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ACORD 88 (2009/02) rev. 06-30-2009 1 of 33
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 88 (2009/02) |
Personal Insurance Application |
The title of the form. ACORD 88, Personal Insurance Application, is used in the underwriting process with the submission of a completed application for any personal lines policy. |
|
IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION SECTION |
Contact Name |
Enter text: The name of the individual at the producer's establishment that is the primary contact. |
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IDENTIFICATION SECTION |
Phone No. |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION SECTION |
Fax No. |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION SECTION |
E-Mail Address |
Enter text: The producer's contact person e-mail address. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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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). |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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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. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
ACORD 88 (2009/02) rev. 06-30-2009 2 of 33
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Section Name |
Field Name |
Field and/or Section Description |
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IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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IDENTIFICATION SECTION |
Policy # |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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IDENTIFICATION SECTION |
Plan |
Enter code: The product code of the insurer for the policy. |
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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. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Expiration Date |
Enter date: The date on which the terms and conditions of the policy will expire. |
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STATUS OF TRANSACTION |
New |
Check the box (if applicable): Indicates the response expected from the company is a new issued policy. |
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STATUS OF TRANSACTION |
Renew |
Check the box (if applicable): Indicates the response expected from the company is a renewed policy. |
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STATUS OF TRANSACTION |
Policy Change |
Check the box (if applicable): Indicates the policy is being submitted for a policy change. |
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STATUS OF TRANSACTION |
Other |
Check the box (if applicable): Indicates the response expected from the company is a policy other than those listed. |
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STATUS OF TRANSACTION |
Other Description |
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.). |
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STATUS OF TRANSACTION |
Policy Change Effective Date |
Enter date: The date the policy status becomes effective. This date is used for policy statuses of bound, change, and cancel. |
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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. |
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STATUS OF TRANSACTION |
AM |
Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm. |
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STATUS OF TRANSACTION |
PM |
Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or later. |
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INDICATE SECTIONS ATTACHED |
Personal Automobile 90 |
Check the box (if applicable): Indicates the Personal Automobile (ACORD 90) section is attached to this policy. |
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INDICATE SECTIONS ATTACHED |
Residential 89 |
Check the box (if applicable): Indicates the Residential (ACORD 89) section is attached to this policy. |
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Section Name |
Field Name |
Field and/or Section Description |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates the Personal Umbrella (ACORD 83) section is |
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ATTACHED |
Personal Umbrella 83 |
attached to this policy. |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates the Personal Inland Marine (ACORD 81) section is |
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ATTACHED |
Personal Inland Marine 81 |
attached to this policy. |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates the Watercraft (ACORD 82) section is attached to |
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ATTACHED |
Watercraft 82 |
this policy. |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates that a section that is not listed specifically on the |
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ATTACHED |
Other |
form is attached to this policy. |
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INDICATE SECTIONS |
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ATTACHED |
Other Description |
Enter text: The type of section being attached to the policy. |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates that a section that is not listed specifically on the |
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ATTACHED |
Other |
form is attached to this policy. |
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INDICATE SECTIONS |
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ATTACHED |
Other Description |
Enter text: The type of section being attached to the policy. |
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INDICATE SECTIONS |
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Check the box (if applicable): Indicates that a section that is not listed specifically on the |
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ATTACHED |
Other |
form is attached to this policy. |
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INDICATE SECTIONS |
