ACORD 825, Professional / Specialty Insurance Application, (For Use in Management, Executive & Professional Lines - Applicant Section), is the

ACORD 825 (2013/09) - Specialty Insurance Application
ACORD 825, Professional / Specialty Insurance Application, (For Use in Management, Executive & Professional Lines - Applicant Section), is the
foundation on which the ACORD professional / specialty application program is built. ACORD 825, Professional / Specialty Insurance Application -
Applicant Section, is a required part of every professional / specialty lines submission (except Medical Professional Liability) and no professional /
specialty lines application is complete without it.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date (MM/DD/YYYY)
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency. As used here, in Florida and Nebraska, also
include the producer's state license number, and in Nebraska, add the agency state license
number.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer / agency.
IDENTIFICATION SECTION
Agency's State License #
Enter identifier: The agency's state license number.
IDENTIFICATION SECTION
Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION
Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax No. (A/C, No, Ext)
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ACORD 825 (2013/09) FIG rev. 03-05-2014
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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
Underwriter
Enter text: The company underwriter (or other company staff person) that this form should be
directed to.
IDENTIFICATION SECTION
Underwriter Off.
Enter identifier: The company underwriting office that this application should be directed to.
IDENTIFICATION SECTION
Policies or Program
Requested
Enter code: The product code assigned by the insurer for the policy.
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
CRIME
Check the box (if applicable): Indicates the Crime section is attached to this application.
IDENTIFICATION SECTION
D&O (Directors & Officers)
Check the box (if applicable): Indicates the Directors And Officers section is attached to this
application.
IDENTIFICATION SECTION
E&O (Errors & Omissions)
Check the box (if applicable): Indicates the Errors & Omissions section is attached to this
application.
IDENTIFICATION SECTION
EPLI (Employment Practices
Liability)
Check the box (if applicable): Indicates the Employment Practices Liability Insurance (EPLI)
section is attached to this application.
IDENTIFICATION SECTION
FIDUCIARY
Check the box (if applicable): Indicates the Fiduciary section is attached to the application.
IDENTIFICATION SECTION
KIDNAP / RANSOM
Check the box (if applicable): Indicates the Kidnap/Ransom section is attached to this
application.
IDENTIFICATION SECTION
PROFESSIONAL LIABILITY
Check the box (if applicable): Indicates the Professional Liability section is attached to the
application.
IDENTIFICATION SECTION
PROF LIAB -
ACCOUNTANTS
PROFESSIONAL
Check the box (if applicable): Indicates the Accountants Professional Liability section is attached
to this application.
IDENTIFICATION SECTION
PROF LIAB - ARCHITECTS
PROFESSIONAL
Check the box (if applicable): Indicates the Architects Professional Liability section is attached to
this application.
IDENTIFICATION SECTION
PROF LIAB - INSURANCE
AGENTS
Check the box (if applicable): Indicates the Insurance Agents Professional Liability section is
attached to this application.
IDENTIFICATION SECTION
PROF LIAB - LAWYERS
PROFESSIONAL
Check the box (if applicable): Indicates the Lawyers Professional Liability section is attached to
this application.
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IDENTIFICATION SECTION
PROF LIAB - MEDIA
PROFESSIONAL
Check the box (if applicable): Indicates the Media Professional Liability section is attached to
this application.
IDENTIFICATION SECTION
PROF LIAB - MEDICAL
MALPRACTICE
Check the box (if applicable): Indicates the Medical Malpractice Professional Liability section is
attached to this application.
IDENTIFICATION SECTION
CYBER AND PRIVACY
COVERAGE SECTION
Check the box (if applicable): Indicates the Cyber and Privacy Coverage Section is attached to
this application.
IDENTIFICATION SECTION
TECHNOLOGY
Check the box (if applicable): Indicates the Technology section is attached to this application.
IDENTIFICATION SECTION
WORKPLACE VIOLENCE
Check the box (if applicable): Indicates the Workplace Violence section is attached to this
application.
