This form contains 818 fields organized into 76 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Agency Customer Identifier
Agency Customer ID	Text	Enter the unique identifier assigned to the customer by the agency.
Agency Information
Agency Name	Text	The full legal name of the insurance agency submitting this form.
Agency	Text	Enter the name of the insurance agency or broker responsible for this application (the agency's official business name).
Agency City	Text	The city where the agency’s office is located.
Agency State	Text	The two-letter state abbreviation for the agency’s office location.
Agency ZIP Code	Text	The postal ZIP code for the agency’s mailing address.
Agency Contact Name	Text	The primary contact person’s name at the agency.
Agency Phone Number	Text	The agency’s telephone number including area code and extension if applicable.
Agency Fax Number	Text	The agency’s fax number including area code.
Agency E-mail Address	Text	The agency’s primary email address for correspondence.
Agency Code	Text	The main agency code assigned by the insurer to identify the agency.
Agency Subcode	Text	The subcode that further identifies the agency under its main code in the insurer’s system.
Agency Customer ID	Text	The unique customer identifier assigned to this agency by the insurer or agency management system.
Applicant Contact & Residence
Primary Home Phone	CheckBox	Check this box if the primary phone number you entered is your home phone.
Primary Business Phone	CheckBox	Check this box if the primary phone number you entered is your business phone.
Primary Cell Phone	CheckBox	Check this box if the primary phone number you entered is your cell phone.
Primary Phone Number	Text	Enter the applicant’s primary phone number, including area code.
Secondary Home Phone	CheckBox	Check this box if the secondary phone number you entered is your home phone.
Secondary Business Phone	CheckBox	Check this box if the secondary phone number you entered is your business phone.
Secondary Cell Phone	CheckBox	Check this box if the secondary phone number you entered is your cell phone.
Secondary Phone Number	Text	Enter the applicant’s secondary phone number, including area code.
Primary Email Address	Text	Enter the applicant’s primary email address for correspondence.
Secondary Email Address	Text	Enter an additional email address for the applicant, if applicable.
Current Residence	Text	Enter the street address of the applicant’s current residence.
Applicant Employment
Previous Address	Text	Enter your previous residence address, including street, city, state and ZIP code.
Years at Previous Address	Number	Provide the number of years you lived at your previous address (complete only if less than three years).
Current Residence – Same as Mailing Address	CheckBox	Check this box if the applicant’s current residence is the same as the mailing address.
Current Residence – Owned	CheckBox	Check this box if the applicant owns the current residence.
Current Residence – Rented	CheckBox	Check this box if the applicant rents the current residence.
Years with Current Employer	Number	Enter the total number of years you have been employed with your current employer.
Employer Name and Street Address	Text	Enter the name of your current employer and the street address of the business.
Employer City and State	Text	Provide the city and state where your current employer’s office is located.
Employer ZIP Code	Text	Enter the ZIP code for your current employer’s address.
Applicant Occupation	Text	Enter your current job title or occupation; if self-employed, describe the nature of your business.
Years in Current Occupation	Number	Enter the total number of years you have worked in your current occupation.
Years with Previous Employer	Number	Enter the total number of years you worked with your previous employer.
Applicant Mailing Address
Mailing Address – Street and Number	Text	Enter the street number and name for the applicant's mailing address.
Mailing Address – Apartment, Suite, Unit	Text	Enter the apartment, suite, or unit number for the applicant's mailing address, if applicable.
Mailing Address – City	Text	Enter the city for the applicant's mailing address.
Mailing Address – State	Text	Enter the two-letter state abbreviation for the applicant's mailing address.
Mailing Address – ZIP Code	Text	Enter the ZIP code for the applicant's mailing address.
Enter text: The named insured's physical address line one. As used here, this is the current residence	Text
Enter text: The named insured's physical address line two. As used here, this is the current residence	Text
Applicant Occupation & Experience
Current Residence Address Line 1	Text	Enter the street address of the applicant’s current residence if it differs from the mailing address.
Current Residence Address Line 2	Text	Enter the city, state, and ZIP code of the applicant’s current residence if it differs from the mailing address.
Date at Current Residence	Date	Enter the date (MM/DD/YYYY) when the applicant began residing at the current residence.
