ACORD Forms : How to Complete a Dwelling Fire Application 84
The underwriting process for any personal lines policy begins with the submission of a completed application. This guide will provide assistance in completing the ACORD Dwelling Fire Application.
The generic section of personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS.
APPLICANT INFORMATION
Previous Address
Enter previous physical address of the first named insured if the applicant has been at the current address for less than three years. Also indicate the number of years at the previous address.
Location of Property if Diff From Above
Enter the physical address of the property to be insured only if it is different from the address listed above.
Applicant's/Co-applicant's Occupation
Briefly describe the occupation for the applicant(s) named in the identification section. State the nature of business if self-employed.
Applicant's/Co-Applicant's Employer Name and Address
Name and address of the organization that employs the applicant(s) named in the identification section.
Yrs in Curr. Occ.
Number of years in current occupation or business.
Yrs w/Curr. Empl.
Number of years with present employer. If less than 3 years, provide the number of years in career field or industry in the Remarks section.
Yrs w/Prior Empl.
Number of years with the prior employer.
Mar Stat
Marital status of each named applicant. Codes:
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single
M. . . . . . . . . . . . . . . . . . . . . . . . . . . . .Married
D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced
SP . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated
W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed
Date of Birth
Birth date of each named applicant (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.)
Social Security #
Social security number for each named applicant.
Questions Relating to Knowledge of Applicant and Date Property Was Inspected
Indicate how long the applicant is known to the agent, and when the property was last inspected by the agent.
COVERAGES/LIMITS OF LIABILITY/ ENDORSEMENTS
Enter the anticipated dollar limit amounts for each applicable coverage. List any optional endorsement(s), corresponding limit(s) and any endorsement information that is to be included in this policy.
Policy Type
Show the policy form, form number or company form designation for the type of policy/coverage desired.
Deductibles
Several deductible fields are shown. One or more may be selected, depending on the company, the jurisdiction for the policy and the property coverage. Enter the appropriate deductible amount in each field. (Note: Deductibles may be the same amount or they may differ by coverage.)
Premium
Enter the estimated total premium calculated by the insurance agency, as well as the applicant's deposit.
Payment Plan
Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment.
RATING/UNDERWRITING
Provide the information below for each dwelling.
Construction Type
Check the primary type of building material used to construct the dwelling. Also indicate the siding type.
Examples of siding types not shown on the form include stucco, log, asbestos, and synthetic stucco/ EIFS (Exterior Insulation Finishing System).
Synthetic stucco is an artificial stucco used for exterior insulation and finishing systems (EIFS). It is created by affixing a styrofoam panel to the wall sheathing. The styrofoam is covered with reinforcing mesh, followed by a base coat and a finish coat. Both the base coat and the finish coats include an acrylic resin. The resin is water soluble in its liquid form, but once applied and dried, it becomes waterproof. Typically, this type of surface is less than a half-inch thick. It is relatively light, and sounds hollow when tapped. Real stucco is relatively heavy and feels and sounds solid when tapped. It is a much harder material than synthetic stucco, and is more resistant to injury by a blow or impact.
NOTE: you must advise the insurer if synthetic stucco (EIFS) siding is present.
Yr Built
Year the dwelling was built. Use four digits (e.g., 1952). If significant alterations were made, indicate the year and describe the alternations in the Remarks section. Also complete the Renovation Update section.
Sq Ft
Dwelling's total square footage of living area.
# Rooms
Total number of rooms in a residence, including full and half rooms (bath).
# Apts
Complete only for tenant or condominium policies. Enter the number of apartments (residences) in the building.
Market Value
Estimated total dollar amount for which the dwelling could be sold under current market conditions.
Replacement Cost
Estimated total dollar amount required to rebuild the dwelling without depreciation.
Structure Type
Indicate the residence type. The full meaning of each abbreviation is:
DWELLING Dwelling, intended to be a free standing, up to 4 family building.
APART Apartment.
CONDO Condominium.
TOWNHOUSE Townhouse
ROWHOUSE Rowhouse
CO-OP Co-operative.
