hull Material - Fiberglass
Check the box (if applicable): Indicates the hull is constructed with fiberglass.
BOAT HULL
Metal
Check the box (if applicable): Indicates the hull is constructed with metal.
BOAT HULL
Wood
Check the box (if applicable): Indicates the hull is constructed with wood.
ACORD 82 (2013/09)
Page 16 of 39
BOAT HULL
Hull Design - Flat Bottom
Check the box (if applicable): Indicates the hull design is flat bottom.
BOAT HULL
Round Bottom
Check the box (if applicable): Indicates the hull design is round bottom.
BOAT HULL
Vee Bottom
Check the box (if applicable): Indicates the hull design is vee bottom.
BOAT HULL
Catamaran
Check the box (if applicable): Indicates the hull design is catamaran bottom.
BOAT HULL
Other
Check the box (if applicable): Indicates the hull design is other than those listed.
BOAT HULL
Other Description
Enter text: The description of the hull design.
BOAT HULL
Fuel Tank - Fiberglass
Check the box (if applicable): Indicates the fuel tank is fiberglass.
BOAT HULL
Metal
Check the box (if applicable): Indicates the fuel tank is metal.
BOAT HULL
Spar Material - Aluminum
Check the box (if applicable): Indicates the type of spar material used (i.e. masts, riggings, etc.)
is aluminum.
BOAT HULL
Wood
Check the box (if applicable): Indicates the type of spar material used (i.e. masts, riggings, etc.)
is wood.
BOAT HULL
Carbon Fiber
Check the box (if applicable): Indicates the type of spar material used (i.e. masts, riggings, etc.)
is carbon fiber.
BOAT HULL
Other
Check the box (if applicable): Indicates the type of spar material used (i.e. masts, riggings, etc.)
is other than those listed.
BOAT HULL
Other Description
Enter text: The description of the spar material used (i.e. masts, riggings, etc.).
BOAT HULL
Year
Enter year: The model year of the watercraft.
BOAT HULL
Manufacturer
Enter text: The manufacturer of the watercraft.
BOAT HULL
Model
Enter text: The manufacturer's model name for the watercraft.
BOAT HULL
Length
Enter number: The length of the watercraft expressed in feet.
BOAT HULL
Max Speed
Enter number: The maximum speed attainable by the watercraft. State if the speed in in miles
per hour or knots per hour.
BOAT HULL
Date Purchased
Enter date: The date the watercraft was purchased.
BOAT HULL
Cost New
Enter amount: The cost of the watercraft when it was purchased new, in whole dollar amounts.
BOAT HULL
Present Value
Enter amount: The watercraft's present value, stated or agreed, in whole dollar amounts.
BOAT HULL
Name of Boat
Enter text: The name in which the watercraft is registered.
BOAT HULL
Name of Beneficial Owner
Enter text: The additional interest's full name. As used here, this is the beneficial owner.
BOAT HULL
Registration Number
Enter identifier: The unique identifier for the watercraft assigned by the registering authority.
ACORD 82 (2013/09)
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BOAT HULL
Country of Registration
Enter code: The country code in which the boat is registered.
BOAT HULL
Hull Identification Number
Enter identifier: The 12 character Hull Identification Number of the watercraft. It is typically
located on the transom of the watercraft.
BOAT HULL
Waters Navigated - Atlantic
(checkbox)
Check the box (if applicable): Indicates the waters navigated is the Atlantic ocean.
BOAT HULL
Great Lakes (checkbox)
Check the box (if applicable): Indicates the waters navigated are the Great Lakes.
BOAT HULL
Inland Waterways
(checkbox)
Check the box (if applicable): Indicates the waters navigated are inland waterways. Inland
Waterways are all inland bodies of water including lakes and intercoastal waterways, excluding
rivers and the great lakes.
BOAT HULL
Pacific (checkbox)
Check the box (if applicable): Indicates the waters navigated is the Pacific ocean.
BOAT HULL
Rivers (checkbox)
Check the box (if applicable): Indicates the waters navigated are rivers.
BOAT HULL
Gulf of Mexico (checkbox)
Check the box (if applicable): Indicates the waters navigated is the Gulf Of Mexico.
