ACORD Forms

ACORD Forms : How to Complete an Additional Interest 45

Additional Interest 45

The Additional Interest form is used in multiple situations to expand upon
the additional interest sections within line of business applications. This form may be used for both personal and commercial accounts. The form is used to secure information on additional interests and certificate holders.

IDENTIFICATION SECTION

Date (MM/DD/YYYY)
Month/day/year on which the form is completed.

Agency
Agency's name and address.

Phone (A / C, No, Ext)
Agency's telephone number.

Code
Identification code assigned to the agency or brokerage firm by the Insurance Company receiving this form.

Agency Customer ID
Customer's identification number assigned by the agency.

Applicant (First Named Insured)
First Named Insured as it appears on the line of business form to which this form will be attached.

Phone (A / C, No, Ext)
Applicants telephone number.

Effective Date
Month/day/year on which the terms and conditions of the policy will commence.

Expiration Date
Month/day/year on which the terms and conditions of the policy will terminate unless renewed.

Co/Plan
Name of the insurance company that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. Also, if applicable, indicate the type of plan or policy program (Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company.

Policy Number
Number assigned by the insurance company for the policy.

Account Number
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 company assigns.

ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS

Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance.

Interest
Indicate all appropriate options for the individual named.

Rank
Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee.

Name and Address
List the additional interests name and address.
If the additional interest is the owner of a motor vehicle, and the owner is different from the Named Insured, show the owner's name here.

Reference #
Indicate the additional interests reference number for this applicant such as the loan or mortgage number.

Certificate Required
If a Certificate of Insurance is required check this box.

Interest in Item Number
List the item number corresponding with the application for the item of interest for this additional insured.

Item Description
If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting.

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posted by Wayne @ 11:06 AM 0 comments

ACORD Forms : How to Complete a Cancellation Request/Policy Release 35

Cancellation Request/Policy Release 35

This guide provides basic instructions for completing the ACORD Cancellation Request/Policy Release form. It explains information the company needs to process the transaction.

This form is used as tangible evidence of the insured's instruction to cancel a contract. It can be used for either Personal or Commercial Lines, or as an enclosure to the returned original contract, when available.

* Method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured. Caution should be exercised to ensure proper signature specifications are followed, as required by the company.

Insured entities must have an authorized signature and title where applicable. Individual companies may have specific requirements for additional information particularly in situations of "Policy Rewritten" or "Pro Rata" cancellations.

Verify that cancellation notice rights have not been extended to additional parties.

Premium financed policies should be discreetly handled to ensure proper transmittal of premium and information.

IDENTIFICATION SECTION

Date
Month/day/year on which the form was completed.

Producer
Name and address of the producer of record whose policy is being cancelled or released.

Phone (A/C, No, Ext)
Producer's telephone number.

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

Subcode
If your agency uses a subcode identification system with the company, enter the appropriate code.

Agency Customer ID
Customer's identification number assigned by the agency.

Company Name and Address
Issuing company's name, NAIC code, and address shown on the policy being cancelled or released. Do not use group or trade name.

Policy Type
Specific type of insurance (e.g., Automobile Policy, Workers Compensation, Homeowners, etc.).

Insured Name and Address
Name, mailing address and ZIP code of the insured as it appears on the policy. If the policy is issued to multiple named insureds, and the space is not adequate to list them all, enter only the first named insured followed by "et al."

CANCELED POLICY INFORMATION

Policy Number
Policy Number exactly as it appears on the policy, including both prefix and suffix symbols.

Effective Date and Hour of Cancellation
List the effective date of the policy cancellation in month/day/year format. Enter the time including, AM or PM, that the policy cancellation takes effect.

Policy Term
List the full term effective and expiration dates as listed on the policy.

CANCELLATION REQUEST (Policy Attached)

If this form is being used to notify the carrier of policy cancellation and the insured's original copy of the policy is attached, check this box and return both this form and original policy to the company.

POLICY RELEASE (Complete Statement Section below)

Policy Release
Mark "X" in this block only if this document is used as a Policy Release (policy not attached).

Witness
When this document is used as a Policy Release, an insured should have a witness sign and date the form before returning it to the agent.

Signature of Named Insured
First named insured must sign and date this form when used as either a Cancellation Request or Policy Release.

Additional Interest
Provide the name and address of any Lien Holder, Mortgagee or Loss Payee. Identify this entity by marking "X" in the appropriate box.

The signature and title of an authorized representative of any additional interest indicated in the contract must be obtained if the document is used as a Policy Release. Space is provided for the corresponding signature date.

FOR AGENCY/COMPANY USE

Reason for Cancellation
Mark "X" in the appropriate block to indicate the reason for cancellation of the policy. Available options are:
Not Taken
Request of Insured
Rewritten (complete below)
Other (Identify)

If Rewritten is indicated, enter the new Company, Policy Number, and Inception Date in the spaces provided. If Other is indicated, identify the reason in the space provided.

Company
The name of the company that the rewritten policy has been placed with.

Policy Number
The new policy number for the rewritten policy.

Effective Date
The effective date of the rewritten policy.