IDENTIFICATION SECTION
Other
Check the box (if applicable): Indicates that a section that is not listed specifically on the form is
attached to this application.
IDENTIFICATION SECTION
Describe Other
Enter text: The type of section being attached to this application.
IDENTIFICATION SECTION
Miscellaneous Professional
Liability
Check the box (if applicable): Indicates a miscellaneous professional liability section is attached
to this application.
IDENTIFICATION SECTION
Describe
Enter text: The type of section being attached to this application. As used here the type of
Miscellaneous Professional Liability section being attached to this application.
IDENTIFICATION SECTION
Public
Check the box (if applicable): Indicates the nature of business is public.
IDENTIFICATION SECTION
Private
Check the box (if applicable): Indicates the nature of business is private.
IDENTIFICATION SECTION
Not For Profit
Check the box (if applicable): Indicates the nature of business is not for profit.
IDENTIFICATION SECTION
Health Care
Check the box (if applicable): Indicates the nature of business is health care.
IDENTIFICATION SECTION
Financial Institution
Check the box (if applicable): Indicates the nature of business is a financial institution.
STATUS OF TRANSACTION
Quote
Check the box (if applicable): Indicates the response expected from the company is a quote.
STATUS OF TRANSACTION
Issue Policy
Check the box (if applicable): Indicates the response expected from the company is an issued
policy.
STATUS OF TRANSACTION
Renewal
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
STATUS OF TRANSACTION
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
STATUS OF TRANSACTION
Bound
Check the box (if applicable): Indicates the coverage has been bound.
STATUS OF TRANSACTION
Date Bound
Enter date: The date the policy status becomes effective. This date is used for policy statuses
of bound, change, and cancel.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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STATUS OF TRANSACTION
Time
Enter time: The time the policy status becomes effective. The time is used for policy statuses of
bound, change, and cancel.
STATUS OF TRANSACTION
AM
Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm.
STATUS OF TRANSACTION
PM
Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or
later.
POLICY INFORMATION
Proposed Eff. Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
POLICY INFORMATION
Proposed Exp. Date
Enter date: The date on which the terms and conditions of the policy will expire.
POLICY INFORMATION
Direct Bill
Check the box (if applicable): Indicates if the policy is to be direct billed.
POLICY INFORMATION
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer / agency billed.
POLICY INFORMATION
Payment Plan
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
APPLICANT / FIRM
INFORMATION
Name (First Named Insured
& Other Named Insureds)
Enter text: The named insured(s) as it / they will appear on the policy declarations page. As
used here, The first named Insured is given certain rights and responsibilities by the policy
contract language. If more than one insured is named, be sure the one intended to receive
these rights and responsibilities is named first. If joint ownership, the name used may include
both names (e.g., John and Mary Smith). Wording such as et al or As their interests may
appear is not acceptable as the name of the insured. These phrases do not designate legal
entities.
APPLICANT / FIRM
INFORMATION
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT / FIRM
INFORMATION
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT / FIRM
INFORMATION
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
APPLICANT / FIRM
INFORMATION
FEIN (of First Named
Insured)
Enter identifier: The tax identifier of the named insured. As used here, this is the Federal
Employers Identification Number.
APPLICANT / FIRM
INFORMATION
Soc Sec # (if no FEIN)
Enter identifier: The tax identifier of the named insured. As used here, this is the Social Security
Number.
APPLICANT INFORMATION
Primary Phone #
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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APPLICANT / FIRM
INFORMATION
Secondary Phone #
Enter number: The named insured's secondary phone number.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
APPLICANT / FIRM
INFORMATION
Fax No. (A/C, No)
Enter number: The named insured's fax number.
APPLICANT / FIRM
INFORMATION
Website Addresses
Enter text: The primary website address for the named insured.
APPLICANT / FIRM
INFORMATION
Mailing Address Incl ZIP+4
(of First Named Insured)
Enter text: The named insured's mailing address line one.