BOAT HULL
Other (checkbox)
Check the box (if applicable): Indicates the waters navigated are other than those listed.
BOAT HULL
Other Description
Enter text: The waters where the watercraft is predominantly used.
BOAT HULL
Territory
Enter code: This is typically the navigation territory. However, use company manuals to
determine territory.
BOAT HULL
Date of Last Survey
Enter date: The date the last survey was completed.
BOAT HULL
LOC #
Enter number: The producer assigned number of the location. As used here, this is the primary
berth/storage location.
BOAT HULL
Primary Berth / Storage
Location
Enter text: The first address line of the physical location.
BOAT HULL
Summer
Check the box (if applicable): Indicates the primary storage location is used in the summer.
BOAT HULL
Winter
Check the box (if applicable): Indicates the primary storage location is used in the winter.
BOAT HULL
City
Enter text: The city of the physical location.
BOAT HULL
State
Enter code: The state or province of the physical location.
BOAT HULL
Zip
Enter code: The postal code of the physical location.
BOAT HULL
Country
Enter code: The code that identifies the country.
BOAT HULL
LOC #
Enter number: The producer assigned number of the location. As used here, this is the
secondary berth/storage location.
BOAT HULL
Secondary Berth / Storage
Location
Enter text: The first address line of the physical location.
ACORD 82 (2013/09)
Page 18 of 39
BOAT HULL
Summer
Check the box (if applicable): Indicates the secondary storage location is used in the summer.
BOAT HULL
Winter
Check the box (if applicable): Indicates the secondary storage location is used in the winter.
BOAT HULL
City
Enter text: The city of the physical location.
BOAT HULL
State
Enter code: The state or province of the physical location.
BOAT HULL
Zip
Enter code: The postal code of the physical location.
BOAT HULL
Country
Enter code: The code that identifies the country.
BOAT HULL
Lay-Up Period - Dry
(checkbox)
Check the box (if applicable): Indicates the unit is stored dry during the lay up period.
BOAT HULL
Afloat (checkbox)
Check the box (if applicable): Indicates the unit is stored afloat during the lay up period.
BOAT HULL
Start Date
Enter date: The start of the period during which the unit is not in use.
The date the lay up period starts.
BOAT HULL
End Date
Enter date: The end of the period during which the unit is not in use.
ENGINE / MOTOR
Motor #
Enter number: The producer assigned number for the engine / motor.
ENGINE / MOTOR
Year
Enter year: The model year of the engine/motor.
ENGINE / MOTOR
Manufacturer
Enter text: The manufacturer of the engine/motor.
ENGINE / MOTOR
Model
Enter text: The manufacturer's model name for the engine/motor.
ENGINE / MOTOR
Serial Number
Enter identifier: The serial number of the engine/motor.
ENGINE / MOTOR
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.
ENGINE / MOTOR
Fuel - Gasoline
Check the box (if applicable): Indicates the engine/motor runs on gasoline.
ENGINE / MOTOR
Diesel
Check the box (if applicable): Indicates the engine/motor runs on diesel fuel.
ENGINE / MOTOR
Battery
Check the box (if applicable): Indicates the engine/motor is runs on battery power.
ENGINE / MOTOR
Other (checkbox)
Check the box (if applicable): Indicates the engine/motor is runs on other power.
ENGINE / MOTOR
Other Description
Enter text: The description of the other fuel power.
ENGINE / MOTOR
Date Purchased
Enter date: The date the engine/motor was purchased.
ENGINE / MOTOR
Cost New
Enter amount: The cost of the engine/motor when it was purchased new, in whole dollar
amounts. (For Outboard Motors Only)
ACORD 82 (2013/09)
Page 19 of 39
ENGINE / MOTOR
Present Value
Enter amount: The engine/motor's present value, stated or agreed, in whole dollar amounts.
(For Outboard Motors Only)
ENGINE / MOTOR
Motor #
Enter number: The producer assigned number for the engine / motor.
ENGINE / MOTOR
Year
Enter year: The model year of the engine/motor.