Remarks

Method of Cancellation
Mark "X" in the appropriate box indicating method of cancellation. Available options are:
Flat
Short Rate
Pro Rata

Note: Individual companies may have specific requirements for additional information, particularly in situations of rewritten or pro-rata cancellations. The method of cancellation and all calculations should be confirmed with the company before final settlement of the account with the insured.
Full Term Premium
Premium for the full term (six months, annual, etc.) of the policy, including endorsements.

Unearned Factor
Unearned factor from either the short rate or pro-rata tables for the unearned period of time; from date of cancellation to date of policy expiration.

Return Premium
Gross return premium equals the unearned factor multiplied by the full term premium.

REMARKS

List any additional comments regarding the cancellation. Explanations should be made regarding back-dated cancellations or why premium is listed as being pro-rated instead of short-rated.

NAME AND ADDRESS - Request/ Release Distribution

Use these sections to list any additional distributions for this form, including the new agent of record, if any. Check the appropriate box for the corresponding address. The line within the name and address field is a margin setting used for window envelopes.

PRODUCER'S SIGNATURE

This form should be signed by the agent completing it.

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posted by Wayne @ 11:55 AM 2 comments

ACORD Forms : How to Complete an Evidence of Personal Property Insurance 27

ACORD 27 Instructions

Section Name Field Name Field and/or Section Description
TITLE ACORD 27 (2006/07) Evidence of Property Insurance ACORD 27, Evidence of Property Insurance, provides a coverage statement for mortgagees and loss payees who provide mortgages or loans on residential property, personal property or small commercial properties, and are named in the policy. ACORD 27, Evidence of Property Insurance, provides information about coverages currently in force on a policy.
TITLE Evidence of Property Insurance Research reveals that information included on the form satisfies requirements of mortgagees in most situations. Discussions with various lenders indicate that inclusion of items such as coinsurance are not important with respect to Personal Lines policies or small commercial policies. The primary concern is that the amount of insurance is sufficient to cover the amount of the loan. Sufficient space is provided in the Coverage and Remarks sections of the form to include any additional information that may be required. Although many lenders pay the premium for certain types of policies such as Homeowners, inclusion of the premium amount is inappropriate on the EPI. This information will be communicated to the payor via an invoice. Furthermore, in the case of continuing coverage, the premium amount would be invalid after the first year.
TITLE Evidence of Property Insurance IMPORTANT Use ACORD 28, Evidence of Commercial Property Insurance, to provide information to mortgagees and loss payees who provide mortgages or loans on real property or personal property insured under a Commercial Lines policy and more detail is required by the mortgagee or loss payee.


ACORD 27 (2006/07) rev. 09-05-2008 1 of 3 ACORD 27 (2006/07) rev. 09-05-2008 2 of 3 ACORD 27 (2006/07) rev. 09-05-2008 3 of 3

Section Name Field Name Field and/or Section Description
TITLE Evidence of Property Insurance IMPORTANT Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Department of Insurance. Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date Month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Agency's name and address
IDENTIFICATION SECTION Phone (A/C, No, Ext) Agency's telephone number.
IDENTIFICATION SECTION Fax (A/C, No) Agency's facsimile number.
IDENTIFICATION SECTION E-Mail Address Agency's e-mail address.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company providing the policy coverages
IDENTIFICATION SECTION Subcode If the agency uses a sub-code identification system with the company, enter the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
IDENTIFICATION SECTION Company Name and address of the applicable insurance company. Use the actual name of the company within the group to which the policy has been issued. Do not use group names.
IDENTIFICATION SECTION Insured Insured’s name and address as they appear on the policy declarations page.
IDENTIFICATION SECTION Loan Number Insured’s loan or account number for this additional interest.
Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Policy Number Number exactly as it appears on the policy, including prefix and suffix symbols.
IDENTIFICATION SECTION Effective Date Date on which the terms and conditions of the policy commence.
IDENTIFICATION SECTION Expiration Date Date on which the terms and conditions of the policy expires.
IDENTIFICATION SECTION Continued Until Terminated if Checked If the policy is issued on a Continuous basis, check the available box.
IDENTIFICATION SECTION This Replaces Prior Evidence Dated If a prior Evidence of Property Insurance was issued to this additional interest and this form replaces the old one, enter the date the old form was issued; otherwise, leave this field blank.
PROPERTY INFORMATION Location/Description For buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave, Endicott - one-family dwelling with detached two car garage, or Route 66, five miles south of intersection with I99 - 12 X 12 Storage Building). For other property items, such as inland marine scheduled property (for lessor information), describe the item specifically.
COVERAGE INFORMATION Coverage/Perils/Forms Narrative description of the coverages provided, causes of loss (perils), and the forms attached (e.g., Homeowner - HO3 0792).
COVERAGE INFORMATION Amount of Insurance Amount of insurance for the associated coverage.
COVERAGE INFORMATION Deductible Deductible for the associated coverage.
REMARKS Remarks Space for any additional comments or to list any special conditions that may exist upon the policy.
CANCELLATION Number of Days Number of days before cancellation that the issuing insurer will endeavor to notify the additional interest prior to termination of the policy (e.g., 10 days).
ADDITIONAL INTEREST Name and Address Name and address of the additional interest.
ADDITIONAL INTEREST Nature of Interest Indicate the type of interest by checking the appropriate box. Available options are: Mortgagee, Additional Insured, Loss Payee. Use the optional space to enter any other type of interest. Note: Additional Insured status generally does not apply to property insurance. Exceptions should be discussed with the company underwriter.
ADDITIONAL INTEREST Loan # List any loan number, account number or other controlling number that the additional interest may have assigned the insureds.
ADDITIONAL INTEREST Authorized Representative This form should be signed by an authorized representative of the issuing company.