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ATTACHED |
Other Description |
Enter text: The type of section being attached to the policy. |
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Applicant's Name (First, Middle, |
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APPLICANT INFORMATION |
Last) |
Enter text: The named insured's given name. |
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APPLICANT INFORMATION |
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Enter text: The named insured's other given name initial. |
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APPLICANT INFORMATION |
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Enter text: The named insured's surname. |
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APPLICANT INFORMATION |
Date of Birth |
Enter date: The date of birth of the insured. |
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APPLICANT INFORMATION |
Social Security # |
Enter identifier: The tax identifier of the named insured. |
ACORD 88 (2009/02) rev. 06-30-2009 3 of 33 ACORD 88 (2009/02) rev. 06-30-2009 14 of 33 ACORD 88 (2009/02) rev. 06-30-2009 32 of 33 ACORD 88 (2009/02) rev. 06-30-2009 33 of 33
ACORD 88 (2009/02) rev. 06-30-2009 4 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
APPLICANT INFORMATION |
Marital Status |
Enter code: The insured's marital status. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other As used here, this field may not be utilized for policyholders applying for residential property insurance in CA. |
|
APPLICANT INFORMATION |
Applicant's Mailing Address |
Enter text: The named insured's mailing address line one. |
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APPLICANT INFORMATION |
Address 2 |
Enter text: The named insured's mailing address line two. |
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APPLICANT INFORMATION |
City |
Enter text: The named insured's mailing address city name. |
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APPLICANT INFORMATION |
State |
Enter code: The named insured's mailing address state or province code. |
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APPLICANT INFORMATION |
Zip |
Enter code: The named insured's mailing address postal code. |
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APPLICANT INFORMATION |
Home |
Check the box (if applicable): Indicates the primary phone number is for a home phone. |
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APPLICANT INFORMATION |
Bus |
Check the box (if applicable): Indicates the primary phone number is for a business phone. |
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APPLICANT INFORMATION |
Cell |
Check the box (if applicable): Indicates the primary phone number is for a cell phone. |
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APPLICANT INFORMATION |
Primary Phone # |
Enter number: The named insured's primary phone number. |
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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. |
ACORD 88 (2009/02) rev. 06-30-2009 5 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
APPLICANT INFORMATION |
Secondary Phone # |
Enter number: The named insured's secondary phone number. |
|
APPLICANT INFORMATION |
Primary e-mail address |
Enter text: The named insured's primary e-mail address. |
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APPLICANT INFORMATION |
Secondary e-mail address |
Enter text: The named insured's secondary e-mail address. |
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APPLICANT INFORMATION |
Years At Previous Address |
Enter number: The number of years at the previous address. |
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APPLICANT INFORMATION |
Previous Address |
Enter text: The first address line of the previous residence address. |
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APPLICANT INFORMATION |
Address Continued |
Enter text: The second address line of the previous residence. |
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APPLICANT INFORMATION |
City |
Enter text: The city of the previous residence. |
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APPLICANT INFORMATION |
State |
Enter code: The state or province code of the previous residence. |
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APPLICANT INFORMATION |
Zip |
Enter text: The postal code of the previous residence. |
|
APPLICANT INFORMATION |
Check if same as mailing Address |
Check the box (if applicable): Indicates the named insured's physical address is the same as the mailing address. |
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APPLICANT INFORMATION |
Owned |
Check the box (if applicable): Indicates if the insured owns their current residence. |
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APPLICANT INFORMATION |
Rented |
Check the box (if applicable): Indicates if the insured rents their current residence. |
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APPLICANT INFORMATION |
Current Residence |
Enter text: The named insured's physical address line one. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter text: The named insured's physical address line two. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter text: The named insured's physical address city name. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter code: The named insured's physical address state or province code. As used here, this is the current residence. |
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APPLICANT INFORMATION |
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Enter code: The named insured's physical address postal code. As used here, this is the current residence. |
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APPLICANT INFORMATION |
Date at Current Residence |
Enter date: The date insured moved into their current residence. (MM/DD/YYYY) |
ACORD 88 (2009/02) rev. 06-30-2009 6 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
APPLICANT INFORMATION |
Yrs with Current Employer |
Enter number: The number of years the named insured has been with their current employer. |