APPLICANT / FIRM
INFORMATION
Enter text: The named insured's mailing address line two.
APPLICANT / FIRM
INFORMATION
Enter text: The named insured's mailing address city name.
APPLICANT / FIRM
INFORMATION
Enter code: The named insured's mailing address state or province code.
APPLICANT / FIRM
INFORMATION
Enter code: The named insured's mailing address postal code.
APPLICANT / FIRM
INFORMATION
Applicant's Title
Enter text: The title of the individual in the organization or his relationship to the organization.
APPLICANT / FIRM
INFORMATION
NAICS Code
Enter code: The North American Industry Classification System (NAICS) 6-digit industry code
assigned to the business activity (if known).
APPLICANT / FIRM
INFORMATION
SIC Code
Enter code: The Standard Industry Classification code assigned to the business activity (if
known). This is the code which represents the nature of the employer's business which is
contained in the Standard Industrial Classification Manual published by the Federal Office of
Management and Budget.
APPLICANT / FIRM
INFORMATION
CR Bureau Name
Enter text: The code identifies an external source that may be used to provide financial or credit
information. For example, a Dun and Bradstreet Number, TRW number, Equifax, Trans-Union,
etc.
APPLICANT / FIRM
INFORMATION
ID Number
Enter identifier: The identifier assigned by the credit bureau for the risk.
APPLICANT / FIRM
INFORMATION
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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APPLICANT / FIRM
INFORMATION
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
APPLICANT / FIRM
INFORMATION
Individual
Check the box (if applicable): Indicates the legal entity code for the named insured is
Individual.
APPLICANT / FIRM
INFORMATION
Partnership
Check the box (if applicable): Indicates the legal entity code for the named insured is
Partnership.
APPLICANT / FIRM
INFORMATION
Corporation
Check the box (if applicable): Indicates the legal entity code for the named insured is
Corporation.
APPLICANT / FIRM
INFORMATION
Joint Venture
Check the box (if applicable): Indicates the legal entity code for the named insured is Joint
Venture.
APPLICANT / FIRM
INFORMATION
Subchapter S Corporation
Check the box (if applicable): Indicates the legal entity code for the named insured is
Subchapter S Corporation.
APPLICANT / FIRM
INFORMATION
PC
Check the box (if applicable): Indicates the legal entity code for the named insured is
Professional Company.
APPLICANT / FIRM
INFORMATION
LLC
Check the box (if applicable): Indicates the legal entity code for the named insured is Limited
Liability Corporation.
APPLICANT / FIRM
INFORMATION
GP/LLP
Check the box (if applicable): Indicates the legal entity code for the named insured is General
Partnership/Limited Liability Partnership.
APPLICANT / FIRM
INFORMATION
Number of Members and
Managers
Enter number: The number of members and managers for a limited liability corporation.
APPLICANT / FIRM
INFORMATION
Other
Check the box (if applicable): Indicates the legal entity code for the named insured is not listed
on the form.
APPLICANT / FIRM
INFORMATION
Describe Other
Enter text: The description of the legal entity if not listed on the form.
APPLICANT / FIRM
INFORMATION
Operations U.S
Check the box (if applicable): Indicates the insured has USA based operations.
APPLICANT / FIRM
INFORMATION
Operations Non U.S
Check the box (if applicable): Indicates the insured has operations based outside the USA.
APPLICANT / FIRM
INFORMATION
State of Incorporation
Enter code: The state or province where the business is incorporated.
APPLICANT / FIRM
INFORMATION
Date Business Started
Enter date: The date the current owners purchased or started the business.
APPLICANT / FIRM
INFORMATION
Total Employees - Full Time
Enter number: The number of full time employees.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 6 of 22
APPLICANT / FIRM
INFORMATION
Total Employees - Part Time
Enter number: The number of part time employees.