Usage Type
Applicant's use for the dwelling within the guidelines listed. ("COC" refers to dwellings in the "course of construction.")
# Families
Number of separate family units in the dwelling. Not required for HO-4 or HO-6.
# Hsehold Res
Number of residents in the household.
Purchase Date/Price
Year the applicant acquired the dwelling and the purchase price. The year should be expressed in YYYY format.
# of Fire Div/ # of Units in Fire Div
Complete only for apartments, townhouses, rowhouses and condominiums. Enter the number of residences that are in the same fire division with the insured residence (including the insured's residence). A fire division is the number of units within the building or within approved firewalls.
Terr Code
Dwelling location based on individual state bureau or company homeowners manual pages.
Prem Group
Premium group codes are found in individual state homeowner manuals. Some companies may require this data, others will generate it. Premium Group is a combination of Protection Class, Territory Code and Construction Type Code used to determine the applicable rate
based upon the dwelling's location, construction and fire protection code.
Protect Class
Dwelling's four-character fire protection grade found in individual state homeowners manuals.
Distance to Hydrant
Distance in feet from the nearest hydrant to support the protection class used.
Distance to Fire Station
Distance in miles from the nearest fire station to support the protection class used.
Fire/EC Rate
Complete if residence is specifically rated. Refer to thecompany rate manual.
Fire District/Code Number
Residence's fire district name and correspoding code number, which can be found in the idividual state manual pages.
Protection Device Type
For temperature, smoke and burglar alarms to qualify for credit, a copy of the manufacturer's specification sheet must be submitted with the application. The combination of dead bolt, smoke detector and fire extinguisher qualifies for a separate credit with some companies.
Heat Type
Type of heating device for the residence. If there is more than one type, indicate the primary and secondary types. Use the Remarks section if necessary. Some possible types are:
Electric - Permanent/Portable
Liquid Propane - Permanent/Portable
Natural Gas
Kerosene - Permanent/Portable
Coal -Professionally/Non-Professionally Installed
Oil
Wood
Solar
Other - Explain the heating system in Remarks
Housekeeping Condition
Enter the evaluation of the interior upkeep of the dwelling.
Renovation Type
If wiring, plumbing, heating or roofing have been partially or completely replaced, provide the year updated. If the exterior has been repainted, provide the year.
Date Heating System Last Serviced
Indicate the date (mm/dd/yyyy) heating system was last serviced.
Num of Amps (Elec. Syst)
Indicate the number of amps in the electrical system.
Circuit Breakers
Check the applicable box.
Fuses
Check the applicable box.
Knob & Tube or Aluminum Wiring
Check the appropriate box.
Plumbing System Condition
Indicate condition of the plumbing system.
Plumbing System - Any Known Leaks
Indicate if there are any known leaks in the plumbing system.
Foundation
Check the applicable box.
Dwelling Location
Location of the dwelling within the guidelines listed. Complete only if applicable.
Occupancy
Indicate if the dwelling is occupied by the owner or a tenant, unoccupied or vacant.
Deadbolt
If all entry (exterior) doors are fitted with deadbolt locks, check the box.
Fire Extinguisher
If the dwelling is equipped with fire extinguisher(s), check the box. Indicate the number of fire extinguishers and their locations in the blank space.
Visible to Neighbors
If the residence is visible from a road, or from another residence usually occupied by an adult during the day, check the box.
Oil Storage Tank Location
If the fuel type is oil, provide the location of the fuel oil storage tank. Options are:
Indoors above ground on masonry floor
Indoors above ground not on a masonry floor
Outdoors above ground
Outdoors below ground
Also show the distance from the dwelling, if the storage tank is outdoors.
Swimming Pool
If a swimming pool is on the residence property, check the appropriate boxes to indicate the existence of the pool, whether the pool is above ground, in ground, has a diving board, slide or approved fence.
Storm Shutters
Check the applicable boxes.
Hurricane Resistant Glass
Check the applicable box.
Bldg Code Grade
Enter the ISO Building Code Grade, if applicable. Also check the appropriate box to indicate whether or not the building was inspected.