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Labels: How to Complete an Evidence of Personal Property Insurance 27

posted by Wayne @ 10:31 AM 1 comments

ACORD Forms : How to Complete a Certificate of Liability Insurance 25

ACORD 25 Instructions

Section Name Field Name Field and/or Section Description
The title of the form. ACORD 25, Certificate of Liability Insurance, is "issued as a matter of information only, and confers no rights upon the certificate holder. This certificate does not affirmatively or negatively amend, extend, or alter the coverage afforded by policies".
The above information is included in the opening statement of the form.
If the receiver of the form wants to verify that liability coverage exists on a policy and has no direct interest in the policy, use the certificate of insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as an additional insured, the liability policy must be amended by endorsement, to provide the appropriate coverage for the interested party prior to issuing a certificate of insurance (since the certificate confers no rights upon the holder and does not amend the policy).
TITLE ACORD 25 (2009/09) Certificate of Liability Insurance ACORD 25 was designed to collect policy limit information based on the ISO commercial lines program. It addresses both Claims Made and Occurrence policies.

ACORD 25 (2009/09) rev. 10-30-2009 1 of 13 ACORD 25 (2009/09) rev. 10-30-2009 2 of 13

Section Name Field Name Field and/or Section Description
The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder.
In a 1974 court decision (United States Pipe & Foundry Co. v United States Fidelity & Guar. Co, 505 F. 2d 88 (5th Cir. 1974), the court ruled that a certificate is not a contract between the holder and the insurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration." Although many companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract.
TITLE The Certificate of Liability Insurance is used for most casualty situations in which the insured has requested certification to a third party of issued casualty coverages. The uses of the Certificate can include large and small contracting or manufacturing risks, lessor/lessee agreements, or other areas of liability certification.
ACORD 25 (2009/09) rev. 10-30-2009 3 of 13
Section Name Field Name Field and/or Section Description
TITLE The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the following situations: * To waive rights * To provide information to the owner of a leased motor vehicle or the lender about both liability and physical damage coverages applying to the vehicle (ACORD 23, Automobile Certificate of Insurance, should be used for this) * To quote wording from a contract * To attach to an endorsement * To quote any wording which amends a policy unless the policy itself has been amended IMPORTANT Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Department of Insurance.
TITLE Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Producer Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
ACORD 25 (2009/09) rev. 10-30-2009 4 of 13
Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name Enter text: The name of the individual at the producer's establishment that is the primary contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Producer Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Insured Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured's mailing address postal code.
INSURERS AFFORDING COVERAGE Insurer A 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. As used here, this is Insurer A.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC. As used here, this is Insurer A.
ACORD 25 (2009/09) rev. 10-30-2009 5 of 13
Section Name Field Name Field and/or Section Description
INSURERS AFFORDING COVERAGE Insurer B 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. As used here, this is Insurer B.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC. As used here, this is Insurer B.
INSURERS AFFORDING COVERAGE Insurer C 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. As used here, this is Insurer C.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC. As used here, this is Insurer C.
INSURERS AFFORDING COVERAGE Insurer D 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. As used here, this is Insurer D.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC. As used here, this is Insurer D.
INSURERS AFFORDING COVERAGE Insurer E 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. As used here, this is Insurer E.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC. As used here, this is Insurer E.
INSURERS AFFORDING COVERAGE Insurer F 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.
INSURERS AFFORDING COVERAGE NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
COVERAGES Certificate Number Enter identifier: The producer assigned number for the certificate.
COVERAGES Revision Number Enter number: The producer assigned revision number for the certificate.
COVERAGE INFORMATION Insr Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial general liability policy.
COVERAGE INFORMATION Commercial General Liability Check the box (if applicable): Indicates the claims made or occurrence option applies for the general liability policy.
ACORD 25 (2009/09) rev. 10-30-2009 6 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Other General Liability Coverages -Claims-Made Check the box (if applicable): Indicates the "claims made" option applies on the general liability policy.
COVERAGE INFORMATION Occur Check the box (if applicable): Indicates the general liability policy, occurrence basis applies.
COVERAGE INFORMATION Check Box Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy.
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Check Box Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy.
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION General Aggregate Limit Applies Per: - Policy Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per policy.
COVERAGE INFORMATION Project Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per project.
COVERAGE INFORMATION Loc Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per location.
COVERAGE INFORMATION Addl Insr Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.
COVERAGE INFORMATION Subr Wvd Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.
COVERAGE INFORMATION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the general liability policy number exactly as it appears on the policy, including prefix and suffix symbols.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the general liability policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire. As used here, the general liability policy expiration date.
ACORD 25 (2009/09) rev. 10-30-2009 7 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Limits - Each Occurrence $ Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Damage to Rented Premises $ Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Med Exp $ Enter limit: The general liability, medical expense each person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Personal & Adv Injury Enter limit: The general liability, personal and advertising injury limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION General Aggregate $ Enter limit: The general liability, general aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Products- Comp/Op Agg $ Enter limit: The general liability, products and completed operations aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Other Limits Enter text: The description of other coverage (not the limit). Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Other Occurrence $ Enter limit: The general liability, other coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Insr Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial vehicle policy.
ACORD 25 (2009/09) rev. 10-30-2009 8 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Automobile Liability - Any Auto Check the box (if applicable): Indicates the commercial vehicle policy covers any auto. As used here, complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Automobile Certificate of Insurance.