Applicant’s Occupation	Text	Provide the applicant’s current job title or occupation, and if self-employed, state the nature of the business.
Years in Current Occupation	Number	Enter the total number of years the applicant has worked in their current occupation.
Years with Previous Employer	Number	Enter the total number of years the applicant was employed by their previous employer.
Applicant Personal Details
Applicant First Name	Text	Enter the applicant’s first (given) name.
Applicant Middle Name or Initial	Text	Enter the applicant’s middle name or initial.
Applicant Last Name	Text	Enter the applicant’s last name (surname).
Applicant Date of Birth	Date	Enter the applicant’s date of birth.
Applicant Social Security Number	Text	Enter the applicant’s Social Security number.
Applicant Marital Status	Text	Enter the applicant’s marital or civil union status if applicable.
Applicant Previous Address
Years at Previous Address	Text	Enter the number of years you resided at your previous address (complete only if less than three years).
Previous Residence Street Address	Text	Provide the street address of your previous residence.
Previous Residence City	Text	Enter the city of your previous residence.
Previous Residence State and ZIP Code	Text	Provide the state abbreviation and ZIP code for your previous residence.
Application Date
Application Date	Date	Enter the date the homeowner application is completed in MM/DD/YYYY format.
Apts & Households
Number of Household Residents	Text	Enter the total number of individuals residing in the household at this location.
Tax Code	Text	Enter the tax code assigned to this property or location for underwriting purposes.
Basic Type
Primary	CheckBox	Check this box if the property is used as the applicant’s primary residence.
Secondary	CheckBox	Check this box if the property is used as a secondary residence.
Seasonal	CheckBox	Check this box if the property is occupied only on a seasonal or recreational basis.
Farm	CheckBox	Check this box if the property is used for farming purposes.
Check the box (if applicable): Indicates the usage of the residence is other than those listed	CheckBox
Other Usage Type	Text	Provide the property’s usage type if it does not match any of the listed options (Primary, Seasonal, Secondary, Farm).
Other Residence Type	Text	Provide the property’s residence type if it does not match any of the listed options (Dwelling, Apartment, Condominium, Townhouse, Rowhouse, Co-op).
Billing Account Identifiers
Billing Account Number	Text	Enter the agency’s unique billing account number assigned to this policy.
Deposit Amount	Number	Enter the dollar amount of the initial deposit required for this policy.
Estimated Total Premium	Number	Enter the estimated total premium for this policy in U.S. dollars.
Billing Method Choice
Direct Bill - Policy	CheckBox	Select this box if the premium bill should be sent directly to the policyholder under the policy.
Direct Bill - Account	CheckBox	Select this box if the premium bill should be sent directly to the insured’s account.
Agency Bill	CheckBox	Select this box if the agency should issue the premium bill.
Carrier Information
Carrier	Text	Enter the full name of the insurance carrier providing the homeowner coverage.
NAIC Code	Text	Enter the NAIC (National Association of Insurance Commissioners) code assigned to the carrier.
Named Insured(s)	Text	Enter the full legal names of all individuals or entities to be insured under this policy.
Policy Number	Text	Enter the unique policy number assigned by the carrier for this homeowner insurance.
Plan	Text	Enter the carrier’s internal plan designation or program code for this policy.
Facility Code	Text	Enter the facility code used by the carrier to classify the policy’s underwriting tier.
Effective Date	Date	Enter the date on which this insurance policy becomes effective (MM/DD/YYYY).
Expiration Date	Date	Enter the date on which this insurance policy expires or ends (MM/DD/YYYY).
Co-Applicant Address
Same as Applicant	CheckBox	Check this box if the co-applicant’s address is the same as the applicant’s address.
Co-Applicant Address Line 1	Text	Enter the co-applicant’s primary street address (house number and street name). Fill only if the 'Check if same as Applicant' is 'No'.
Co-Applicant Address Line 2	Text	Enter the co-applicant’s secondary address information (apartment, suite, unit, etc.), if applicable. Fill only if the 'Check if same as Applicant' is 'No'.
Co-Applicant City	Text	Enter the city for the co-applicant’s address. Fill only if the 'Check if same as Applicant' is 'No'.
Co-Applicant State	Text	Enter the two-letter state abbreviation for the co-applicant’s address. Fill only if the 'Check if same as Applicant' is 'No'.