ENGINE / MOTOR
Manufacturer
Enter text: The manufacturer of the engine/motor.
ENGINE / MOTOR
Model
Enter text: The manufacturer's model name for the engine/motor.
ENGINE / MOTOR
Serial Number
Enter identifier: The serial number of the engine/motor.
ENGINE / MOTOR
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.
ENGINE / MOTOR
Fuel - Gasoline
Check the box (if applicable): Indicates the engine/motor runs on gasoline.
ENGINE / MOTOR
Diesel
Check the box (if applicable): Indicates the engine/motor runs on diesel fuel.
ENGINE / MOTOR
Battery
Check the box (if applicable): Indicates the engine/motor is runs on battery power.
ENGINE / MOTOR
Other (checkbox)
Check the box (if applicable): Indicates the engine/motor is runs on other power.
ENGINE / MOTOR
Other Description
Enter text: The description of the other fuel power.
ENGINE / MOTOR
Date Purchased
Enter date: The date the engine/motor was purchased.
ENGINE / MOTOR
Cost New
Enter amount: The cost of the engine/motor when it was purchased new, in whole dollar
amounts. (For Outboard Motors Only)
ENGINE / MOTOR
Present Value
Enter amount: The engine/motor's present value, stated or agreed, in whole dollar amounts.
(For Outboard Motors Only)
TRAILER
#
Enter number: The producer assigned number for the trailer.
TRAILER
Year
Enter year: The model year of the trailer.
TRAILER
Manufacturer
Enter text: The manufacturer of the trailer.
TRAILER
Model
Enter text: The manufacturer's model name for the trailer.
TRAILER
Serial Number
Enter identifier: The serial number of the trailer.
TRAILER
# Axles
Enter number: The number of axels on the trailer.
TRAILER
Capacity
Enter number: The capacity/volume of the watercraft trailer. As used here, enter the trailer
capacity in pounds.
TRAILER
Date Purchased
Enter date: The date the trailer was purchased.
ACORD 82 (2013/09)
Page 20 of 39
TRAILER
Cost
Enter amount: The cost of the boat trailer when it was purchased, in whole dollar amounts.
HULL INFORMATION
1. Is the boat chartered to
others? - Yes
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the boat chartered to others?. If yes, describe the type of arrangements, destination, length
of time and frequency. Indicate if it is a bare boat charter where no crew or supervision is
furnished, a voyage charter, a time charter, etc. Include the purpose of the charter (sight-seeing,
fishing) and whether alcohol is served.
HULL INFORMATION
Destination
Enter text: The description of the charter destination.
HULL INFORMATION
Length
Enter text: The length of time of the charter.
HULL INFORMATION
Frequency
Enter code: The frequency of charters.
HULL INFORMATION
Bare Boat Charter (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the boat is chartered as a
bare boat.
HULL INFORMATION
Voyage Charter (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the boat is chartered on a
voyage basis.
HULL INFORMATION
Time Charter (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the boat is chartered on a
period of time basis.
HULL INFORMATION
Alcohol Served (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if alcohol is served on the
charter.
HULL INFORMATION
Arrangements
Enter text: The description of the charter arrangements.
HULL INFORMATION
Purpose
Enter text: The description of the charter purpose.
HULL INFORMATION
2. Is the boat used
commercially or for
business purposes?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the boat used commercially or for business purposes?. If yes, describe the commercial or
business use of the vessel. Indicate if the vessel is used for demonstrations, promotions,
fishing, sight-seeing trips, etc.
HULL INFORMATION
2. Is the boat used
commercially or for
business purposes? -
Remarks
Enter text: An explanation as to whether the boat is used for business purposes.
HULL INFORMATION
3. Is the boat used for
racing?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the boat used for racing?. If yes, indicate the frequency of such races during the year, the
extent of the race, the waters navigated, etc.
HULL INFORMATION
Frequency
Enter code: The frequency the boat is used for racing.
HULL INFORMATION
Extent of Races
Enter text: The description of the extent of the races.
HULL INFORMATION
Waters Navigated
Enter text: The description of the waters navigated during races.
