ACORD Forms

ACORD Forms : How to Complete a Property Loss Notice 1

Property Loss Notice 1 - ACORD Form
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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.

IDENTIFICATION SECTION

Date

Month/day/year on which the form is completed.

Producer

Producer's name and address.

Phone (A/C, No, Ext)

Producer's telephone number.

Code

Identification code assigned to your agency or brokerage firm by the insurance company receiving this form.

Subcode

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.

Miscellaneous Info

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.).

Previously Reported

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.

Policy Type

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.

Property/Home

For commercial or personal property, homeowner, dwelling fire, inland marine and similar type policies.

Flood

For monoline flood policies.

Wind

For monoline wind/hail policies.

Company

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.

Policy Number

Number assigned by the insurance company for the policy.

NAIC Code

NAIC code of the insurance company that issued the policy.

Effective Date

Date on which the terms and conditions of the policy commenced.

Expiration Date

Date on which the terms and conditions of the policy will or have expire(d).


INSURED

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).

Residence Phone

For an individual, the home telephone number, including area code of the insured.
Business Phone

Business telephone number, including area code and extension of the insured.

CONTACT

Contact 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.

Residence Phone

Enter the home phone number, including area code, of the contact named above. If it is the insured, leave this field blank.

Business Phone

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.).

LOSS

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.



POLICY INFORMATION



Mortgagee

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.



Deductibles

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.



Item

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.



Amount

Dollar amount of insurance provided on the policy for this subject of insurance.



% Coins

Percent of coinsurance that applies to this subject of insurance.



Deductible

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

insured.



Subject to Forms

Enter all form numbers and edition dates that affect the policy coverages. For manuscript endorsements, briefly describe the endorsement.



FLOOD POLICY

This section outlines the coverages issued on a separate flood policy.



Building/Contents

Appropriate building and contents policy limits.



Deductible

Deductible amounts for the building and contents parts of the policy.



Zone

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.



Form Type

Indicate whether the flood policy is issued on a general, dwelling or condominium form.



WIND POLICY

This section outlines the coverages issued on a separate wind policy.



Building

Building policy limits.



Deductible

Deductible for the building limit.



Contents

Contents policy limit.



Zone

Wind rating zone if appropriate.



Form Type

Indicate whether the wind policy is issued on a general, dwelling or condominium form.



REMARKS/OTHER INSURANCE

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.)



CAT #

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.



FICO #

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.



Adjuster Assigned

If known, enter the name and telephone number, including area code and extension, of the adjuster assigned to this loss.



Adjuster #

Control number assigned to the adjuster.



Date Assigned

Date the adjuster was assigned to this loss.



Reported by

Indicate the name of the individual who reported the loss.



Reported to

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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posted by Wayne @ 9:18 PM