APPLICANT / FIRM
INFORMATION
Total Payroll
Enter amount: The total annual payroll of the business in whole dollars.
APPLICANT / FIRM
INFORMATION
Total Revenues
Enter amount: The total revenue for the organization for the current year.
APPLICANT / FIRM
INFORMATION
Total Assets
Enter amount: The total assets of the organization for the current year.
APPLICANT / FIRM
INFORMATION
Total Liabilities
Enter amount: The total liabilities of the organization for the current year.
CONTACT INFORMATION
Primary Contact
Enter text: The name of the person to contact to arrange for a premises inspection. This should
be an individual under the insured's employment, not the insurance agent's name and number.
CONTACT INFORMATION
Primary Phone #
Enter number: The telephone number of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment.
CONTACT INFORMATION
Home
Check the box (if applicable): Indicates the inspection contact's primary phone is a home phone.
CONTACT INFORMATION
Bus
Check the box (if applicable): Indicates the inspection contact's primary phone is a business
phone.
CONTACT INFORMATION
Cell
Check the box (if applicable): Indicates the inspection contact's primary phone is a cell phone.
CONTACT INFORMATION
Secondary Phone #
Enter number: The secondary telephone number of the person to contact to arrange for a
premises inspection. This should be an individual under the insured's employment.
CONTACT INFORMATION
Home
Check the box (if applicable): Indicates the inspection contact's secondary phone is a home
phone.
CONTACT INFORMATION
Bus
Check the box (if applicable): Indicates the inspection contact's secondary phone is a business
phone.
CONTACT INFORMATION
Cell
Check the box (if applicable): Indicates the inspection contact's secondary phone is a cell
phone.
CONTACT INFORMATION
Primary E-Mail Address
Enter text: The e-mail address (if applicable) of the person to contact to arrange for a premises
inspection. This should be an individual under the insured's employment, not the insurance
agent's name and number.
CONTACT INFORMATION
Secondary E-Mail Address
Enter text: The secondary e-mail address of the inspection contact.
CONTACT INFORMATION
Contact Type
Enter text: The type of contact being described (e.g. accounting, claims, etc.).
CONTACT INFORMATION
Name
Enter text: The full name of the contact.
CONTACT INFORMATION
Primary Phone #
Enter number: The primary phone number of the contact.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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CONTACT INFORMATION
Home
Check the box (if applicable): Indicates the contact's primary phone is a home phone.
CONTACT INFORMATION
Bus
Check the box (if applicable): Indicates the contact's primary phone is a business phone.
CONTACT INFORMATION
Cell
Check the box (if applicable): Indicates the contact's primary phone is a cell phone.
CONTACT INFORMATION
Secondary Phone #
Enter number: The contact's secondary phone number.
CONTACT INFORMATION
Home
Check the box (if applicable): Indicates the contact's secondary phone number is a home
phone.
CONTACT INFORMATION
Bus
Check the box (if applicable): Indicates the contact's secondary phone number is a business
phone.
CONTACT INFORMATION
Cell
Check the box (if applicable): Indicates the contact's secondary phone number is a cell phone.
CONTACT INFORMATION
Primary E-Mail Address
Enter text: The contact's primary e-mail address.
CONTACT INFORMATION
Secondary E-Mail Address
Enter text: The contact's secondary e-mail address.
NATURE OF
BUSINESS/DESCRIPTION
OF OPERATIONS BY
PREMISES
Nature of Business
Enter text: The text description of the operations of this risk or insured.
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).
GENERAL INFORMATION
1a. Is the applicant a
subsidiary of another
entity?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is this company a subsidiary of another entity?.
GENERAL INFORMATION
Parent Company
Enter text: The name of the parent organization.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percentage Ownership By
Parent
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
1b. Does the applicant have
any subsidiaries?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does the applicant have subsidiaries? If yes, explain..
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
Name of Subsidiary
Enter text: The name of the subsidiary of the company. This may also contain owned
foundations or charitable trusts.