Tax Code
Enter the city, county or state tax code, if required.
Rating
Check the applicable box.
Occupied Daily
Check the applicable box.
# Weeks Rented
Number of weeks the dwelling is rented by the insured to others.
Wind Class
Check the applicable box.
Roof Material
Enter the material used to construct the roof. Examples:
Composition (fiberglass, asphalt, etc.)
Metal
Poured
Slate
Tile
Wood Shake/Shingle
Other If used, explain in Remarks
Condition of Roof
Indicate the condition of the roof.
If Replacement Cost coverage applies, check the appropriate box if an ACORD replacement cost worksheet has been used (i. e., ACORD 40, 41, or 42.)
Basement
Indicate the number of square feet in the basement. Leave this field blank if there is no basement.
Garage
Indicate the number of square feet in the garage. Leave this field blank if there is no garage.
Breezeway
Indicate the number of square feet in the breezeway. Leave this field blank if there is no breezeway.
Rating Credits
Check the applicable box(es) if any rating credits apply.
Sprinkler
If the dwelling is equipped with a fire sprinkler system, indicate whether it is full or partial. Leave this field blank if there is no sprinkler system.
Fireplaces
Enter the number in the applicable box(es) to describe the fireplace(s.)
GENERAL INFORMATION QUESTIONS
Use the Remarks section to provide additional information for any questions answered with a "Yes" response. (Except questions 15, 16 and 17.)
1. Any farming or other business conducted on premises?
Describe the business, where the business is conducted on the premises, and if applicable, whether corporal punishment coverage is to be provided.
2. Any residence employees?
Describe the number and type of full and part time employees.
3. Any flooding, brush, forest fire hazard, landslide, etc.?
Use the Remarks section to describe the type of hazard and the distance between the residence and the hazard. Some companies may require a photograph.
4. Any other residence owned, occupied or rented?
Use the Remarks section to describe the occupancy or use of the other residence. If no liability coverage is requested for this residence and this policy will provide liability coverage, detail where the coverage for the other residence is provided.
5. Any other insurance with this company?
Indicate whether other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the Remarks section along with any policy numbers available.
6. Has insurance been transferred within agency?
Indicate why this insurance has been moved from the last company.
7. Any coverage declined, cancelled, or non-renewed?
Explain the circumstances surrounding this situation. Indicate the reason for the cancellation, etc. This question cannot be asked in Missouri.
8. Has applicant had a foreclosure, repossession, bankruptcy, judgement or lien during the past five years?
Use the Remarks section to provide information regarding any real estate foreclosure, personal property repossession, bankruptcy filing, judgement or lien during the specified time period.
9. Are there any animals or exotic pets kept on the premises?
Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also, give any history of biting or causing injury to others or to other animals.
10. Is property located within two miles of tidal water?
Use the Remarks section to describe the coastal hazard, if applicable.
11. Is property situated on more than five acres?
Use the Remarks section to indicate if any part of the property is farmed, or used to grow crops or animals for sale, or used for any other non-residential purpose.
12. Does applicant own any recreational vehicles (snowmobiles, dune buggys, ATVs, mini-bikes, etc.)?
Use the Remarks section to describe the recreational vehicle. Include the year, type, make, model, and any other information necessary to provide a complete description.
13. Is Building retrofitted for earthquake?
Answer this question only in those earthquake zones where existing buildings may be retrofitted to comply with the latest "earthquake resistant" technology and building codes.
14. During the last ten years, has any applicant been convicted of any degree of the crime of arson? (In Rhode Island, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)
Rhode Island law requires that all applicants for property insurance must answer this question.
15-17. Renters and Condos Only
Indicate if:
15. There is a manager on the premises.
16. A security attendant.
17. The building entrance is locked.
18. Any uncorrected code violations?
Describe any violations of applicable building codes that have not been corrected.
19. Is building undergoing renovation or reconstruction?
Describe the type and scope of renovation or reconstruction of any part of the building.
20. Is the house for sale?
Provide the length of time the house has been for sale, and the expected sale date if known.
21. Is property within 300 ft. of a commercial or non-residential property?
Describe the occupancy of any commercial or non-residential property.