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APPLICANT INFORMATION |
Applicant's Employer Name And Address |
Enter text: The employer name (business name if self-employed). |
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APPLICANT INFORMATION |
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Enter text: The first address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The second address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The city of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The state code of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The postal code of the employer's physical address. |
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APPLICANT INFORMATION |
Applicant's Occupation (State Nature of Business if Self-Employed) |
Enter text: The named insured's primary occupation or business activity. |
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APPLICANT INFORMATION |
Years in Current Occupation |
Enter number: The number of years the named insured has been employed in their current occupation. |
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APPLICANT INFORMATION |
Years with Previous Employer |
Enter number: The number of years the named insured has been with their previous employer. |
|
APPLICANT INFORMATION |
Co-Applicant's Name (First, Middle, Last) |
Enter text: The named insured's given name. |
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APPLICANT INFORMATION |
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Enter text: The named insured's other given name initial. |
|
APPLICANT INFORMATION |
|
Enter text: The named insured's surname. |
|
APPLICANT INFORMATION |
Date of Birth |
Enter date: The date of birth of the insured. |
|
APPLICANT INFORMATION |
Social Security # |
Enter identifier: The tax identifier of the named insured. |
ACORD 88 (2009/02) rev. 06-30-2009 7 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
APPLICANT INFORMATION |
Marital Status |
Enter code: The insured's marital status. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other As used here, this field may not be utilized for policyholders applying for residential property insurance in CA. |
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APPLICANT INFORMATION |
Co-Applicant's Mailing Address |
Enter text: The named insured's mailing address line one. |
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APPLICANT INFORMATION |
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Enter text: The named insured's mailing address line two. |
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APPLICANT INFORMATION |
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Enter text: The named insured's mailing address city name. |
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APPLICANT INFORMATION |
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Enter code: The named insured's mailing address state or province code. |
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APPLICANT INFORMATION |
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Enter code: The named insured's mailing address postal code. |
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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. |
|
APPLICANT INFORMATION |
Primary Phone # |
Enter number: The named insured's primary 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. |
ACORD 88 (2009/02) rev. 06-30-2009 8 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
APPLICANT INFORMATION |
Secondary Phone # |
Enter number: The named insured's secondary phone number. |
|
APPLICANT INFORMATION |
Primary e-mail address |
Enter text: The named insured's primary e-mail address. |
|
APPLICANT INFORMATION |
Secondary e-mail address |
Enter text: The named insured's secondary e-mail address. |
|
APPLICANT INFORMATION |
Yrs with Current Employer |
Enter number: The number of years the named insured has been with their current employer. |
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APPLICANT INFORMATION |
Co-Applicant's Employer Name And Address |
Enter text: The employer name (business name if self-employed). |
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APPLICANT INFORMATION |
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Enter text: The first address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The second address line of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter text: The city of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The state code of the employer's physical address. |
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APPLICANT INFORMATION |
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Enter code: The postal code of the employer's physical address. |
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APPLICANT INFORMATION |
Co-Applicant's Occupation (State Nature of Business if Self-Employed) |
Enter text: The named insured's primary occupation or business activity. |
|
APPLICANT INFORMATION |
Years in Current Occupation |
Enter number: The number of years the named insured has been employed in their current occupation. |
|
APPLICANT INFORMATION |
Years with Previous Employer |
Enter number: The number of years the named insured has been with their previous employer. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
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LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
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LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
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LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
ACORD 88 (2009/02) rev. 06-30-2009 9 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
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LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
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LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
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LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