Co-Applicant ZIP Code	Text	Enter the postal ZIP code for the co-applicant’s address. Fill only if the 'Check if same as Applicant' is 'No'.
Co-Applicant Contact
Co-Applicant Primary Phone - Home	CheckBox	Check this box if the co-applicant’s primary phone number is a home phone.
Co-Applicant Primary Phone - Business	CheckBox	Check this box if the co-applicant’s primary phone number is a business phone.
Co-Applicant Primary Phone - Cell	CheckBox	Check this box if the co-applicant’s primary phone number is a cell phone.
Primary Phone Number	Text	Enter the co-applicant’s primary phone number (including area code) for contact purposes.
Co-Applicant Secondary Phone - Home	CheckBox	Check this box if the co-applicant’s secondary phone number is a home phone.
Co-Applicant Secondary Phone - Business	CheckBox	Check this box if the co-applicant’s secondary phone number is a business phone.
Co-Applicant Secondary Phone - Cell	CheckBox	Check this box if the co-applicant’s secondary phone number is a cell phone.
Secondary Phone Number	Text	Enter the co-applicant’s secondary phone number (including area code) for additional contact.
Primary E-Mail Address	Text	Enter the co-applicant’s primary e-mail address for correspondence.
Secondary E-Mail Address	Text	Enter the co-applicant’s secondary e-mail address for additional correspondence.
Co-Applicant Employment
Co-Applicant’s Years with Current Employer	Number	Enter the number of years the co-applicant has been employed by their current employer.
Co-Applicant’s Employer Name	Text	Enter the full legal name of the co-applicant’s current employer.
Co-Applicant’s Employer Street Address	Text	Enter the street address of the co-applicant’s current employer.
Co-Applicant’s Employer City/State/ZIP	Text	Enter the city, state, and ZIP code for the co-applicant’s current employer.
Co-Applicant’s Occupation	Text	Enter the co-applicant’s current occupation or the nature of business if self-employed.
Co-Applicant’s Years in Current Occupation	Number	Enter the number of years the co-applicant has worked in their current occupation.
Co-Applicant’s Years with Previous Employer	Number	Enter the number of years the co-applicant was employed by their most recent previous employer.
Co-Applicant Occupation & Experience
Co-Applicant Occupation	Text	Enter the co-applicant’s current occupation or job title (state the nature of business if self-employed).
Co-Applicant Years in Current Occupation	Text	Enter the number of years the co-applicant has been in their current occupation.
Co-Applicant Years with Previous Employer	Text	Enter the number of years the co-applicant worked for their most recent previous employer.
Co-Applicant Personal Details
Co-Applicant First Name	Text	Enter the first given name of the co-applicant.
Co-Applicant Middle Name	Text	Enter the middle name of the co-applicant.
Co-Applicant Last Name	Text	Enter the surname (last name) of the co-applicant.
Co-Applicant Date of Birth	Date	Enter the co-applicant’s date of birth in MM/DD/YYYY format.
Co-Applicant Social Security Number	Text	Provide the co-applicant’s Social Security number.
Co-Applicant Marital Status/Civil Union	Text	Enter the co-applicant’s marital status or civil union, if applicable.
Construction Style
Masonry Construction Percentage	Number	Enter the percentage of the dwelling that is masonry construction style.
Aluminum Siding	CheckBox	Check this box if the dwelling’s exterior siding is aluminum.
Construction Type
Masonry Veneer	CheckBox	Check this box if the dwelling’s construction type is masonry veneer.
Masonry Veneer Percentage	Number	Enter the percentage of the dwelling’s exterior walls constructed with masonry veneer.
Frame	CheckBox	Check this box if the dwelling’s construction type is frame.
Frame Percentage	Number	Enter the percentage of the dwelling’s construction that is wood frame.
Masonry	CheckBox	Check this box if the dwelling’s construction type is masonry.
Masonry Percentage	Number	Enter the percentage of the dwelling’s construction that is solid masonry.
Other Construction Type	CheckBox	Check this box if the dwelling’s construction type is not listed above and specify the type in the adjacent field.
Other Construction Type	Text	If the construction type is not listed above, specify the other construction type and its percentage of total exterior walls.