22. Is there a trampoline on the premises?
Describe the device.
23. Was the structure originally built for other than a private residence and then converted?
Describe what the structure was originally built for.
24. Any lead paint hazard?
Describe the location and extent of the hazard.
25. If a fuel oil tank is on premises, has other insurance been obtained for the tank?
Give the First Party to the insurance and the applicable limit, and the Third Party and the applicable limit.
26. If building is under construction, is the applicant the general contractor?
LOSS HISTORY
This section shows the losses this applicant has had in the past. List losses for the time period specified by the company.
OTHER STRUCTURES
Describe the other structure(s) and its coverage limit to be included under Coverage B - Other Structures.
PRIOR COVERAGE
Prior Carrier
Provide the prior insurance company's name.
Prior Policy Number /Expiration Date
List the complete policy number including prefix and suffix, and the policy's expiration date.
ADDITIONAL INTEREST
Provide the following information for each entity having an interest in the dwelling(s) to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the mortgage holder (i.e., bank in which the mortgage is held), or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
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ACORD Forms.
Labels: Dwelling Fire Application 84
ACORD Forms : How to Complete a Personal Umbrella Application 83
Personal Umbrella or Personal Excess insurance policies are personal lines insurance contracts that provide for indemnification of third parties as a result of damages and/or injuries sustained due to the insured's negligence with respect to personal acts. Coverage for negligence arising out of any professional activities and nearly all business pursuits conducted by the insured is normally excluded. It is important to note that personal umbrellas normally provide personal injury in addition to bodily injury coverage. While the latter coverage deals solely with physical injuries, the former includes "injuries" sustained as a result of libel, slander, defamation of character, false arrest and other "non-physical" perils.
Personal umbrellas typically operate in excess of or "overlay" the primary
liability coverage contained in other personal lines insurance contracts such as private passenger auto, homeowners and watercraft. Coverage limits are written on a combined single limit (CSL) basis. In some cases, Personal umbrellas may provide basic or "first dollar" coverage for certain types of negligence for which there is no primary coverage. Personal umbrellas can also overlay coverages afforded under certain commercial insurance contracts such as owners, landlords and tenants liability policies. They also provide that the insurer will pay legal defense costs on a first-dollar basis in addition to the policy limits. The majority of personal umbrellas contain a provision for a retained limit which effectively operates as a per occurrence deductible.
Although insurance coverage afforded by a personal umbrella is typically
operative "worldwide" and specific units at risk (such as automobiles) may be related to locations in varying geographical locations (rotary territories), premiums are developed on the basis of unique personal umbrella rates applicable at the insured's primary residence. No known requirement for allocating premiums back to other exposure locations exists.
The underwriting process for any personal lines policy begins with the
submission of a completed application. The generic sections of each personal lines form are explained in the Personal Lines Generic section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website, (www.acord.org), this information appears under the title PERSONAL LINES GENERIC SECTIONS.
UMBRELLA INFORMATION
Policy Amount
Limit of liability.
Retention
The amount of liability retained by the insured. Retention is generally expressed in whole dollars but can be a percentage.
Optional Coverages to Apply
Insurance companies often provide options or special coverages. Examples:
Professional
Business
Major medical
Uninsured/underinsured motorists
Specifically note each option desired and provide all the information necessary for underwriter review and policy issuance.
In Florida, Indiana, Louisiana, and Vermont, Uninsured Motorists coverages (and Underinsured Motorist coverages in Indiana) must be offered in umbrella policies up to the liability limit of the policy when auto liability coverage is included. In Florida, auto supplement ACORD 61 FL should be used with umbrella policies. Refer to the instructions for use of this form in the State Forms section of this guide. In the other states mentioned above, no supplement is required, but the insured must initial the appropriate statement at the bottom of the back of this form, indicating selection or rejection of UM (and UIM in IN) coverage.
Premiums
Methods for calculating the policy premiums differ by company, but usually include a basic amount. Any additional autos, residences, watercraft or special options involve additional premiums based on an established schedule.