|
LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
|
LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
|
LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
|
LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
|
LOCATION SCHEDULE |
Loc # |
Enter number: The producer assigned number of the location. |
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LOCATION SCHEDULE |
Street |
Enter text: The first address line of the physical location. |
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LOCATION SCHEDULE |
City |
Enter text: The city of the physical location. |
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LOCATION SCHEDULE |
County |
Enter text: The county of the location. |
|
LOCATION SCHEDULE |
State |
Enter code: The state or province of the physical location. |
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LOCATION SCHEDULE |
Zip + 4 |
Enter code: The postal code of the physical location. |
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PRIOR COVERAGE |
No Prior Coverage |
Check the box (if applicable): Indicates there was no prior coverage. |
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PRIOR COVERAGE |
Line Of Business |
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability. |
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PRIOR COVERAGE |
Prior Carrier |
Enter text: The name of the previous insurer. |
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PRIOR COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
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PRIOR COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
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PRIOR COVERAGE |
BI or CSL Limit(s) if Applicable Per Person ($) |
Enter amount: The bodily injury per person limit on the prior policy (if applicable). |
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PRIOR COVERAGE |
Per Accident ($) |
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if applicable). |
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PRIOR COVERAGE |
Line Of Business |
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability. |
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PRIOR COVERAGE |
Prior Carrier |
Enter text: The name of the previous insurer. |
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PRIOR COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
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PRIOR COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
ACORD 88 (2009/02) rev. 06-30-2009 10 of 33
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Section Name |
Field Name |
Field and/or Section Description |
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PRIOR COVERAGE |
BI or CSL Limit(s) if Applicable Per Person ($) |
Enter amount: The bodily injury per person limit on the prior policy (if applicable). |
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PRIOR COVERAGE |
Per Accident ($) |
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. |
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PRIOR COVERAGE |
Prior Carrier |
Enter text: The name of the previous insurer. |
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PRIOR COVERAGE |
Prior Policy Number |
Enter identifier: The policy number of the previous coverage. |
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PRIOR COVERAGE |
Expiration Date |
Enter date: The expiration date of the previous coverage. |
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PRIOR COVERAGE |
BI or CSL Limit(s) if Applicable Per Person ($) |
Enter amount: The bodily injury per person limit on the prior policy (if applicable). |
|
PRIOR COVERAGE |
Per Accident ($) |
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 Limit(s) if Applicable Per Person ($) |
Enter amount: The bodily injury per person limit on the prior policy (if applicable). |
|
PRIOR COVERAGE |
Per Accident ($) |
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if applicable). |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
LOSS HISTORY |
Any Losses, whether or not paid by insurance, during the last__years, at this or at any other location? |
Enter number: The number of years of loss information required by the insurer. |
|
LOSS HISTORY |
Any Losses at this or at any other location? |
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 |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
ACORD 88 (2009/02) rev. 06-30-2009 11 of 33
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Section Name |
Field Name |
Field and/or Section Description |
|
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 ($) |
Enter amount: The amount that has been paid on this claim to date. |
|
LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
|
LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
|
LOSS HISTORY |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
|
LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
|
LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
|
LOSS HISTORY |
Amount Paid ($) |
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 |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
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 ($) |
Enter amount: The amount that has been paid on this claim to date. |
|
LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
ACORD 88 (2009/02) rev. 06-30-2009 12 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
|
LOSS HISTORY |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
|
LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
|
LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
|
LOSS HISTORY |
Amount Paid ($) |
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 |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
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 ($) |
Enter amount: The amount that has been paid on this claim to date. |
|
LOSS HISTORY |
Entered by (A)gent (C)ompany |
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company). |
|
LOSS HISTORY |
In Dispute (Y/N) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the claim is in dispute. |