COVERAGE INFORMATION All Owned Autos Check the box (if applicable): Indicates the commercial vehicle policy covers all owned autos.
COVERAGE INFORMATION Scheduled Autos Check the box (if applicable): Indicates the vehicle policy covers scheduled autos.
COVERAGE INFORMATION Hired Autos Check the box (if applicable): Indicates the vehicle policy covers hired autos.
COVERAGE INFORMATION Non- Owned Autos Check the box (if applicable): Indicates the vehicle policy covers non-owned autos.
COVERAGE INFORMATION Check Box Check the box (if applicable): Indicates other coverage not found on the form exists for the vehicle policy.
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the vehicle policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Addl Insr Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.
COVERAGE INFORMATION Subr Wvd Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.
COVERAGE INFORMATION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the automobile liability policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the automobile policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire. As used here, the automobile policy expiration date.
ACORD 25 (2009/09) rev. 10-30-2009 9 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Combined Single Limit $ Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Bodily Injury (Per Person) $ Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Bodily Injury (Per Accident) $ Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Property Damage Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Other Description Enter text: The description of the coverage.
COVERAGE INFORMATION Other Limit Enter limit: The limit amount of the other coverage.
COVERAGE INFORMATION Other Description Enter text: The description of the coverage.
COVERAGE INFORMATION Other Limit Enter limit: The limit amount of the other coverage.
COVERAGE INFORMATION Insr Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial excess umbrella liability policy.
COVERAGE INFORMATION Umbrella Liab Check the box (if applicable): Indicates the type of policy is umbrella.
COVERAGE INFORMATION Excess Liab Check the box (if applicable): Indicates the type of policy is excess.
COVERAGE INFORMATION Type of Insurance -Excess/Umbrella Liability - Occur Check the box (if applicable): Indicates "coverage trigger" is on an occurrence basis on an excess or umbrella liability policy.
COVERAGE INFORMATION Claims-Made Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on an excess or umbrella liability policy.
ACORD 25 (2009/09) rev. 10-30-2009 10 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Deductible Check the box (if applicable): This indicates whether a deductible or retention amount applies to the excess or umbrella liability policy.
COVERAGE INFORMATION Retention Check the box (if applicable): Indicates the excess or umbrella liability policy has an applicable deductible or retention amount.
COVERAGE INFORMATION $ Field Box Enter deductible: The excess or umbrella liability deductible or retention amount.
COVERAGE INFORMATION Addl Insr Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.
COVERAGE INFORMATION Subr Wvd Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.
COVERAGE INFORMATION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the excess / umbrella policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the excess / umbrella policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire. As used here, the excess / umbrella policy expiration date.
COVERAGE INFORMATION Limits - Each Occurrence $ Enter limit: The excess umbrella liability limit each occurrence limit. As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Aggregate $ Enter limit: The excess/umbrella liability aggregate limit should be listed as whole dollar amount, as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the description of Other Excess / Umbrella Liability Limit as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
ACORD 25 (2009/09) rev. 10-30-2009 11 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION $ Field Box Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION $ Field Box Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION Insr Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial workers compensation and employers liability policy.
COVERAGE INFORMATION Type of Insurance -Workers Compensation and Employers' Liability - Any Proprietor/Partner/Executive/Offic er/Member Excluded? Enter Y for a “Yes” response. Input N for “No” response. Indicates whether the workers compensation and employers liability policy excludes any proprietor, partner, executive officer, or member. As used here, this question is mandatory in New Hampshire.
COVERAGE INFORMATION Subr Wvd Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.
COVERAGE INFORMATION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the workers compensation policy number.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the workers compensation policy effective date.
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire. As used here, the workers compensation policy expiration date.
COVERAGE INFORMATION Limits - WC Statutory Limits Check the box (if applicable): Indicates that workers compensation statutory limits apply.
COVERAGE INFORMATION Limits - Other Check the box (if applicable): Indicates that additional coverage above the workers compensation statutory limits applies (permitted in some states). Describe the additional coverage in the Special Provisions section.
ACORD 25 (2009/09) rev. 10-30-2009 12 of 13
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Field Box Enter text: The description of other coverage (not the limit) on the workers compensation and employers liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Each Accident $ Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION E.L. Disease- EA Employee $ Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
COVERAGE INFORMATION E.L. Disease- Policy Limit $ Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGE INFORMATION Insr Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the other policy.
COVERAGE INFORMATION Type of Insurance - Other Enter text: The description of the other policy not listed on the form.
COVERAGE INFORMATION Addl Insr Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.
COVERAGE INFORMATION Subr Wvd Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.
COVERAGE INFORMATION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the policy number of the other policy.
COVERAGE INFORMATION Policy Eff (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the effective date of the other policy,
COVERAGE INFORMATION Policy Exp (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire. As used here, the expiration date of the other policy.
COVERAGE INFORMATION Limits Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.
Section Name Field Name Field and/or Section Description
COVERAGE INFORMATION Description of Operations / Locations / Vehicles / Exclusions Added by Endorsement / Special Provisions Enter text: The Certificate Of Liability Insurance general remarks. As used here, records information necessary to identify the operations, locations, vehicles, exclusions added by endorsement, and/or special provisions for which the certificate was issued.
CERTIFICATE HOLDER Certificate Holder Name & Address Enter text: The certificate holder's full name.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address line one.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address line two.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address city name.
CERTIFICATE HOLDER Enter code: The certificate holder's mailing address state or province code.
CERTIFICATE HOLDER Enter code: The certificate holder's mailing address postal code.
CANCELLATION Authorized Representative 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. As used here, the authorized representative by all companies to issue Certificates.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).