ACORD 82 (2013/09)
Page 21 of 39
HULL INFORMATION
4. Is the boat used for
waterskiing?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the boat used for waterskiing?. If yes, indicate how frequently the vessel is used for
waterskiing.
HULL INFORMATION
Frequency
Enter code: The frequency the boat is used for waterskiing.
HULL INFORMATION
5. Does the applicant
employ a paid crew?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant employ a paid crew?.
HULL INFORMATION
Number of Full-Time Crew
Enter number: The number of full time crew.
HULL INFORMATION
Number of Part-Time Crew
Enter number: The number of part time crew.
HULL INFORMATION
6. Any sleeping facilities?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any sleeping facilities?.
HULL INFORMATION
Number of Beds
Enter number: The number of beds on the watercraft.
HULL INFORMATION
7. Any existing damage to
the boat?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any existing damage to the boat?.
HULL INFORMATION
7. Any existing damage to
the boat? - Remarks
Enter text: An explanation of any existing damage to the boat.
HULL INFORMATION
8. Is the boat used as a
primary residence?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is the boat used as a primary residence?.
HULL INFORMATION
Number of Residents
Enter number: The number of residents.
HULL INFORMATION
Permanent Residence (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the boat is used as a
permanent residence.
HULL INFORMATION
9. Are there any additional
owners not listed as the
named insured? - Yes
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any additional owners not listed as the named insured?.
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).
GENERAL INFORMATION
1. Any other insurance with
this company?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any other insurance with this company?.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
ACORD 82 (2013/09)
Page 22 of 39
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
2. Has coverage been
declined, cancelled or
non-renewed during the last
three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any coverage declined, cancelled or non-renewed during the mandated number of years (not
applicable in Missouri)?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of any coverage declined within the last specified number of years.
GENERAL INFORMATION
3. Has applicant had a
foreclosure, repossession,
bankruptcy or filed for
bankruptcy during the past
five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the
past specified number of years?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of any foreclosures or bankruptcies in the last specified number of
years.
GENERAL INFORMATION
4. Has applicant had a
judgement or lien during the
past five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a judgment or lien during the past specified number of years?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of any judgment or liens during the past five (5) years.
GENERAL INFORMATION
5. Has insurance been
transferred within the
agency?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has insurance been transferred within agency?.
GENERAL INFORMATION
Explanation
Enter text: An explanation of insurance transferred within the agency.
GENERAL INFORMATION
6. During the last five (5)
years [ten (10) years in
Rhode Island], has any
applicant been indicted for
or convicted of any degree
of the crime of fraud,
bribery, arson or any other
arson-related crime in
connection with this or any
other property?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
During the last five (5) years [ten (10) years in Rhode Island], has any applicant been indicted
for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related
crime in connection with this or any other property? (In RI, failure to disclose the existence of an
arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of
imprisonment.).
GENERAL INFORMATION
Explanation
Enter text: An explanation of applicant convicted of fraud, bribery or arson in the last specified
number of years.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
ACORD 82 (2013/09)
Page 23 of 39
OPERATORS
Name
Enter text: The driver's first name (given name).
OPERATORS
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Name
Enter text: The driver's first name (given name).
OPERATORS
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Name
Enter text: The driver's first name (given name).
ACORD 82 (2013/09)
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OPERATORS
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Name
Enter text: The driver's first name (given name).
OPERATORS
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Name
Enter text: The driver's first name (given name).
OPERATORS
Enter text: The driver's middle name or initial (other given name).
ACORD 82 (2013/09)
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OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS
#
Enter number: The number assigned to the driver by the producer.
OPERATORS
Name
Enter text: The driver's first name (given name).
OPERATORS
Enter text: The driver's middle name or initial (other given name).
OPERATORS
Enter text: The driver's last name (surname).
OPERATORS
Sex
Enter code: The gender of the driver.
OPERATORS
Marital Status / Civil Union
(if applicable)
Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D - Divorced;
P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union/Registered
Domestic Partner, F- Fianc/Fiance, U - Unknown, O - Other
OPERATORS
Date of Birth
Enter date: The birth date of the driver.
OPERATORS
Occupation
Enter text: The occupation of the driver.