Calculations
The insurance company may require use of specific multipliers or factors which can be shown here.
PAYMENT PLAN
Indicate whether the agency or the company (direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan for payment.
PRIMARY POLICY INFORMATION
Type of Policy
The most common coverages are pre-printed on the application. Space for additional primary policies in force is provided.
Company/Policy Number
Provide the name of the insurance company and the full policy number including any alphabetical prefix and/or suffix. Be sure to list all primary policies for all insureds in the household such as children with their own auto policies.
Policy Period
Effective and expiration dates for each primary policy in force.
Limits of Liability
Limits for each policy. Some policies may offer different limits for specific hazards (fire, legal liability or waterskiing) which must be identified. Use the blank spaces to provide this information.
REAL ESTATE
Location
Address of all owned, leased, rented or occupied residences, buildings, farms and vacant land.
Description
Differentiate locations such as vacant land, apartment buildings, townhouses, single family dwellings, farms. Provide the number of acres if farm land.
Interest
Show the interest of the applicant (owner, lessor, lessee, occupier, etc.) for each described location.
Yr Built
Year the dwelling was built, use four digits (e.g., 1952).
Occupancy
Identify the occupants of the premises (self, self and tenant, tenant, three families, doctor's office). Indicate if the occupancy is seasonal.
AUTOMOBILES
Year and Make and Model
List all automobiles owned, leased or furnished for regular use.
RECREATIONAL VEHICLES
Year and Type, Make and Model
Provide the same information as for automobiles; be specific regarding the type of vehicle. Specify if it is a dirt bike, van, scooter, etc. Include size of engine in cubic centimeter displacement and/or horsepower.
WATERCRAFT
Year
Model year of the unit in YYYY format. If built at home, the year built.
Motor Type, Manufacturer and Model
Indicate type of motor (inboard, outboard, etc.), manufacturer and model.
Length
Overall length measured in feet from bow to stern.
Horsepower
Total horsepower of the watercraft.
Max Speed
Enter the maximum speed of the craft. State if measured in knots or miles per hour.
Value
Companies may require either one or both dollar amounts. Indicate in the corresponding box whether cost new or current value applies. If two amounts are required, enter the cost new first.
Waters Navigated
Body of water or geographical area navigated (e.g., Atlantic, Great Lakes, Inland Waterways, Pacific, Rivers). Specific names (Hudson River, San Francisco Bay) can also be provided.
OPERATOR INFORMATION
Name
Names of all household members and all operators of vehicles or watercraft, even if they are not members of the household. The listing should include children at home or relatives/friends who may use a vehicle or watercraft.
Sex/Mar Stat
Sex and marital status of each driver and household member.
Date of Birth
Date of birth of each driver and household resident (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944.)
Drivers License #/Licensed State
Complete drivers license number and license state for each licensed operator. Copy directly from license if possible.
Social Security #
Social security number for each driver.
Vehicle, % Use
The vehicle operated by each of those named above, the percentage of use of the vehicle attributed to that operator, and annual mileage or any other information required by the insurance company.
Craft, % Use
The watercraft operated by each of those named above, the percentage of use of the craft attributed to that operator, and annual mileage or any other information required by the insurance company.
EMPLOYMENT
Occupation
Some job titles are not very specific (Manager, Analyst). Expand upon the title as necessary (e.g., Department Manager of Plastics Manufacturer).
Employer's Name and Address
Name of the employer and the address of the location where employed.
Yrs Empl
Number of years the applicant(s) has been with the employer indicated above. If less than 3 years, provide the number of years in the same or other career field or industry in the Remarks area.
PRIOR EXPERIENCE
Losses
Follow the company guidelines for required information on prior losses.
Prior Carrier and Policy Number
Provide the prior insurance company's name and the complete policy number, including prefix and suffix.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any of the questions below answered with a "Yes" response.
1. Any aircraft owned, leased, chartered or furnished for regular use?
This does not include scheduled commercial airlines. If the applicant is a licensed pilot, the company may require additional information.
2. Any operators convicted for any traffic violations?
Provide the name of driver involved, the date and nature of the violation and/or conviction.