ACORD 25 (2009/09) rev. 10-30-2009 13 of 13

Click here to view my web site ACORD Forms.

Labels: How to Complete a Certificate of Liability Insurance 25

posted by Wayne @ 11:37 AM 1 comments

ACORD Forms : How to Complete a Certificate of Property Insurance 24

ACORD 24 Instructions

ACORD 24 (2009/09) rev. 10-30-2009 1 of 9 Section Name Field Name Field and/or Section Description
The title of the form. ACORD 24, Certificate of Property Insurance.
Certificate of Property Insurance vs. Evidence of Property Insurance: An important distinction exists between the Certificate of Property Insurance (ACORD 24) and the Evidence of Property Insurance (ACORD 27) or the Evidence of Commercial Property Insurance (ACORD 28).
TITLE ACORD 24 (2009/09) Certificate of Property Insurance If the receiver of the form wants to verify that property coverage exists on a policy and has no direct interest in the policy, use ACORD 24, Certificate of Property Insurance. However, if the receiver of the form does have a verifiable insurable interest in the policy, such as a mortgagee or a lender, use ACORD 27, Evidence of Property Insurance, when the property is insured under a Personal Lines or small Commercial policy. When the property is insured under a Commercial Lines policy with a large limit and the lender requires specific detailed coverage information, use ACORD 28, Evidence of Commercial Property Insurance.
Purpose of the Certificate of Insurance The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder. This is particularly important when the difference between a certificate holder and lien holder, loss payee, or mortgagee is considered.
TITLE In a 1974 court decision (United States Pipe & Foundry Co. v United States Fidelity & Guar. Co, 505 F. 2d 88 (5th Cir. 1974), the court ruled that a certificate is not a contract between the holder and the insurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration." Although some companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract.
ACORD 24 (2009/09) rev. 10-30-2009 2 of 9
Section Name Field Name Field and/or Section Description
TITLE The Certificate of Property Insurance is used for most property situations in which the insured has requested certification to a third party of issued property coverages. The uses of this Certificate can include parties involved in condominium association agreements, lessor/lessee agreements, or other areas of certification. The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the following situations: * To satisfy a mortgagee or lienholder (ACORD 27, Evidence of Property Insurance or ACORD 28, Evidence of Commercial Property Insurance should be used for this) * To provide information to the owner of a leased motor vehicle or the lender about both liability and physical damage coverages applying to the vehicle (ACORD 23, Automobile Certificate of Insurance, should be used for this) * To quote wording from a contract * To waive rights * To attach to an endorsement * To quote any wording which amends a policy unless the policy itself has been amended.
TITLE IMPORTANT Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD’s certificates cannot be modified, unless the modified form is filed for approval by the respective state Departments of Insurance. Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Producer Enter text: The full name of the producer/agency.
ACORD 24 (2009/09) rev. 10-30-2009 3 of 9
Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name Enter text: The name of the individual at the producer's establishment that is the primary contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Producer Customer ID Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Insured Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured's mailing address postal code.
COMPANIES AFFORDING COVERAGE Company A 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.
ACORD 24 (2009/09) rev. 10-30-2009 4 of 9
Section Name Field Name Field and/or Section Description
COMPANIES AFFORDING
COVERAGE NAIC # A Enter code: The identification code assigned to the insurer by the NAIC.
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
COMPANIES AFFORDING Use the actual name of the company within the group to which the policy has been issued.
COVERAGE Company B This is not the insurer's group name or trade name.
COMPANIES AFFORDING
COVERAGE NAIC # B Enter code: The identification code assigned to the insurer by the NAIC.
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
COMPANIES AFFORDING Use the actual name of the company within the group to which the policy has been issued.
COVERAGE Company C This is not the insurer's group name or trade name.
COMPANIES AFFORDING
COVERAGE NAIC # C Enter code: The identification code assigned to the insurer by the NAIC.
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
COMPANIES AFFORDING Use the actual name of the company within the group to which the policy has been issued.
COVERAGE Company D This is not the insurer's group name or trade name.
COMPANIES AFFORDING
COVERAGE NAIC # D Enter code: The identification code assigned to the insurer by the NAIC.
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
COMPANIES AFFORDING Use the actual name of the company within the group to which the policy has been issued.
COVERAGE Company E This is not the insurer's group name or trade name.
COMPANIES AFFORDING
COVERAGE NAIC # E Enter code: The identification code assigned to the insurer by the NAIC.
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
COMPANIES AFFORDING Use the actual name of the company within the group to which the policy has been issued.
COVERAGE Company F This is not the insurer's group name or trade name.
COMPANIES AFFORDING
COVERAGE NAIC # F Enter code: The identification code assigned to the insurer by the NAIC.
COVERAGES Certificate Number Enter identifier: The producer assigned number for the certificate.
COVERAGES Revision Number Enter number: The producer assigned revision number for the certificate.
Enter text: The Certificate Of Liability Insurance general remarks. As used here, for
Location of Premises/Description buildings, provide the street address and a brief description of the occupancy of the building (e.g., 123 Johnstone Ave, Endicott - Grocery Store with Apartments, or Route 66,
COVERAGES of Property five miles south of intersection with I99 - Tobacco Barn).
Enter code: The company letter of the insurer, as identified in the "Insurers Affording
COVERAGES Co Ltr Coverage" form section, associated with the property policy.
COVERAGES Property Check the box (if applicable): Indicates the type of policy is property.
ACORD 24 (2009/09) rev. 10-30-2009 5 of 9
Section Name Field Name Field and/or Section Description
COVERAGES Causes of Loss - Basic Check the box (if applicable): Indicates the type of policy/perils insured is basic.
COVERAGES Broad Check the box (if applicable): Indicates the type of policy/perils insured is broad.
COVERAGES Special Check the box (if applicable): Indicates the type of policy/perils insured is special.
COVERAGES Earthquake Check the box (if applicable): Indicates earthquake coverage is included in the policy.
COVERAGES Wind Check the box (if applicable): Indicates the type of policy is wind.
COVERAGES Flood Check the box (if applicable): Indicates flood coverage exists.
COVERAGES Checkbox Check the box (if applicable): Indicates the type of policy/perils insured is other than those listed.
COVERAGES Blank field text Enter text: The description of the type of policy issued to the insured.
COVERAGES Checkbox Check the box (if applicable): Indicates the type of policy/perils insured is other than those listed.
COVERAGES Blank field text Enter text: The description of the type of policy issued to the insured.
COVERAGES Building Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance. As used here, this is the deductible for the building coverage.
COVERAGES Contents Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance. As used here, this is the deductible for the contents coverage.