OPERATORS
Auto Driver's License
Number
Enter identifier: The driver's license number.
OPERATORS
Licensed State
Enter code: The state in which the driver is licensed.
OPERATORS
Social Security
Enter identifier: The tax identifier (social security number) of the driver.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
ACORD 82 (2013/09)
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OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
ACORD 82 (2013/09)
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OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
OPERATORS EXPERIENCE
#
Enter number: The producer assigned number for the driver.
OPERATORS EXPERIENCE
Prior Boat Make
Enter text: The name of the manufacturer of the prior watercraft.
OPERATORS EXPERIENCE
Model
Enter text: The manufacturer's model name for the prior watercraft.
OPERATORS EXPERIENCE
Number of Years Owned
Enter number: The number of years the prior watercraft was owned.
OPERATORS EXPERIENCE
USCGA Courses (Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any United States Coast Guard Auxiliary (USCGA) courses.
OPERATORS EXPERIENCE
Power Squadron Courses
(Y/N)
Enter Y for a Yes response. Input N for No response. Indicates if the operator has completed
any Power Squadron courses.
OPERATORS EXPERIENCE
Other Education
Enter text: Describe any operator completed courses offered by the United States Coast Guard
Auxiliary, the Power Squadron or other recognized training.
GENERAL INFORMATION
1. Any operator have
physical impairment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any driver have physical impairment?. As used here, not applicable in MT and WI.
GENERAL INFORMATION
#
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Description of Special
Equipment
Enter text: The description of any special equipment.
ACORD 82 (2013/09)
Page 28 of 39
GENERAL INFORMATION
2. Any operator undergoing
a course of treatment for a
physical / mental
impairment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any driver undergoing a course of medical treatment for a physical or mental impairment that
would affect the ability to drive?. As used here, not applicable in MT, OR and WI.
GENERAL INFORMATION
#
Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION
Explanation
Enter text: The description of any medication or treatments for a driver with physical or mental
impairments.
GENERAL INFORMATION
3. Any drivers license
suspended / revoked during
the last three (3) years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any drivers license been suspended/revoked during the last mandated number of years?. If
yes, indicate if the drivers license of any operator was suspended or revoked and explain the
circumstances.
OPERATORS EXPERIENCE
#
Enter number: The number assigned to the driver by the producer.
OPERATORS EXPERIENCE
Suspension Period - Start
Date
Enter date: The date the driver's license suspension became effective.
OPERATORS EXPERIENCE
End Date
Enter date: The date the driver's license suspension is scheduled to end.
OPERATORS EXPERIENCE
Explanation
Enter text: The reason the driver's license was suspended or revoked.
OPERATORS EXPERIENCE
Reinstatement Date
Enter date: The date a suspended or revoked driver's license was reinstated.
ACCIDENTS / CONVICTIONS Within Last_Years?
Enter number: The number of years reviewed, in accordance with the company's and state's
requirements.
ACCIDENTS / CONVICTIONS Y / N
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any operator had an accident/conviction during the last specified number of years?. If yes,
describe accidents/convictions for both driving and boating records.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACORD 82 (2013/09)
Page 29 of 39
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACORD 82 (2013/09)
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ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv #
Enter number: The producer's driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS
Date of Accident /
Conviction
Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS
Description of Accident or
Conviction
Enter text: The description of the accident or conviction. ACORD 101, Additional Remarks
Schedule, may be attached if more space is needed.
ACCIDENTS / CONVICTIONS
Place of Accident /
Conviction
Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the accident or conviction
resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage
Enter amount: The amount of property damage resulting from the accident or conviction.
Form Page 4
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).
ACORD 82 (2013/09)
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LOSS HISTORY
Any losses whether or nor
paid by insurance, during
the last (enter number)
years, at this or any
location?
Enter number: The number of years of loss information required by the insurer.
LOSS HISTORY
Y / N
Enter Y for a Yes response. Input N for No response. Indicates if there have been any losses
at any location, whether paid or not paid by insurance, in the last mandated number of years.