3. Any operator have physical /mental impairment?
Provide the name of the driver and the details. Determine if the operator's impairment (e.g., amputation or epilepsy) could hinder the safe operation of a vehicle. Provide a description of any special equipment installed and treatment or medication being administered.
4. Any swimming pool, spa or hot tub on premises?
Indicate if there is a swimming pool, spa or hot tub on any covered premises. If there is a swimming pool, indicate whether the pool is above/in ground and whether there is an approved fence.
5. Any real estate, vehicles, watercraft, aircraft used commercially or for business purposes?
Describe all commercial or business use.
6. Any real estate, vehicles watercraft, aircraft owned, hired, leased or regularly used, not covered by primary policies?
If yes, explain why no primary coverage exists.
7. Do you engage in farming operation?
Describe all farming operations performed by the applicant including custom farming. Include size of the farm, its acreage and annual sales.
8. Do you hold any non-compensated positions?
List any unsalaried or other philanthropic position the insured holds. Examples:
Corporation's board of directors
Master of a lodge
Commodore of yacht club
9. Any full-time employees?
If the applicant employs any full or part time employees, provide information on whether they work inside or outside, number of employees, duties, number of hours worked per week and total payroll (e.g., housekeeper, gardener).
10. Any non-owned property exceeding $1,000 in value in your custody?
If the applicant is responsible for the property of others, list the type of property. Examples:
Firearms
Art
Computers
11. Any business and/or professional activities included in primary policies?
Provide the nature of such professional or commercial activities and whether or not income is produced.
12. Any primary policy have reduced limits of liability?
Include any primary policy endorsed to limit, restrict, exclude or otherwise modify coverage provided by the basic policy form (e.g., liability may be reduced when the applicant is using watercraft for waterskiing, or for a youthful operator when operating a motor vehicle).
13. Any coverage declined, cancelled, non-renewed?
If any policy had this action taken, provide the reasons and circumstances. This question cannot be asked in Missouri.
14. Does applicant or tenants have any animals or exotic pets?
Use the remarks section to give the age, breed, or other information about livestock or pets that may be vicious or dangerous to human beings. Also give any history of biting or causing injury to others or to other animals.
15. Has insurance been transferred within agency?
Indicate if prior carrier information shown on the front of the application represents a policy being transferred within the agency. Give reason for transfer.
16. Any pending litigation, court proceedings or judgment?
If yes, describe in detail.
17. Is there a trampoline on the premises?
Indicate if there is a trampoline on any covered premises.
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Labels: Personal Umbrella Application 83
ACORD Forms : How to Complete a Watercraft Application 82
The underwriting process for any personal lines policy begins with the
submission of a completed application. This guide will provide assistance in completing the ACORD Watercraft Application.
This form can be used either as a stand-alone application or as a supplement to the Homeowners Application (ACORD 80) if physical damage on watercraft is being written under the Homeowners policy. Check with the company to determine whether physical damage can be written on the Homeowners policy.
If coverage will be provided under a yacht policy, do not use this form. Use ACORD 210, Yacht Section.
The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide. On the ACORD website, this information appears under the title PERSONAL LINES GENERIC SECTIONS.
BOAT HULL
Provide hull number if more than one hull is to be insured.
Power
Indicate the method of propulsion. Sailboats can be powered by an auxiliary engine, therefore, please check SAIL in addition to the auxiliary type of propulsion for sailboats.
Type of Hull
Indicate the type of watercraft to be insured. "Personal WC" refers to "personal watercraft".
Hull Material
If the hull material is not fiberglass, metal or wood, please indicate the material type in the remarks area.
Hull Design
Indicate the type of hull to be insured.
Fuel Tank
Indicate whether the fuel tank is made of fiberglass or metal.
Year
Model year of the unit in YYYY format. If built at home, enter the year built.
Manufacturer/Model
Name of the manufacturer and the model (e.g., Chris Craft Tournament Fisherman, Pacemaker Runabout).
Length
Overall length measured in feet from bow to stern.
Max Speed
Enter the maximum speed of the craft. State if measured in knots or miles per hour.