COVERAGES Earthquake Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance. As used here, this is the deductible for the earthquake coverage.
COVERAGES Wind Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance. As used here, this is the deductible for the wind coverage.
COVERAGES Flood Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance. As used here, this is the deductible for the flood coverage.
COVERAGES Other Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
COVERAGES Other Deductible Enter deductible: The deductible amount that is to apply to this subject of insurance.
COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
COVERAGES Policy Effective Date (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
COVERAGES Policy Expiration Date (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES Covered Property - Building (Checkbox) Check the box (if applicable): Indicates that Building Coverage applies.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for building coverage.
COVERAGES Personal Property (Checkbox) Check the box (if applicable): Indicates that Personal Property Coverage applies.
ACORD 24 (2009/09) rev. 10-30-2009 6 of 9
Section Name Field Name Field and/or Section Description
COVERAGES Limits - $ Field text box Enter limit: The limit amount for personal property coverage.
COVERAGES Business Income (Checkbox) Check the box (if applicable): Indicates business income coverage is included in the policy.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for business income coverage.
COVERAGES Extra Expense (Checkbox) Check the box (if applicable): Indicates extra expense coverage is included in the policy.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for extra expense coverage.
COVERAGES Rental Value (Checkbox) Check the box (if applicable): Indicates rental value coverage is included in the policy.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for rental value coverage.
COVERAGES Blanket Building (Checkbox) Check the box (if applicable): Indicates blanket coverage exists. As used here this is blanket coverage for the building.
COVERAGES $ Field text box Enter limit: The limit amount for the blanket coverage. As used here this is blanket coverage for the building.
COVERAGES Blanket Pers Prop (Checkbox) Check the box (if applicable): Indicates blanket coverage exists. As used here this is blanket coverage for personal property.
COVERAGES $ Field text box Enter limit: The limit amount for the blanket coverage. As used here this is blanket coverage for personal property.
COVERAGES Blanket Bldg & PP (Checkbox) Check the box (if applicable): Indicates blanket coverage exists. As used here this is blanket coverage for the building and personal property.
COVERAGES $ Field text box Enter limit: The limit amount for the blanket coverage. As used here this is blanket coverage for the building and personal property.
COVERAGES Checkbox Check the box (if applicable): Indicates the coverage is included in the policy.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates the coverage is included in the policy.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Co Ltr Enter code: The company letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the inland marine policy.
COVERAGES Inland Marine Checkbox Check the box (if applicable): Indicates the type of policy is inland marine.
COVERAGES Type of Policy Blank field text Enter text: The description of the type of policy issued to the insured.
COVERAGES Causes of Loss - Named Perils (Checkbox) Check the box (if applicable): Indicates the coverage is to be written on a named perils basis.
COVERAGES Causes of Loss - Other (Checkbox) Check the box (if applicable): Indicates the type of policy/perils insured is other than those listed.
ACORD 24 (2009/09) rev. 10-30-2009 7 of 9
Section Name Field Name Field and/or Section Description
COVERAGES Blank field text Enter text: The description of the type of policy issued to the insured.
COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
COVERAGES Policy Effective Date (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
COVERAGES Policy Expiration Date (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES Covered Property - Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES Limits - $ Field text box Enter limit: The limit of the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit of the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit of the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit of the coverage.
COVERAGES Co Ltr Enter code: The company letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the crime policy.
COVERAGES Crime - Checkbox Check the box (if applicable): Indicates crime coverage applies.
COVERAGES Type of Policy Enter text: The description of the type of policy issued to the insured.
COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
COVERAGES Policy Effective Date (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
COVERAGES Policy Expiration Date (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire.
ACORD 24 (2009/09) rev. 10-30-2009 8 of 9
Section Name Field Name Field and/or Section Description
COVERAGES Covered Property - Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates a coverage other than those listed is applicable to the risk.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Co Ltr Enter code: The company letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the boiler and machinery policy.
COVERAGES Boiler & Machinery Checkbox Check the box (if applicable): Indicates boiler and machinery coverage applies.
COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
COVERAGES Policy Effective Date (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
COVERAGES Policy Expiration Date (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES Covered Property - Checkbox Check the box (if applicable): Indicates the coverage is included in the policy.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES Limits - $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Checkbox Check the box (if applicable): Indicates the coverage is included in the policy.
COVERAGES Blank field text Enter text: The description of the coverage.
COVERAGES $ Field text box Enter limit: The limit amount for the coverage.
COVERAGES Co Ltr Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the other policy.
COVERAGES Blank field text Enter text: The description of the other policy not listed on the form.
COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
COVERAGES Policy Effective Date (MM/DD/YYYY) Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
Section Name Field Name Field and/or Section Description
COVERAGES Policy Expiration Date (MM/DD/YYYY) Enter date: The date on which the terms and conditions of the policy will expire.
COVERAGES Covered Property (Checkbox) Check the box (if applicable): Indicates the coverage described is included in the policy.
COVERAGES Covered Property Enter text: The description of the coverage.
COVERAGES Limits Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES Covered Property (Checkbox) Check the box (if applicable): Indicates the coverage described is included in the policy.
COVERAGES Covered Property Enter text: The description of the coverage.
COVERAGES Limits Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES Special Conditions/Other Coverages Enter text: The Certificate Of Liability Insurance general remarks. As used here, record any special policy conditions or coverages not fully explained in the Coverages section.
CERTIFICATE HOLDER Certificate Holder Enter text: The certificate holder's full name.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address line one.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address line two.
CERTIFICATE HOLDER Enter text: The certificate holder's mailing address city name.
CERTIFICATE HOLDER Enter code: The certificate holder's mailing address state or province code.
CERTIFICATE HOLDER Enter code: The certificate holder's mailing address postal code.
CANCELLATION Authorized Representative 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.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).