Coverages Metadata
Location Number	Number	Enter the numeric identifier of the property location to which this coverage schedule applies.
HO Form Number	Text	Enter the code of the ACORD homeowners form (for example, HO-3, HO-5, HO-8) used for this location.
Base Deductible Amount	Number	Enter the base deductible in dollars that must be met before coverage applies.
Base Deductible Percent	Number	Enter the base deductible as a percentage of the insured limit.
Named Storm/Hurricane Deductible Amount	Number	Enter the dollar amount of the deductible that applies specifically to named storm or hurricane losses.
Named Storm/Hurricane Deductible Percent	Number	Enter the deductible for named storm or hurricane losses as a percentage of the coverage limit.
Annual Hurricane Deductible Amount	Number	Enter the annual hurricane deductible amount in dollars that applies to hurricane losses over the policy period.
Date Heating System Last Serviced
Date Heating System Last Serviced	Date	Enter the date the property’s heating system was last serviced in MM/DD/YYYY format.
Deductibles and Theft Options
Personal Liability (Each Occurrence) Base Deductible Amount	Number	Enter the dollar amount of the base deductible for Personal Liability (Each Occurrence).
Personal Liability (Each Occurrence) Base Deductible Percent	Number	Enter the percentage of the base deductible for Personal Liability (Each Occurrence).
Personal Liability (Each Occurrence) Base Deductible Type	Text	Specify the type of the base deductible for Personal Liability (Each Occurrence).
Medical Payments (Per Person) Wind/Hail Deductible Amount	Number	Enter the dollar amount of the Wind/Hail deductible for Medical Payments (Per Person).
Medical Payments (Per Person) Wind/Hail Deductible Percent	Number	Enter the percentage of the Wind/Hail deductible for Medical Payments (Per Person).
Medical Payments (Per Person) Wind/Hail Deductible Type	Text	Specify the type of the Wind/Hail deductible for Medical Payments (Per Person).
Theft Deductible Amount	Number	Enter the dollar amount of the deductible for theft coverage.
Theft Deductible Percent	Number	Enter the percentage of the deductible for theft coverage.
Theft Deductible Type	Text	Specify the type of the deductible for theft coverage.
HO Form # Deductible Code	Text	Enter the code identifying the deductible applied to the specified HO form number.
HO Form # Deductible Amount	Number	Enter the dollar amount of the deductible applied to the specified HO form number.
HO Form # Deductible Percent	Number	Enter the percentage of the deductible applied to the specified HO form number.
Personal Liability (Each Occurrence) Named Hurricane Deductible Amount	Number	Enter the dollar amount of the Named Hurricane deductible for Personal Liability (Each Occurrence).
Personal Liability (Each Occurrence) Named Hurricane Deductible Percent	Number	Enter the percentage of the Named Hurricane deductible for Personal Liability (Each Occurrence).
Personal Liability (Each Occurrence) Named Hurricane Deductible Type	Text	Specify the type of the Named Hurricane deductible for Personal Liability (Each Occurrence).
Medical Payments (Per Person) Annual Hurricane Deductible Amount	Number	Enter the dollar amount of the Annual Hurricane deductible for Medical Payments (Per Person).
Medical Payments (Per Person) Annual Hurricane Deductible Percent	Number	Enter the percentage of the Annual Hurricane deductible for Medical Payments (Per Person).
Medical Payments (Per Person) Annual Hurricane Deductible Type	Text	Specify the type of the Annual Hurricane deductible for Medical Payments (Per Person).
Enter text: The coverage associated with the deductible you are entering	Text
Theft Option Deductible Amount	Number	Enter the dollar amount of the additional deductible option for theft coverage.
Theft Option Deductible Percent	Number	Enter the percentage of the additional deductible option for theft coverage.
Theft Option Deductible Type	Text	Specify the type of the additional deductible option for theft coverage.
Distance to Tidal Water
Distance to Tidal Water	Number	Enter the distance from the property to the nearest tidal water, using the selected unit of measure (miles or feet).
Distance to Tidal Water – Miles	CheckBox	Check this box if the distance to tidal water is reported in miles.
Distance to Tidal Water – Feet	CheckBox	Check this box if the distance to tidal water is reported in feet.
Door Lock
Direct Temperature	CheckBox	Check this box if you have a direct temperature protection device.