Date Purchased
Date the watercraft was purchased by the insured in MMYY format.
Cost New
Cost of the boat when it was purchased new, in whole dollar amounts.
Present Value
Boat's present value, stated or agreed, in whole dollar amounts.
Name of Boat
Name in which the watercraft is registered.
Registration Number/Hull Identification Number
Enter the registration number and the serial number of the watercraft.
Waters Navigated
Identify the primary area of operation (e.g., San Francisco Bay Area, Hudson River).
Territory
This is typically the navigation territory. However, use company manuals to determine territory.
Berth/Storage Location
Physical address where the boat is stored; no P.O. boxes.
Lay-Up Period
Specify the period when the boat is not in operation (e.g., October through March). Also, state if the boat is stored afloat or in a dry dock. If the boat is stored afloat, indicate the devices used to prevent ice damage (e.g., bubble system).
ENGINE/MOTOR
Use this section to provide information about all engines and motors used to propel the boat.
Year
Model year of the engine/outboard motor in YYYY format.
Manufacturer/Model/Serial Number
Enter the name of the manufacturer, the model (e.g., Mercury Mark 50, Evinrude 200), and the serial number.
Horsepower
Enter the horsepower. There is a method for determining the maximum safe horsepower for a specific boat based on length and width. If the company employs this formula, it may be helpful to make note of the width in the space labeled "other".
Fuel
Indicate the fuel used to power the engine.
For Outboard Motors Only
Provide the date purchased, cost when new and present value.
TRAILER
If boat trailer insurance is to be included on the watercraft policy (usually only available for stand-alone watercraft policies), enter all pertinent information regarding the boat trailer: year, manufacturer, serial number, number of axles, capacity, date purchased, cost.
COVERAGES/LIMITS OF LIABILITY
Indicate the limit of insurance, deductible and coverage premium for each applicable coverage. List any additional coverages, including their limit and premium in the other coverage section.
Hull
Amount of coverage for boat damage; this may include collision liability.
Outboard Motor
Amount of coverage for damage to the outboard motor. Limits may be entered for three motors.
* Coverage for inboard motors is included in the hull coverage.
Portable Accessories
Coverage amount for those items not permanently attached to the boat. Examples:
Oars
Anchors
Life Preservers
Fire extinguishers
Trailer
Amount of coverage for damage to the trailer.
Liability
Coverage amount for bodily injury and property damage. May be called protection and indemnity.
Medical Payments
Amount of coverage for medical expenses for bodily injury to occupants of the boat.
Uninsured Boaters Liability
Coverage amount for bodily injury caused by an uninsured boat operator. Some companies offer this coverage.
Total
Estimated total premium.
Describe all Credits to Apply to each Boat
List all credit amounts and names for each boat.
Credit
Total credit amount for the watercraft portion of the policy.
PAYMENT PLAN
Indicate whether the agency or the company(direct) will bill the insured or other payee for the policy. If direct bill, also indicate who is to be billed, and the plan to be used for payment.
ADDITIONAL INTEREST
Provide the following information for each entity having an interest in the motors or the watercraft to be insured: the interest number or rank (1st, 2nd), whether the additional interest is the lienholder (e.g., bank in which the loan is held) or other interest, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
RATING/UNDERWRITING
Provide a description of the equipment on the boat that is of particular interest to the underwriter.
Indicate the number present on the boat and an appropriate description of each piece of equipment.
Bilge Pumps
A bilge pump is a manually operated or automatically activated device used for pumping water from the inner part of the ship's hull. Using the same principle as the manual pump, the automatic pump is activated by the rise of water within the hull. Specify the manufacturer and the model (e.g., Dynaflow Pump 304).
Cooking Stove
Indicate the manufacturer, model and fuel type. Also indicate if there is more than one stove.
Fume Detector
A device used for detecting the presence of fuel vapors below deck. Specify the manufacturer and model (e.g., Sniffer 203).
CO2 / Chemical System
A built-in fire extinguishing device. Indicate if it is manual or automatic and identify the spaces protected. Include the manufacturer and model. Use the Remarks section if necessary.