ACORD 24 (2009/09) rev. 10-30-2009 9 of 9

Click here to view my web site ACORD Forms.

Labels: How to Complete a Certificate of Property Insurance 24

posted by Wayne @ 2:27 PM 2 comments

ACORD Forms : How to Complete a Leased Auto Certificate of Insurance 23

ACORD 23 Instructions

Section Name Field Name Field and/or Section Description
Use ACORD 23, Automobile Certificate of Insurance, to provide a coverage statement with respect to physical damage and/or liability insurance coverage to additional insured-lessors, loss payees or "Other" entities with an insurable interest in a vehicle, but only when the insurance policy covering the subject motor vehicle includes an "Additional Insured-Lessor" endorsement or a "loss payee endorsement" that contains a statement that the insurance company will send a notice to the lessor or loss payee in the event of policy termination.
TITLE ACORD 23 (2007/05) Automobile Certificate of Insurance For all other situations requiring certification of property or liability insurance or evidence of property insurance, use ACORD 24, Certificate of Property Insurance; ACORD 25, Certificate of Liability Insurance; ACORD 27, Evidence of Property Insurance; or ACORD 28, Evidence of Commercial Property Insurance.
IMPORTANT:
Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Departments of Insurance.
IMPORTANT Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Cert # Enter the certificate number assigned by the insurer.
IDENTIFICATION SECTION Date Month, Day, year on which the form is completed.
IDENTIFICATION SECTION Agency Name and address of the agency or broker issuing the form.
Telephone number of the agency or broker issuing the form. Include area code and
IDENTIFICATION SECTION Phone (A/C, No, Ext) extension, if applicable.
IDENTIFICATION SECTION Fax (A/C, No) Agency's facsimile number.