GENERAL INFORMATION
Relationship
Enter text: The description of the relationship between the parent company and the subsidiary.
GENERAL INFORMATION
Percent Ownership By
Applicant
Enter percentage: The percent of ownership by the parent company.
GENERAL INFORMATION
2. Any other insurance with
this company or being
submitted?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any other insurance with this company?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has any other insurance with this
company.
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GENERAL INFORMATION
3. Has any policy or
coverage being applied for
been declined, cancelled or
non-renewed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has any policy or coverage being applied for been declined, cancelled or non-renewed? (Not
applicable in Missouri).
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has any policy or coverage declined,
cancelled or non-renewed.
GENERAL INFORMATION
4. Any bankruptcies, tax or
credit liens against the
applicant in the past five (5)
years?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any bankruptcies, tax or credit liens against the applicant in the past mandated number of
years?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether the applicant has had any bankruptcies, tax or credit
liens in the past mandated number of years.
GENERAL INFORMATION
5. Has business been placed
in a trust?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Has business been placed in a trust?.
GENERAL INFORMATION
Remarks
Enter text: Indicates the name of the trust if the answer to Has business been placed in a
trust? is Yes.
GENERAL INFORMATION
6. Are there any
predecessor firms?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are there any predecessor firms?.
GENERAL INFORMATION
Remarks
Enter text: An explanation as to whether there are any predecessor firms.
REMARKS
Remarks
Enter text: The commercial policy general remarks.
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).
D&O LIABILITY
Carrier
Enter text: The name of the previous insurer for the Directors & Officers line of business.
D&O LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Directors & Officers line of
business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Directors & Officers line of business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Directors & Officers line of business.
D&O LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Directors & Officers line of business.
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D&O LIABILITY
Enter date: The expiration date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
D&O LIABILITY
Continuity Date
Enter date: The continuity date.
D&O LIABILITY
Limit Per Claim
Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Retention
Enter amount: The retention amount of the prior Directors & Officers coverage.
D&O LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy did not have
additional layers.
D&O LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Directors & Officers line of business.
D&O LIABILITY
Carrier
Enter text: The name of the previous insurer for the Directors & Officers line of business.
D&O LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Directors & Officers line of
business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Directors & Officers line of business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Directors & Officers line of business.
D&O LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Enter date: The expiration date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
D&O LIABILITY
Continuity Date
Enter date: The continuity date.
D&O LIABILITY
Limit Per Claim
Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Retention
Enter amount: The retention amount of the prior Directors & Officers coverage.
D&O LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers.
ACORD 825 (2013/09) FIG rev. 03-05-2014
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D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy did not have
additional layers.
D&O LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Directors & Officers line of business.
D&O LIABILITY
Carrier
Enter text: The name of the previous insurer for the Directors & Officers line of business.
D&O LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Directors & Officers line of
business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Directors & Officers line of business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Directors & Officers line of business.
D&O LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Enter date: The expiration date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
D&O LIABILITY
Continuity Date
Enter date: The continuity date.
D&O LIABILITY
Limit Per Claim
Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Retention
Enter amount: The retention amount of the prior Directors & Officers coverage.
D&O LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy did not have
additional layers.
D&O LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Directors & Officers line of business.
D&O LIABILITY
Carrier
Enter text: The name of the previous insurer for the Directors & Officers line of business.
D&O LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Directors & Officers line of
business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Directors & Officers line of business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Directors & Officers line of business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 12 of 22
D&O LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Enter date: The expiration date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
D&O LIABILITY
Continuity Date
Enter date: The continuity date.
D&O LIABILITY
Limit Per Claim
Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Retention
Enter amount: The retention amount of the prior Directors & Officers coverage.
D&O LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy did not have
additional layers.
D&O LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Directors & Officers line of business.
D&O LIABILITY
Carrier
Enter text: The name of the previous insurer for the Directors & Officers line of business.
D&O LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Directors & Officers line of
business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Directors & Officers line of business.