Fire Extinguishers
Indicate the number of fire extinguishers on the boat. Specify the type, size, and the date last weighed, if available.
Depth Sounder
An electronic device for determining the depth of the water beneath the boat. Indicate the manufacturer and model (e.g., Moran 6" - 150/SV-300).
Radar
A device for detecting distant objects and determining their position. Specify the manufacturer and model.
Radio Direction Finder
A navigational aid employing a radio signal. Enter the manufacturer and model (e.g., Loran, GSP).
Ship to Shore Radio
Indicate the type of radio. Examples:
SSB-Single Side Band
VHF-FM-Very High Frequency - Frequency Modulation
CB -Citizens Band
Cellular Phones
Marine Radio
Anti-Theft Devices
Special locks, burglar alarms or engine cut-out devices may be employed by the applicant. Marina security may be noted as well.
Heating
Describe heating system, if any.
Other
Use the blank spaces to list additional equipment. Attach a separate list if necessary.
PORTABLE ACCESSORIES
List the portable accessories that are to be insured. Include the name of the equipment, year of manufacture, name of manufacturer, and the model and serial number if applicable. Also provide the limit(s) of insurance required.
OPERATORS
List the name, sex, marital status (S-Single, M-Married, D-Divorced, SEP-Separated, W-Widowed), date of birth (MM/DD/YY), social security #, auto drivers license number and licensed state if applicable, for each household member and any other frequent operators.
OPERATORS EXPERIENCE
Indicate if any operator completed courses offered by the United States Coast Guard Auxiliary, the Power Squadron or other recognized training. The underwriter will also be interested in the number of years of boating experience and the type of boats operated or owned. Some companies require the percentage of use for each operator. Be sure to cross-reference the operator number.
HULL INFORMATION
Use the Remarks section to provide additional information for any questions answered with a "Yes" response.
1. Is the boat chartered to others?
If the vessel is chartered, describe the type of arrangements, destination, length of time and frequency. Indicate if it is a bare boat charter where no crew or supervision is furnished, a voyage charter, a time charter, etc. Include the purpose of the charter (sight-seeing, fishing) and whether alcohol is served.
2. Is the boat used commercially or for business purposes?
Describe the commercial or business use of the vessel. Indicate if the vessel is used for demonstrations, promotions, fishing, sight-seeing trips, etc.
3. Is the boat used for racing?
If the vessel is used for racing, indicate the frequency of such races during the year, the extent of the race, the waters navigated, etc.
4. Is the boat used for waterskiing?
Indicate how frequently the vessel is used for waterskiing.
5. Does the applicant employ a paid crew?
Specify the number of crew members, and whether they are full or part time. Be sure to list the crew members in the Operator section of the application.
6. Any sleeping facilities?
Provide number of beds.
7. Any existing damage to the boat?
If yes, describe in detail.
GENERAL INFORMATION
Use the Remarks section to provide additional information for any question answered with a "yes" response.
1. Has the applicant lived at current address for less than 3 years?
Indicate the previous address of the applicant.
2. Any operator have physical/mental impairment?
Answer "yes" only if the impairment impedes the use of the watercraft. Indicate the impairment and any applicable medical treatment being used.
3.Any drivers license suspended/revoked during the last 3 years?
Indicate if the drivers license of any operator was suspended or revoked and explain the circumstances.
4. Has any operator had an accident/conviction during the last 3 years?
Indicate accidents/convictions for both driving and boating records.
5. Any other insurance with this company?
Indicate if other insurance is currently written for this applicant by the company. If a submission was mailed to another department recently, note it in the remarks section along with any policy numbers available.
6. Any losses occur during the last 3 years?
Describe in detail, all losses during the last three years. Include data on the operator, the type of loss, the amount of the loss, the date and the disposition.
7. Any coverage declined, cancelled, or non-renewed?
Provide the circumstances surrounding this situation. This question cannot be asked in Missouri.
8. During the last five years(ten in RI), has any applicant been convicted of any degree of the crime of arson?
In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.
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Labels: Watercraft Application 82