ACORD 23 (2007/05) rev. 09-04-2008 1 of 3 ACORD 23 (2007/05) rev. 09-04-2008 2 of 3 ACORD 23 (2007/05) rev. 09-04-2008 3 of 3

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION E-Mail Address Agency's e-mail address.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
IDENTIFICATION SECTION Sub Code If the agency or brokerage uses a sub-code identification system with the company, enter the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Insurers Affording Coverage
IDENTIFICATION SECTION Company A Name of the company issuing the policy.
IDENTIFICATION SECTION Company B Name of the company issuing the policy.
IDENTIFICATION SECTION NAIC # Enter the NAIC number for the insurer affording coverage.
IDENTIFICATION SECTION Insured Insured's name and address as they appear on the policy declarations page.
DESCRIPTION OF AUTO Year Enter the year of the leased vehicle.
DESCRIPTION OF AUTO Make Indicate the make of the vehicle. (e.g., Ford)
DESCRIPTION OF AUTO Model Indicate the model of the vehicle. (e.g., Taurus)
DESCRIPTION OF AUTO Body Type Indicate the body type of the vehicle. (e.g., 2-door)
DESCRIPTION OF AUTO Vehicle Identification Number Indicate the vehicle identification number of the vehicle
COVERAGES Enter the coverage information for both auto liability and auto physical damage, as described on the policy declarations page.
COVERAGES Insr Ltr Enter the Company Letter of the company, as identified in the Insurers Affording Coverage section, next to the appropriate coverage(s).
COVERAGES Type Of Insurance Indicate the type of insurance.
COVERAGES Auto Liability Check this box to certify auto liability coverage. Complete the requested information.
COVERAGES Policy Number The number assigned by the insurance company for the policy.
COVERAGES Policy Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
COVERAGES Policy Expiration Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless renewed.
Section Name Field Name Field and/or Section Description
COVERAGES Limits All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES Auto Physical Damage Complete this section if you are certifying auto physical damage coverage.
COVERAGES Check boxes Check the applicable boxes for specific types of auto physical damage coverages.
COVERAGES Policy Number The number assigned by the insurance company for the policy.
COVERAGES Policy Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
COVERAGES Policy Expiration Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless renewed.
COVERAGES Check boxes Indicate if the limits are Actual Cash Value (ACV), Agreed Amount, Stated Amount or Other Type of Coverage Option, e.g., Replacement Cost Value (RCV). Identify the other type of coverage option.
COVERAGES Limits All limits should be listed as whole dollar amounts. Enter limits corresponding to those found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES Deductible Enter the applicable deductible.
COVERAGES Remarks Use this space to provide information about additional coverages (e.g., gap coverage), or special conditions included in the policy.
CERTIFICATE HOLDER Check boxes Check the applicable box to indicate if the Certificate Holder is a Lender, Lessor or other entity. Identify the other entity.
CERTIFICATE HOLDER Leased Vehicle Check this box if the vehicle is leased.
CERTIFICATE HOLDER Loan / Lease Number Enter the Loan or Lease number provided by the organization issuing the loan or lease.
CERTIFICATE HOLDER Name and Address of Lender / Lessor Name and mailing address of the individual or entity for whom the certificate is being prepared.
CANCELLATION Cancellation Statement Number of days in which the insurer will endeavor to mail a written cancellation notice. This amount is subject to approval by the company(ies).
CANCELLATION Authorized Representative Authorized representative should sign the form.

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Labels: How to Complete a Leased Auto Certificate of Insurance 23

posted by Wayne @ 1:42 PM 0 comments

ACORD Forms : How to Complete a Workers Comp First Report 4

Workers Comp First Report of Injury or Illness 4

ACORD, in conjunction with the IAIABC (International Association of Industrial Accident Boards & Commissions) developed this standard First Report. The form tracks with the IAIABC and ANSI X12 EDI standard for reporting Workers Compensation losses.

The form is designed as a first notice of a claim for injury or illness by an employee. In nearly all cases, the form is completed by the employer and sent directly to the insurer or to the state workers compensation board. It contains information about the employer, insurance carrier, employee, the occurrence leading to the injury or illness, and the nature of injury or illness. Instructions to the employer regarding completion of the form are contained on the third and fourth pages of the form.

Although the form is accepted by insurers in all states, each jurisdiction mandates the form to be used within that state with respect to the report made to the workers compensation board. . This version of ACORD 4 is accepted in many jurisdictions. It is anticipated that this number will continue to increase significantly as states adopt the IAIABC and ANSI X12 EDI Standard.

As of November 1, 1998, the following states are reported to accept ACORD 4. Consult your company about use in other states.

Connecticut
Florida
Idaho
Illinois
Maryland
Mississippi
New Mexico
Ohio
Rhode Island
South Carolina.

In addition, Wisconsin accepts ACORD 4WI, Wisconsin Employer's First Report of Injury or Illness.

Click here to view my web site ACORD Forms

posted by Wayne @ 7:56 PM 1 comments