D&O LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Directors & Officers line of business.
D&O LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Enter date: The expiration date of the prior policy for the Directors & Officers line of business.
D&O LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
D&O LIABILITY
Continuity Date
Enter date: The continuity date.
D&O LIABILITY
Limit Per Claim
Enter limit: The per claim limit amount of the prior coverage for the Directors & Officers line of
business.
D&O LIABILITY
Retention
Enter amount: The retention amount of the prior Directors & Officers coverage.
D&O LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Directors & Officers line of
business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 13 of 22
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy had additional layers.
D&O LIABILITY
Additional Layers
Check the box (if applicable): Indicates the prior Directors & Officers policy did not have
additional layers.
D&O LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Directors & Officers line of business.
E P L I
Carrier
Enter text: The name of the previous insurer for the EPLI line of business.
E P L I
Policy Number
Enter number: The policy number of the previous coverage for the EPLI line of business.
E P L I
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
EPLI line of business.
E P L I
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
EPLI line of business.
E P L I
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the EPLI line of business.
E P L I
Enter date: The expiration date of the prior policy for the EPLI line of business
E P L I
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
E P L I
Continuity Date
Enter date: The continuity date.
E P L I
Limit Per Claim -
Occurrence
Enter limit: The per occurrence limit amount of the prior coverage for the EPLI line of business.
E P L I
Limit Per Claim - Aggregate
Enter limit: The aggregate limit amount of the prior coverage for the EPLI line of business.
E P L I
Retention
Enter amount: The retention amount of the prior coverage for the EPLI line of business.
E P L I
Deductible
Enter deductible: The deductible amount of the prior coverage for the EPLI line of business.
E P L I
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the EPLI line of business.
E P L I
Carrier
Enter text: The name of the previous insurer for the EPLI line of business.
E P L I
Policy Number
Enter number: The policy number of the previous coverage for the EPLI line of business.
E P L I
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
EPLI line of business.
E P L I
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
EPLI line of business.
E P L I
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the EPLI line of business.
E P L I
Enter date: The expiration date of the prior policy for the EPLI line of business
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 14 of 22
E P L I
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
E P L I
Continuity Date
Enter date: The continuity date.
E P L I
Limit Per Claim -
Occurrence
Enter limit: The per occurrence limit amount of the prior coverage for the EPLI line of business.
E P L I
Limit Per Claim - Aggregate
Enter limit: The aggregate limit amount of the prior coverage for the EPLI line of business.
E P L I
Retention
Enter amount: The retention amount of the prior coverage for the EPLI line of business.
E P L I
Deductible
Enter deductible: The deductible amount of the prior coverage for the EPLI line of business.
E P L I
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the EPLI line of business.
PROFESSIONAL LIABILITY
Carrier
Enter text: The name of the previous insurer for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Professional Liability line of
business.
PROFESSIONAL LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Professional Liability line of business.
PROFESSIONAL LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Professional Liability line of business.
PROFESSIONAL LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Enter date: The expiration date of the prior policy for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
PROFESSIONAL LIABILITY
Continuity Date
Enter date: The continuity date.
PROFESSIONAL LIABILITY
Limit Per Claim -
Occurrence
Enter limit: The per occurrence limit amount of the prior coverage for the Professional Liability
line of business.
PROFESSIONAL LIABILITY
Limit Per Claim - Aggregate
Enter limit: The aggregate limit amount of the prior coverage for the Professional Liability line of
business.
PROFESSIONAL LIABILITY
Retention
Enter amount: The retention amount of the prior Professional Liability coverage.
PROFESSIONAL LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Professional Liability line
of business.
PROFESSIONAL LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Carrier
Enter text: The name of the previous insurer for the Professional Liability line of business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 15 of 22
PROFESSIONAL LIABILITY
Policy Number
Enter number: The policy number of the previous coverage for the Professional Liability line of
business.