LOSS HISTORY
Applicant's Initials
Initial here: The named insured's initials.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
Cat #
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In dispute Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
Cat #
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In dispute Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
ACORD 82 (2013/09)
Page 32 of 39
LOSS HISTORY
Cat #
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In dispute Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
PRIOR COVERAGE
No Prior Coverage
(checkbox)
Check the box (if applicable): Indicates there was no prior coverage.
PRIOR COVERAGE
Line of Business
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
BI or CSL per person
Enter amount: The bodily injury per person limit on the prior policy (if applicable).
PRIOR COVERAGE
BI or CSL per accident
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if
applicable).
PRIOR COVERAGE
Line of Business
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
BI or CSL per person
Enter amount: The bodily injury per person limit on the prior policy (if applicable).
PRIOR COVERAGE
BI or CSL per accident
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if
applicable).
PAYMENT PLAN
Billing Account #
Enter identifier: The account number to be used for billing purposes. This is the billing number
assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns.
If the account already exists, the agent should provide the previously assigned number.
PAYMENT PLAN
Deposit Amount
Enter amount: The amount of the premium received as a deposit.
PAYMENT PLAN
Est Total Premium
Enter amount: The estimated total cost amount of the policy.
PAYMENT PLAN
Billing - Direct Bill - Policy
(checkbox)
Check the box (if applicable): Indicates if the policy is to be direct billed.
PAYMENT PLAN
Direct Bill - Acct (checkbox)
Check the box (if applicable): Indicates if the account is to be direct billed.
ACORD 82 (2013/09)
Page 33 of 39
PAYMENT PLAN
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer / agency billed.
PAYMENT PLAN
Payment Plan - Full Pay
(checkbox)
Check the box (if applicable): Indicates a full payment will be made on the policy.
PAYMENT PLAN
Annual (checkbox)
Check the box (if applicable): Indicates the policy will be paid annually.
PAYMENT PLAN
Semi-Annual (checkbox)
Check the box (if applicable): Indicates the policy will be paid semi-annually.
PAYMENT PLAN
Quarterly (checkbox)
Check the box (if applicable): Indicates the policy will be paid quarterly.
PAYMENT PLAN
Bi-Monthly (checkbox)
Check the box (if applicable): Indicates the policy will be paid bi-monthly.
PAYMENT PLAN
Monthly (checkbox)
Check the box (if applicable): Indicates the policy will be paid monthly.
PAYMENT PLAN
Other (checkbox)
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those
listed.
PAYMENT PLAN
Other Description
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
PAYMENT PLAN
Payment Method - Cash
(checkbox)
Check the box (if applicable): Indicates the invoice will be paid in cash.
PAYMENT PLAN
Check (checkbox)
Check the box (if applicable): Indicates the invoice will be paid by check.
PAYMENT PLAN
Credit Card (checkbox)
Check the box (if applicable): Indicates the invoice will be paid by credit card.
PAYMENT PLAN
EFT (checkbox)
Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer
(EFT).
PAYMENT PLAN
Payroll Deduction
(checkbox)
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction.
PAYMENT PLAN
Pre-Authorized Draft/Check
(PAC) (checkbox)
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or
draft.
PAYMENT PLAN
Other (checkbox)
Check the box (if applicable): Indicates the invoice will be paid by a means other than those
listed.
PAYMENT PLAN
Other Description
Enter text: The method the invoice will be paid.
PAYMENT PLAN
Mail Policy to Agent
(checkbox)
Check the box (if applicable): Indicates if the policy paper should be sent to the producer.
PAYMENT PLAN
Insured (checkbox)
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the
named insured.
PAYMENT PLAN
Other (checkbox)
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the
agent or applicant.
ACORD 82 (2013/09)
Page 34 of 39
PAYMENT PLAN
Other Description
Enter text: The description of whom the policy paper should be mailed to.
PAYMENT PLAN
Payor - Insured (checkbox)
Check the box (if applicable): Indicates the payor of the policy is the insured.
PAYMENT PLAN
Mortgagee (checkbox)
Check the box (if applicable): Indicates the payor of the policy is the mortgagee.
PAYMENT PLAN
Other (checkbox)
Check the box (if applicable): Indicates the payor of the policy is other than those listed.