|
LOSS HISTORY |
Line Of Business |
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General Liability). |
|
LOSS HISTORY |
Loss Date |
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim. |
|
LOSS HISTORY |
Loss Type |
Enter code: The basic coverage provided, under which the loss was incurred. |
|
LOSS HISTORY |
Description of Loss |
Enter text: A brief description of the loss. |
ACORD 88 (2009/02) rev. 06-30-2009 13 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
LOSS HISTORY |
CAT# |
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and similar major loss events. |
|
LOSS HISTORY |
Amount Paid ($) |
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. |
|
GENERAL INFORMATION |
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. |
|
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 |
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 |
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 |
Any coverage declined, cancelled, or non-renewed during the last 3 years? Not applicable for applications for auto insurance. |
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)?". As used here, this is not applicable for applications for auto insurance. Missouri applicant: Do not answer this question. |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Has applicant had a foreclosure, repossession, bankruptcy, 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 foreclosure, repossession, bankruptcy, judgment or lien during the past mandated number of years?". |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
Any other residence, not listed on any application, owned, occupied or rented? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Any other residence, not listed on any application, owned, occupied or rented?". |
|
GENERAL INFORMATION |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Has insurance been transferred within 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 |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
GENERAL INFORMATION |
Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.), not scheduled on this policy? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the answer to the question, "Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, atvs, etc.), not shown on this policy?". |
|
GENERAL INFORMATION |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION |
Body Type |
Enter code: The body type of the vehicle. |
|
GENERAL INFORMATION |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION |
Body Type |
Enter code: The body type of the vehicle. |
|
GENERAL INFORMATION |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION |
Body Type |
Enter code: The body type of the vehicle. |
|
GENERAL INFORMATION |
Year |
Enter year: The model year of the vehicle. |
|
GENERAL INFORMATION |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
|
GENERAL INFORMATION |
Model |
Enter text: The manufacturer's model name for the vehicle. |
|
GENERAL INFORMATION |
Body Type |
Enter code: The body type of the vehicle. |
ACORD 88 (2009/02) rev. 06-30-2009 15 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
GENERAL INFORMATION |
During the last five (5) years [ten (10) 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 |
|
Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
ADDITIONAL INTEREST |
Interest Additional Insured |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Lienholder |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Loss Payee |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Trustee |
Check the box (if applicable): Indicates the additional interest type is a trustee. |
|
ADDITIONAL INTEREST |
Other |
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 |
Certificate Required |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Send Bill |
Check the box (if applicable): Indicates the bill should be sent to the additional interest. |
|
ADDITIONAL INTEREST |
Name And Address |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
|
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 |
Interest in Item Number Location: |
Enter number: The producer assigned number of the location which has an additional interest. |
ACORD 88 (2009/02) rev. 06-30-2009 16 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
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 text: 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 |
Interest Additional Insured |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Lienholder |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Loss Payee |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Trustee |
Check the box (if applicable): Indicates the additional interest type is a trustee. |
|
ADDITIONAL INTEREST |
Other |
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 |
Certificate Required |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Send Bill |
Check the box (if applicable): Indicates the bill should be sent to the additional interest. |
|
ADDITIONAL INTEREST |
Name And Address |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's country code. |
ACORD 88 (2009/02) rev. 06-30-2009 17 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
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 |
Interest in Item Number 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 text: 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 |
Interest Additional Insured |
Check the box (if applicable): Indicates the additional interest type is an additional insured. |
|
ADDITIONAL INTEREST |
Lienholder |
Check the box (if applicable): Indicates the additional interest type is a lien holder. |
|
ADDITIONAL INTEREST |
Loss Payee |
Check the box (if applicable): Indicates the additional interest type is a loss payee. |
|
ADDITIONAL INTEREST |
Mortgagee |
Check the box (if applicable): Indicates the additional interest type is a mortgagee. |
|
ADDITIONAL INTEREST |
Trustee |
Check the box (if applicable): Indicates the additional interest type is a trustee. |
|
ADDITIONAL INTEREST |
Other |
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 |
Certificate Required |