PROFESSIONAL LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
Professional Liability line of business.
PROFESSIONAL LIABILITY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
Professional Liability line of business.
PROFESSIONAL LIABILITY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Enter date: The expiration date of the prior policy for the Professional Liability line of business.
PROFESSIONAL LIABILITY
Retro Date
Enter date: The retroactive date if the policy was issued on a Claims Made basis and there was
a retroactive date.
PROFESSIONAL LIABILITY
Continuity Date
Enter date: The continuity date.
PROFESSIONAL LIABILITY
Limit Per Claim -
Occurrence
Enter limit: The per occurrence limit amount of the prior coverage for the Professional Liability
line of business.
PROFESSIONAL LIABILITY
Limit Per Claim - Aggregate
Enter limit: The aggregate limit amount of the prior coverage for the Professional Liability line of
business.
PROFESSIONAL LIABILITY
Retention
Enter amount: The retention amount of the prior Professional Liability coverage.
PROFESSIONAL LIABILITY
Deductible
Enter deductible: The deductible amount of the prior coverage for the Professional Liability line
of business.
PROFESSIONAL LIABILITY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the Professional Liability line of business.
CRIME
Carrier
Enter text: The name of the previous insurer for the crime line of business.
CRIME
Policy Number
Enter number: The policy number of the previous coverage for the crime line of business.
CRIME
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
crime line of business.
CRIME
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
crime line of business.
CRIME
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the crime line of business.
CRIME
Enter date: The expiration date of the prior policy for the crime line of business.
CRIME
Limit
Enter limit: The limit for the line of business used in the crime section of prior coverage.
CRIME
Deductible
Enter deductible: The deductible amount of the prior coverage for the crime line of business.
CRIME
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the crime line of business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 16 of 22
CRIME
Carrier
Enter text: The name of the previous insurer for the crime line of business.
CRIME
Policy Number
Enter number: The policy number of the previous coverage for the crime line of business.
CRIME
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
crime line of business.
CRIME
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
crime line of business.
CRIME
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the crime line of business.
CRIME
Enter date: The expiration date of the prior policy for the crime line of business.
CRIME
Limit
Enter limit: The limit for the line of business used in the crime section of prior coverage.
CRIME
Deductible
Enter deductible: The deductible amount of the prior coverage for the crime line of business.
CRIME
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the crime line of business.
FIDUCIARY
Carrier
Enter text: The name of the previous insurer for the fiduciary line of business.
FIDUCIARY
Policy Number
Enter number: The policy number of the previous coverage for the fiduciary line of business.
FIDUCIARY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
fiduciary line of business.
FIDUCIARY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
fiduciary line of business.
FIDUCIARY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the fiduciary line of business.
FIDUCIARY
Enter date: The expiration date of the prior policy for the fiduciary line of business.
FIDUCIARY
Limit
Enter limit: The limit for the line of business used in the fiduciary section of prior coverage.
FIDUCIARY
Deductible
Enter deductible: The deductible amount of the prior coverage for the fiduciary line of business.
FIDUCIARY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the fiduciary line of business.
FIDUCIARY
Carrier
Enter text: The name of the previous insurer for the fiduciary line of business.
FIDUCIARY
Policy Number
Enter number: The policy number of the previous coverage for the fiduciary line of business.
FIDUCIARY
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
fiduciary line of business.
FIDUCIARY
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
fiduciary line of business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 17 of 22
FIDUCIARY
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the fiduciary line of business.
FIDUCIARY
Enter date: The expiration date of the prior policy for the fiduciary line of business.
FIDUCIARY
Limit
Enter limit: The limit for the line of business used in the fiduciary section of prior coverage.
FIDUCIARY
Deductible
Enter deductible: The deductible amount of the prior coverage for the fiduciary line of business.
FIDUCIARY
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for the fiduciary line of business.
OTHER
Carrier
Enter text: The name of the previous insurer for the other line of business.
