ACORD
TM
PHONE (A/C, No, Ext):
PRODUCER
DATE
PROPERTY SECTION APPLICANT (First Named Insured) EFFECTIVE DATE
EXPIRATION DATE
PAYMENT PLAN
DIRECT BILL
AUDIT
AGENCY BILL
CODE: AGENCY CUSTOMER ID:
FOR COMPANY USE ONLY
SUB CODE:
PREMISES INFORMATION
PREMISES #:
SUBJECT OF INSURANCE
BUILDING #:
AMOUNT
COINS %
STREET ADDRESS:
VALUATION
CAUSES OF LOSS
ADDITIONAL INFORMATION - BUSINESS INCOME/EXTRA EXPENSE TYPE OF BUSINESS
ORDINARY PAYROLL
NON MFG
EXCL
MFG
INCL
90 DAYS
MINING
POWER/HEAT
DED
ELEC MEDIA
DAYS $
$
TUITION FEES
EXTRA EXPENSE
OFF PREM POWER
DEPEND PROP
STUDENTS
POWER
$
OTHER ED SERV/INC
WATER
CONT LOC
COMM (DESCR BELOW)
REC LOC
LIMIT
ORD OR LAW
FORMS AND CONDITIONS TO APPLY
DAYS $ MO PERIOD
180 DAYS
% COINS
DEDUCTIBLE
BUSINESS INCOME W/O EXTRA EXPENSE
EXT PERIOD
$
INFLATION GUARD %
% COIN
MFG LOC
MAX PERIOD
DAYS
LDR LOC (DESC BELOW) EXTRA EXPENSE
NAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROP
DAYS PERIOD REST
LIMIT LOSS PAY %
%
# STORIES # BASM’TS
YR BUILT
%
%
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
DISTANCE TO HYDRANT FIRE STAT
CONSTRUCTION TYPE
FT
FIRE DISTRICT/CODE NUMBER
WIRING, YR:
PLUMBING, YR:
ROOFING, YR:
HEATING, YR:
TAX CODE
ROOF TYPE
OTHER OCCUPANCIES
WIND CLASS
RIGHT EXPOSURE & DISTANCE
SEMIRESISTIVE LEFT EXPOSURE & DISTANCE
BURGLAR ALARM TYPE
CERTIFICATE #
OTHER:
TOTAL AREA
MI BLDG CODE GRADE
BUILDING IMPROVEMENTS
PROT CL
RESISTIVE
OTHER
HEATING BOILER ON PREMISES?
YES
NO
IF YES, IS INSURANCE PLACED ELSEWHERE?
YES
NO
REAR EXPOSURE & DISTANCE
EXPIRATION DATE
EXTENT
GRADE
CENTRAL STATION WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY
# GUARDS/WATCHMEN
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)
% SPRNK
FIRE ALARM MANUFACTURER
CLOCK HOURLY
CENTRAL STATION LOCAL GONG
ADDITIONAL INTERESTS RANK:
NAME AND ADDRESS
EVIDENCE CERTIFICATE
INTEREST LOSS PAYEE MORTGAGEE
POLICY
RANK:
NAME AND ADDRESS
EVIDENCE CERTIFICATE
INTEREST LOSS PAYEE MORTGAGEE
POLICY
VALUE REPORTING INFORMATION REPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHS SUBJECT OF INSURANCE
ACORD 140 (1/98)
PREMISES/ BUILDING
ANY OTHER LOCATION DECLARED AT INCEPTION
ATTACH TO APPLICANT INFORMATION SECTION
ANY OTHER LOCATION ACQUIRED AFTER INCEPTION
PREMISES NOT OWNED OR ACQUIRED LIMIT
c ACORD CORPORATION 1985 O
PREMISES INFORMATION
PREMISES #:
SUBJECT OF INSURANCE
BUILDING #:
AMOUNT
COINS %
STREET ADDRESS:
VALUATION
CAUSES OF LOSS
ADDITIONAL INFORMATION - BUSINESS INCOME/EXTRA EXPENSE TYPE OF BUSINESS
ORDINARY PAYROLL
NON MFG
EXCL
MFG
INCL
90 DAYS
MINING
POWER/HEAT
DED
ELEC MEDIA
DAYS $
$
TUITION FEES
EXTRA EXPENSE
OFF PREM POWER
DEPEND PROP
STUDENTS
POWER
$
OTHER ED SERV/INC
WATER
CONT LOC
COMM (DESCR BELOW)
REC LOC
LIMIT
ORD OR LAW
FORMS AND CONDITIONS TO APPLY
DAYS $ MO PERIOD
180 DAYS
% COINS
DEDUCTIBLE
BUSINESS INCOME W/O EXTRA EXPENSE
EXT PERIOD
$
INFLATION GUARD %
% COIN
MFG LOC
MAX PERIOD
DAYS
LDR LOC (DESC BELOW) EXTRA EXPENSE
NAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROP
DAYS PERIOD REST
LIMIT LOSS PAY %
%
# STORIES # BASM’TS
YR BUILT
%
%
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
DISTANCE TO HYDRANT FIRE STAT
CONSTRUCTION TYPE
FT
FIRE DISTRICT/CODE NUMBER
WIRING, YR:
PLUMBING, YR:
ROOFING, YR:
HEATING, YR:
TAX CODE
ROOF TYPE
OTHER OCCUPANCIES
WIND CLASS
RIGHT EXPOSURE & DISTANCE
SEMIRESISTIVE LEFT EXPOSURE & DISTANCE
BURGLAR ALARM TYPE
CERTIFICATE #
OTHER:
TOTAL AREA
MI BLDG CODE GRADE
BUILDING IMPROVEMENTS
PROT CL
RESISTIVE
OTHER
HEATING BOILER ON PREMISES?
YES
NO
IF YES, IS INSURANCE PLACED ELSEWHERE?
YES
NO
REAR EXPOSURE & DISTANCE
EXPIRATION DATE
EXTENT
GRADE
CENTRAL STATION WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)
# GUARDS/WATCHMEN
% SPRNK
FIRE ALARM MANUFACTURER
CLOCK HOURLY
CENTRAL STATION LOCAL GONG
ADDITIONAL INTERESTS RANK:
NAME AND ADDRESS
INTEREST LOSS PAYEE MORTGAGEE
EVIDENCE CERTIFICATE
POLICY
RANK:
NAME AND ADDRESS
EVIDENCE CERTIFICATE
INTEREST LOSS PAYEE MORTGAGEE
POLICY
VALUE REPORTING INFORMATION REPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHS SUBJECT OF INSURANCE
REMARKS
ACORD 140 (1/98)
PREMISES/ BUILDING
ANY OTHER LOCATION DECLARED AT INCEPTION
ANY OTHER LOCATION ACQUIRED AFTER INCEPTION
PREMISES NOT OWNED OR ACQUIRED LIMIT