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance, |
|
ADDITIONAL INTEREST |
Send Bill |
Check the box (if applicable): Indicates the bill should be sent to the additional interest. |
|
ADDITIONAL INTEREST |
Name And Address |
Enter text: The additional interest's full name. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line one. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address line two. |
|
ADDITIONAL INTEREST |
|
Enter text: The additional interest's mailing address city name. |
ACORD 88 (2009/02) rev. 06-30-2009 18 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address state or province code. |
|
ADDITIONAL INTEREST |
|
Enter code: The additional interest's mailing address postal code. |
|
ADDITIONAL INTEREST |
|
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 |
Interest in Item Number 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 text: 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. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
|
ATTACHMENTS |
Cert of Mobile Home Tie Downs |
Check the box (if applicable): Indicates a certificate of mobile home tie downs is attached to the policy. |
|
ATTACHMENTS |
Flood Exclusion Notice |
Check the box (if applicable): Indicates a flood exclusion notice is attached. |
|
ATTACHMENTS |
Lead Free Paint Certification |
Check the box (if applicable): Indicates a lead free paint certification is attached. |
|
ATTACHMENTS |
Photograph |
Check the box (if applicable): Indicates a photograph is attached. |
|
ATTACHMENTS |
Protection Device Certificate |
Check the box (if applicable): Indicates a protection device certificate is attached. |
|
ATTACHMENTS |
Recreational Vehicle App |
Check the box (if applicable): Indicates a recreational vehicle application is attached. |
|
ATTACHMENTS |
Replacement Cost Estimate |
Check the box (if applicable): Indicates a replacement cost estimate is attached. |
|
ATTACHMENTS |
Residence Based Businesses Supp |
Check the box (if applicable): Indicates a residence based business supplement is attached. |
|
ATTACHMENTS |
Solid Fuel Supplement |
Check the box (if applicable): Indicates a solid fuel supplement is attached. |
|
ATTACHMENTS |
State Supplement |
Check the box (if applicable): Indicates a state supplement form is attached (if applicable). |
|
ATTACHMENTS |
Windstorm Loss Mitigation |
Check the box (if applicable): Indicates a windstorm loss mitigation form is attached. |
ACORD 88 (2009/02) rev. 06-30-2009 19 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
ACORD 88 (2009/02) rev. 06-30-2009 20 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 21 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 22 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
ACORD 88 (2009/02) rev. 06-30-2009 23 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
ACORD 88 (2009/02) rev. 06-30-2009 24 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 25 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 26 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
ACORD 88 (2009/02) rev. 06-30-2009 27 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
ACORD 88 (2009/02) rev. 06-30-2009 28 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 29 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
|
FORMS AND ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
FORMS AND ENDORSEMENTS |
Loc # |
Enter number: The producer assigned identifier for the location associated with this form. |
|
FORMS AND ENDORSEMENTS |
Veh # |
Enter number: The producer assigned identifier for the vehicle associated with this form. |
|
FORMS AND ENDORSEMENTS |
Boat # |
Enter number: The producer assigned identifier for the boat associated with this form. |
|
FORMS AND ENDORSEMENTS |
Item # |
Enter number: The producer assigned identifier for the item associated with this form. |
ACORD 88 (2009/02) rev. 06-30-2009 30 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
FORMS AND |
|
|
|
ENDORSEMENTS |
Form Number |
Enter identifier: The number used by the insurer for this form. |
|
FORMS AND |
|
|
|
ENDORSEMENTS |
Form Name |
Enter text: The name of the form. |
|
FORMS AND |
|
|
|
ENDORSEMENTS |
Edition Date |
Enter date: The edition date of the form. |
|
FORMS AND |
|
|
|
ENDORSEMENTS |
Copyright Owner Code |
Enter code: Indicates the entity that has copyright ownership of the form. |
|
|
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 |
|
PAYMENT PLAN |
Billing Account # |
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 |
Direct Bill - Policy |
Check the box (if applicable): Indicates if the policy is to be direct billed. |
|
PAYMENT PLAN |
Direct Bill - Acct |
Check the box (if applicable): Indicates if the account is to be direct billed. |
|
PAYMENT PLAN |
Agency Bill |
Check the box (if applicable): Indicates if the policy is to be producer/agency billed. |
|
PAYMENT PLAN |
Full Pay |
Check the box (if applicable): Indicates a full payment will be made on the policy. |
|
PAYMENT PLAN |
Annual |
Check the box (if applicable): Indicates the policy will be paid annually. |
|
PAYMENT PLAN |
Semi-Annual |
Check the box (if applicable): Indicates the policy will be paid semi-annually. |
|
PAYMENT PLAN |
Quarterly |
Check the box (if applicable): Indicates the policy will be paid quarterly. |
|
PAYMENT PLAN |
Bi-Monthly |
Check the box (if applicable): Indicates the policy will be paid bi-monthly. |
|
PAYMENT PLAN |
Monthly |
Check the box (if applicable): Indicates the policy will be paid monthly. |
|
|
Check the box (if applicable): Indicates the policy will be paid in a frequency other than |
|
PAYMENT PLAN |
Other |
those listed. |
|
|
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - |
|
PAYMENT PLAN |
Other Description |
Quarterly, etc.). |
|
PAYMENT PLAN |
Payment Method - Cash |
Check the box (if applicable): Indicates the invoice will be paid in cash. |
|
PAYMENT PLAN |
Check |
Check the box (if applicable): Indicates the invoice will be paid by check. |
|
|
Check the box (if applicable): Indicates the invoice will be paid by credit card. As used |
|
PAYMENT PLAN |
Credit Card |