OTHER
Policy Number
Enter number: The policy number of the previous coverage for the other line of business.
OTHER
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
other line of business.
OTHER
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
other line of business.
OTHER
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the other line of business.
OTHER
Enter date: The expiration date of the previous coverage for the other line of business.
OTHER
Limit
Enter limit: The limit for the line of business used in the other section of prior coverage.
OTHER
Deductible
Enter deductible: The deductible amount of the prior coverage for the other line of business.
OTHER
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for other lines of business.
OTHER
Carrier
Enter text: The name of the previous insurer for the other line of business.
OTHER
Policy Number
Enter number: The policy number of the previous coverage for the other line of business.
OTHER
Policy Type
Check the box (if applicable): Indicates the policy was issued on a claims made basis for the
other line of business.
OTHER
Policy Type
Check the box (if applicable): Indicates the policy was issued on an occurrence basis for the
other line of business.
OTHER
Eff.- Exp. Date
Enter date: The effective date of the prior policy for the other line of business.
OTHER
Enter date: The expiration date of the previous coverage for the other line of business.
OTHER
Limit
Enter limit: The limit for the line of business used in the other section of prior coverage.
OTHER
Deductible
Enter deductible: The deductible amount of the prior coverage for the other line of business.
OTHER
Total Premium
Enter amount: The annual modified premium charged (not including taxes or service charges)
for other lines of business.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 18 of 22
ATTACHMENTS
Financials
Check the box (if applicable): Indicates that a financial statement is attached to the application.
ATTACHMENTS
Carrier Loss Runs
Check the box (if applicable): Indicates that carrier loss runs are attached to the application.
ATTACHMENTS
Carrier Supplement(s)
Check the box (if applicable): Indicates that carrier supplements are attached to the application.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other
Check the box (if applicable): Indicates there is an attachment other than those listed on the
application.
ATTACHMENTS
Other Description
Enter text: The description of the type of other attachment.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 19 of 22
LOSS HISTORY
Check Here if None
Check the box (if applicable): Indicates there are no prior losses or occurrences that may give
rise to claims for the mandated number of years.
LOSS HISTORY
See Attached Loss
Summary
Check the box (if applicable): Indicates that a loss summary report is attached to the application.
LOSS HISTORY
Total Losses
Enter amount: The amount that has been paid on all losses to date.
LOSS HISTORY
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Type/Description of
Occurrence or Claim
Enter text: A brief description of the loss.
LOSS HISTORY
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Type/Description of
Occurrence or Claim
Enter text: A brief description of the loss.
LOSS HISTORY
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Type/Description of
Occurrence or Claim
Enter text: A brief description of the loss.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 20 of 22
LOSS HISTORY
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Type/Description of
Occurrence or Claim
Enter text: A brief description of the loss.
LOSS HISTORY
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status Closed
Check the box (if applicable): Indicates the claim is closed.
LOSS HISTORY
Date of Occurrence
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Type/Description of
Occurrence or Claim
Enter text: A brief description of the loss.
LOSS HISTORY
Date of Claim
Enter date: The date the claim was filed.
LOSS HISTORY
Amount Paid
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Amount Reserved
Enter amount: The reserve amount the previous carrier is holding open for this claim.
LOSS HISTORY
Claim Status Open
Check the box (if applicable): Indicates the claim is still open.
LOSS HISTORY
Claim Status Closed
Check the box (if applicable): Indicates the claim is closed.
REMARKS
Remarks
Enter text: The commercial policy general remarks.
Form Page 4
Section Name
Field Name
Description
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 21 of 22
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
REMARKS
Remarks
Enter text: The commercial policy general remarks.
SIGNATURE
Notice of Information
Practices
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
SIGNATURE
Applicant's Initials
Initial here: The named insured's initials.
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE
Producer's Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
SIGNATURE
State Producer License No
Enter identifier: The State License Number of the producer.
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 825 (2013/09) FIG rev. 03-05-2014
Page 22 of 22