Direct Burglar	CheckBox	Check this box if you have a direct burglar alarm system.
Local Smoke	CheckBox	Check this box if you have a locally monitored smoke alarm.
Dwelling Coverage Row
Dwelling Coverage Limit	Number	Enter the total dollar amount of insurance coverage selected for the dwelling at this location.
Dwelling Coverage Premium	Number	Enter the dollar premium amount charged for the dwelling coverage at this location.
Dwelling Location
In city limits	CheckBox	Check this box if the dwelling is located within municipal city limits.
In fire district	CheckBox	Check this box if the dwelling is located within a recognized fire protection district.
In protected suburb	CheckBox	Check this box if the dwelling is located in a protected suburban area with fire services outside city limits.
Open country	CheckBox	Check this box if the dwelling is located in open country outside city limits and fire protection areas.
Dwelling Location Number	Text	Enter the sequential numeric identifier for this dwelling location (for example, 1 for the first scheduled location).
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is class rating	CheckBox
Check the box (if applicable): Indicates the method of rating used for an HO-4 or HO-6 policy is specific rating	CheckBox
Check the box (if applicable): Indicates the foundation of the structure is open	CheckBox
Check the box (if applicable): Indicates the foundation of the structure is closed	CheckBox
Check the box (if applicable): Indicates there is no foundation on the structure	CheckBox
Dwelling Use
EIFS on Cinder Block Percentage	Number	Enter the percentage of the dwelling’s exterior covered by the exterior insulated finish system on cinder block surfaces.
EIFS (on studs)	CheckBox	Check this box if the dwelling’s siding is EIFS (Exterior Insulation and Finish System) installed on studs.
EIFS on Studs Percentage	Number	Enter the percentage of the dwelling’s exterior covered by the exterior insulated finish system on stud-framed surfaces.
Primary	CheckBox	Check this box if the dwelling is used as the primary residence.
Other Siding Material	Text	Specify any additional siding material not listed above for the dwelling’s exterior.
Other Siding Material Percentage	Number	Enter the percentage of the dwelling’s exterior covered by the specified other siding material.
Co-op	CheckBox	Check this box if the residence type is a co-op.
Electrical System
Copper	CheckBox	Check this box if the dwelling’s electrical wiring is copper.
Aluminum	CheckBox	Check this box if the dwelling’s electrical wiring is aluminum.
Knob & Tube	CheckBox	Check this box if the dwelling’s electrical wiring is knob and tube.
Last Inspected Date	Date	Enter the date when the home’s electrical wiring was last inspected (e.g., MM/DD/YYYY).
Circuit Breakers	CheckBox	Check this box if the dwelling’s electrical system uses circuit breakers.
Fuses	CheckBox	Check this box if the dwelling’s electrical system uses fuses.
Number of Amps	Text	Specify the total amperage capacity of the home’s electrical system in amps.
Exterior Paint / Wind Class
Renovations: Wiring (Partial)	CheckBox	Check this box if the property's wiring has been partially renovated.
Renovations: Wiring (Complete)	CheckBox	Check this box if the property's wiring renovation is fully complete.
Plumbing Renovation Year	Text	Enter the year when plumbing renovations were completed.
Renovations: Plumbing (Partial)	CheckBox	Check this box if the property's plumbing has been partially renovated.
Renovations: Plumbing (Complete)	CheckBox	Check this box if the property's plumbing renovation is fully complete.
Heating Renovation Year	Text	Enter the year when heating system renovations were completed.
Renovations: Heating (Partial)	CheckBox	Check this box if the property's heating system has been partially renovated.
Renovations: Heating (Complete)	CheckBox	Check this box if the property's heating system renovation is fully complete.
Roofing Renovation Year	Text	Enter the year when roofing renovations were completed.
Exterior Paint Renovation Year	Text	Enter the year when exterior paint renovations were completed.
Wind Class: Resistive	CheckBox	Check this box if the property has a resistive wind classification.
Wind Class: Semi-Resistive	CheckBox	Check this box if the property has a semi-resistive wind classification.
Fire District
Sprinkler Full	CheckBox	Check this box if the property has a full sprinkler system.
Protection Class	Number	Enter the ISO fire protection class rating assigned by the local fire department for the insured property’s location.
