ACORD Forms : How to Complete a Property Loss Notice 1Property Loss Notice 1 - ACORD Form
Use the ACORD Property Loss Notice (ACORD 1) for reporting commercial and personal lines property losses including Homeowners, Dwelling Fire, Inland Marine, Commercial Property, Flood, Wind and others.
Month/day/year on which the form is completed.
Producer's name and address.
Phone (A/C, No, Ext)
Producer's telephone number.
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.
If your agency uses a sub-code identification system with the company, enter the appropriate code.
Agency Customer ID
Customer's identification number assigned by the agency.
Use this field for large accounts to list site and location codes or to enter the claim number on a phone-in report.
Date & Time of Loss
Date and approximate time that the loss occurred. The appropriate A.M. or P.M. box should be checked (e.g., 01/11/94 - 12:15 A.M.).
Indicate if this is the first report on the loss that has been given to the company; whether written or by telephone. If not, list in the Remarks section when other report(s) have been made.
Complete the company name and policy number for the types of policies written. Do not repeat the property/homeowners company name and policy number unless flood and/or wind coverages are written on separate policies.
For commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies.
For monoline flood policies.
For monoline wind/hail policies.
Name of the applicable insurance company. Use the actual name of the company within the group to which you are sending the loss notice. Do not use group names.
Number assigned by the insurance company for the policy.
NAIC code of the insurance company that issued the policy.
Date on which the terms and conditions of the policy commenced.
Date on which the terms and conditions of the policy will or have expire(d).
Name and Address of Insured and Spouse
Name and mailing address of the insured and spouse (if applicable) as found on the declarations page of the policy.
Date of Birth, Soc. Sec. # or FEIN
Date of birth and social security number or Federal Employer Identification Number for both the insured and spouse (if applicable).
For an individual, the home telephone number, including area code of the insured.
Business telephone number, including area code and extension of the insured.
If the individual to contact for information is the same as the named insured, check this box and leave blank the areas for contact name, address and phone numbers.
Person to Contact
Name and address of the individual to be contacted as a representative of the insured on all subsequent business relating to this incident. No entry is needed if the 'Contact Insured' option is checked.
Enter the home phone number, including area code, of the contact named above. If it is the insured, leave this field blank.
Business telephone number, including area code and extension of the contact. If it is the insured, leave this field blank.
Where to Contact
Indicate where this person should be contacted (e.g., home, office, hospital).
When to Contact
Indicate the best time of the day to contact this individual (e.g., evenings, days, noon to 3:00 P.M.).
Location of Loss
Give the physical location of the loss. If the insured has multiple locations on the policy, include the policy location number and building number (e.g., insured's home or Loc 3, Bld 2; 151 Main St).
Police or Fire Dept. to Which Reported
Name of the municipal or county police or fire department to which the loss was reported, including the precinct or station number if available.
Kind of Loss
Indicate the type of loss. Check any appropriate box that may apply to the type of loss. If the loss is different from the pre-printed options, check the "other" option and list the loss type in the available space.
Probable Amount Entire Loss
Estimate the dollar amount which may be paid on all claims arising from this incident. If no dollar estimate is available, provide a description such as "small" or "substantial".
Description of Loss & Damage
Briefly describe the cause of the loss and resulting damage, including the areas of buildings which were damaged.
Note: If the loss resulted in bodily injury to individuals or damage to the property of others, indicate in the Remarks Section and complete the appropriate additional claim form.
Name and address of all mortgagees on the property that incurred the loss. If there is more than one, use the Remarks Section if necessary. If there is no mortgagee, check the appropriate box.
HOMEOWNER POLICIES SECTION 1 ONLY
Use this section for Homeowner and Dwelling Fire policies only. For Homeowner, it is limited to the property coverages of section 1. Use ACORD 3 for reporting liability losses.
Coverage A Dwelling
Coverage amount provided for the dwelling on the policy. If wind coverage is excluded, check the box below.
Coverage B Other Structures
Coverage amount provided for appurtenant private structures on the policy.
Coverage C Personal Property
Coverage amount provided for unscheduled personal property on the policy.
Coverage D Loss of Use
Coverage amount provided for loss of use/additional living expenses on the policy.
Indicate any deductibles that apply to the policy.
Describe Additional Coverages Provided
Describe and give amount for any additional property-related coverages on the policy.
Subject to Forms
Enter all attached policy form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe the endorsement.
FIRE, ALLIED LINES AND MULTI-PERIL POLICIES
This section outlines the coverages written on commercial lines policies.
Building number or Inland Marine item number for this subject of insurance.
Subject of Insurance
Indicate whether the corresponding "amount" applies to the coverage of building, contents/personal property, or some other subject of insurance by marking X in the appropriate box. For other than building or contents subjects of insurance, list the subject's name in the available space next to the option box. Examples of other subjects of insurance include business interruption and combined building and contents.
Dollar amount of insurance provided on the policy for this subject of insurance.
Percent of coinsurance that applies to this subject of insurance.
Indicate the deductibles that apply to this subject of insurance.
Coverage and/or Description of Property Insured
Describe the coverages written for this subject of insurance and briefly describe the property
Subject to Forms
Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe the endorsement.
This section outlines the coverages issued on a separate flood policy.
Appropriate building and contents policy limits.
Deductible amounts for the building and contents parts of the policy.
Flood rating zone.
Pre Firm/Post Firm
Check whether the policy was issued based on a Flood Insurance Rate Map (Post Firm) or prior to a map being released (Pre Firm).
Diff in Elev
Difference in Elevation - Indicate the approximate distance above or below sea level.
Indicate whether the flood policy is issued on a general, dwelling or condominium form.
This section outlines the coverages issued on a separate wind policy.
Building policy limits.
Deductible for the building limit.
Contents policy limit.
Wind rating zone if appropriate.
Indicate whether the wind policy is issued on a general, dwelling or condominium form.
Explain any other property insurance in force at the time of loss. Include company, policy number, coverages and amount of coverages. Provide any other information that will assist in properly reporting and settling this claim. (For New York only, provide the previous address of the insured, and the wife's maiden name, if applicable.)
If a catastrophe number has been assigned by the Insurance Services Office Property Claim Service or other industry organization, enter it here. This is the number assigned to the event which caused the claim being described.
If a flood number has been assigned by the Flood Insurance Coordinating Office, enter it here. This is the number assigned to the flood that caused the claim being described.
If known, enter the name and telephone number, including area code and extension, of the adjuster assigned to this loss.
Control number assigned to the adjuster.
Date the adjuster was assigned to this loss.
Indicate the name of the individual who reported the loss.
Indicate the name of the individual within the agency or company to whom this loss was reported.
Signatures of Producer and Insured
This form should be signed by the producer and the insured.
Note: Important state information is on the second side of this form.
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