PAYMENT PLAN
Other Description
Enter text: The description of the payor of the policy.
PAYMENT PLAN
Premium Financed?
Enter Y for a Yes response. Input N for No response. Indicates if the premium has been
financed.
PAYMENT PLAN
Finance Company
Enter text: The name of the company financing the premium, if applicable.
ADDITIONAL INTEREST
Additional Insured
(checkbox)
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
Lienholder (checkbox)
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Trustee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a trustee.
ADDITIONAL INTEREST
Other (checkbox)
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Evidence - Certificate
(checkbox)
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
Send Bill (checkbox)
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST
Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Address Line 1
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Address Line 2
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
City
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
State
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Zip Code
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Country
Enter code: The additional interest's country code.
ACORD 82 (2013/09)
Page 35 of 39
ADDITIONAL INTEREST
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Location
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST
Item Description
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST
Additional Insured
(checkbox)
Check the box (if applicable): Indicates the interest type is an additional insured.
ADDITIONAL INTEREST
Lienholder (checkbox)
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Trustee (checkbox)
Check the box (if applicable): Indicates the additional interest type is a trustee.
ADDITIONAL INTEREST
Other (checkbox)
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the
form.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST
Rank
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Evidence - Certificate
(checkbox)
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance,
ADDITIONAL INTEREST
Send Bill (checkbox)
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST
Name
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Address Line 1
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Address Line 2
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
City
Enter text: The additional interest's mailing address city name.
ACORD 82 (2013/09)
Page 36 of 39
ADDITIONAL INTEREST
State
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Zip Code
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Country
Enter code: The additional interest's country code.
ADDITIONAL INTEREST
Reference / Loan #
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Location
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Item Class
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST
Item
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST
Item Description
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ATTACHMENTS
State Supplement(s)
Check the box (if applicable): Indicates a state supplement is attached.
ATTACHMENTS
Photograph
Check the box (if applicable): Indicates a photograph is attached.
ATTACHMENTS
Survey
Check the box (if applicable): Indicates a survey is attached.
ATTACHMENTS
Coast Guard Certificate
Check the box (if applicable): Indicates a coast guard certificate is attached.
ATTACHMENTS
Inspection
Check the box (if applicable): Indicates an inspection is attached.
ATTACHMENTS
Appraisal
Check the box (if applicable): Indicates an appraisal is attached.
ATTACHMENTS
Motor Vehicle Report
Check the box (if applicable): Indicates a motor vehicle report is attached.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
ATTACHMENTS
Other Description
Enter text: The description of the attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
ATTACHMENTS
Other Description
Enter text: The description of the attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
ATTACHMENTS
Other Description
Enter text: The description of the attachment.
ACORD 82 (2013/09)
Page 37 of 39
REMARKS
Remarks
Enter text: The remarks associated with the watercraft line of business.
BINDER
Effective Date
Enter date: The date on which the terms and conditions of the binder commenced. This date
normally coincides with the effective date of the policy or of an endorsement to the policy.
BINDER
Time
Enter time: The time of the binder effective date that the binder becomes effective.
BINDER
Expiration Date
Enter date: The date on which the terms and conditions of the policy will or have expired.
Certain state laws limit the terms of a binder, so this date may not coincide with the policy
expiration date.
BINDER
12:01 am (checkbox)
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date.
BINDER
Noon (checkbox)
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date.
BINDER
Coverage is not bound
(checkbox)
Check the box (if applicable): Indicates the coverage has not been bound.
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).
NOTICE OF INFORMATION
PRACTICES
Applicant's Initials
Initial here: The named insured's initials.
NOTICE OF INFORMATION
PRACTICES
Copy of the Notice of
Information Practices
Privacy has been given to
the applicant. Not applicable
in all states, consult your
agent or broker for your
state's requirements.
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.
FRAUD STATEMENTS /
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
FRAUD STATEMENTS /
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
FRAUD STATEMENTS /
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
FRAUD STATEMENTS /
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
ACORD 82 (2013/09)
Page 38 of 39
FRAUD STATEMENTS /
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
FRAUD STATEMENTS /
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 82 (2013/09)
Page 39 of 39