here, this is not applicable in North Carolina. |
|
|
Check the box (if applicable): Indicates the invoice will be paid using electronic funds |
|
PAYMENT PLAN |
EFT |
transfer (EFT). |
|
PAYMENT PLAN |
Payroll Deduction |
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction. |
|
Pre-authorization Draft/Check |
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check |
|
PAYMENT PLAN |
(PAC) |
or draft. |
ACORD 88 (2009/02) rev. 06-30-2009 31 of 33
|
Section Name |
Field Name |
Field and/or Section Description |
|
PAYMENT PLAN |
Other |
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 |
Agent |
Check the box (if applicable): Indicates if the policy paper should be sent to the producer. |
|
PAYMENT PLAN |
Insured |
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the named insured. |
|
PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the agent or applicant. |
|
PAYMENT PLAN |
Other Description |
Enter text: The description of whom the policy paper should be mailed to. |
|
PAYMENT PLAN |
Payor Insured |
Check the box (if applicable): Indicates the payor of the policy is the insured. |
|
PAYMENT PLAN |
Mortgagee |
Check the box (if applicable): Indicates the payor of the policy is the mortgagee. |
|
PAYMENT PLAN |
Other |
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? Y/N |
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. |
|
PAYMENT PLAN |
For EFT, PAC Or Check Bank/ABA Number |
Enter identifier: The identifier for the bank routing number (ABA Number). |
|
PAYMENT PLAN |
Account Number |
Enter identifier: The payor's bank account number where the payment will be withdrawn. |
|
PAYMENT PLAN |
Check/Reference Number |
Enter number: The unique number imprinted on a check or draft. |
|
PAYMENT PLAN |
First Payment Due Date |
Enter date: The date on which the first payment is due. |
|
PAYMENT PLAN |
Day of Month Due |
Enter number: The day of the month when the payment is due. |
|
PAYMENT PLAN |
Payroll Deduction Employee Applicant |
Check the box (if applicable): Indicates the employee making the payroll deduction is the applicant. |
|
PAYMENT PLAN |
Co-Applicant |
Check the box (if applicable): Indicates the employee making the payroll deduction is the co-applicant. |
|
PAYMENT PLAN |
Other (If other, complete below) |
Check the box (if applicable): Indicates the employee making the payroll deduction is other than those listed. |
|
PAYMENT PLAN |
Employee ID |
Enter identifier: The employer assigned identification number for the employee. |
|
PAYMENT PLAN |
Number Deductions |
Enter number: The total number of installments/deductions to be made. |
|
PAYMENT PLAN |
Employee Name |
Enter text: The full name of the employee. |
|
PAYMENT PLAN |
Employer Name |
Enter text: The name of the employer. |
|
Section Name |
Field Name |
Field and/or Section Description |
|
PAYMENT PLAN |
For Credit Cards Credit Card Company |
Enter text: The name of the credit card company (e.g. American Express, Visa, Etc.). As used here, this is not applicable in North Carolina. |
|
PAYMENT PLAN |
Account Number |
Enter identifier: The credit card account number. As used here, this is not applicable in North Carolina. |
|
PAYMENT PLAN |
Expiration Date |
Enter date: The expiration date of the credit card. As used here, this is not applicable in North Carolina. |
|
PAYMENT PLAN |
Security Verification Code |
Enter code: The security verification code of the credit card. As used here, this is not applicable in North Carolina. |
|
PAYMENT PLAN |
1. Does the Payor require a physical record of this transaction? Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the payor requires a physical record of the transaction. |
|
SIGNATURE |
Authorized Signature |
Sign here: Accommodates the signature of the payor. |
|
SIGNATURE |
Date |
Enter date: The date the form was signed by the payor. |
|
SIGNATURE |
Authorized Signature |
Sign here: Accommodates the signature of the payor. |
|
SIGNATURE |
Date |
Enter date: The date the form was signed by the payor. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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REMARKS |
Remarks |
Enter text: The remarks associated with the personal lines policy. |
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BINDER/SIGNATURE |
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. |
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BINDER/SIGNATURE |
Time |
Enter time: The time of the binder effective date that the binder becomes effective. |
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BINDER/SIGNATURE |
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. |
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BINDER/SIGNATURE |
12:01 AM |
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date. |
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BINDER/SIGNATURE |
Noon |
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date. |
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BINDER/SIGNATURE |
Coverage is not bound |
Check the box (if applicable): Indicates the coverage has not been bound. |
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Section Name |
Field Name |
Field and/or Section Description |
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BINDER/SIGNATURE |
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 has been given to the applicant. |
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SIGNATURE |
Producer's Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
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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. |
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SIGNATURE |
State Producer License No (Required in FL) |
Enter identifier: The State License Number of the producer. |
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SIGNATURE |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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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. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
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