Fire Extinguisher Availability	Text	Enter Yes or No to indicate whether a fire extinguisher is readily available on the premises.
Territory Code	Text	Enter the underwriting territory code corresponding to the insured property’s geographic location.
Fire District Name	Text	Enter the full name of the local fire district serving the insured property.
Fire District Code	Text	Enter the code used to identify the local fire district for underwriting and rating purposes.
Secondary Heat None	CheckBox	Check this box if the property has no secondary heating system.
Fire Station Attributes
Primary Heating System	Text	Enter the type of the primary heating system for the residence (for example, forced air, radiant, heat pump, or enter ‘None’ if no primary heating system is present).
Primary Heat – None	CheckBox	Check this box if the property does not have a primary heating system.
Secondary Heating System	Text	Enter the type of the secondary or backup heating system for the residence (for example, wood stove, fireplace insert, portable heater, or enter ‘None’ if no secondary heating system is present).
Forms and Endorsements Row 1
Row 1 Location Number	Text	Enter the location number for the form or endorsement on row 1.
Row 1 Vehicle Number	Text	Enter the vehicle number associated with the form or endorsement on row 1.
Row 1 Boat Number	Text	Enter the boat number associated with the form or endorsement on row 1.
Row 1 Item Number	Text	Enter the item number for the form or endorsement on row 1.
Row 1 Form Number	Text	Enter the form number (e.g., ACORD or insurer form code) for the endorsement on row 1.
Row 1 Form Name	Text	Enter the name or title of the form or endorsement on row 1.
Row 1 Edition Date	Date	Enter the edition date (month and year) of the form or endorsement on row 1.
Row 1 Copyright Owner Code	Text	Enter the code identifying the copyright owner of the form or endorsement on row 1.
Fuel Storage Tank Location
Check the box (if applicable): Indicates that other rating credits may apply to the location	CheckBox
Fuel Storage Tank Location	Text	Enter the specific location of the fuel storage tank on the premises (for example: indoors above ground on a masonry floor, indoors above ground without masonry floor, outdoors above ground, or outdoors below ground).
Check the box (if applicable): Indicates there is no swimming pool on the premises	CheckBox
Check the box (if applicable): Indicates the swimming pool is above ground	CheckBox
Furnace Type
Number of Chimneys	Text	Enter the total number of chimneys on the property (enter 0 if none).
Number of Hearths	Text	Enter the total number of hearths in fireplaces on the property (enter 0 if none).
Number of Pre-Fabricated Fireplaces	Text	Enter the number of pre-fabricated fireplaces on the property (enter 0 if none).
Number of Wood Stove Inserts	Text	Enter the number of wood stove inserts installed in fireplaces on the property (enter 0 if none).
Check the box (if applicable): Indicates that a non-smoking rating credit may apply to the location	CheckBox
Check the box (if applicable): Indicates that a manned security rating credit may apply to the location	CheckBox
Check the box (if applicable): Indicates that a lightning protection rating credit may apply to the location	CheckBox
Check the box (if applicable): Indicates that an off premises theft exclusion rating credit may apply to the location	CheckBox
Check the box (if applicable): Indicates that other rating credits may apply to the location	CheckBox
Off-Premise Theft Exclusion Credits	Text	Enter the number of rating credits applied for the off-premise theft exclusion.
General
Agency Address Line 1	Text
Agency Address Line 2	Text
Dwelling	CheckBox	Check this box if the residence type is a dwelling.
Apartment	CheckBox	Check this box if the residence type is an apartment.
Condominium	CheckBox	Check this box if the residence type is a condominium.
Townhouse	CheckBox	Check this box if the residence type is a townhouse.
Rowhouse	CheckBox	Check this box if the residence type is a rowhouse.
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage)	Text
Enter number: The producer assigned number of the location	Text
Enter number: The number of premises covered by the additional premises liability extension. This is used when you don't have the full detail about the individual locations	Text
Enter amount: The premium associated with additional premises liability extension	Text
Enter number: The producer assigned location number for the premises covered by additional premises liability extension	Text
Enter code: The liability territory for the location specified	Text
Enter amount: The premium associated with additional premises liability extension	Text
Enter number: The producer assigned location number for the premises covered by additional premises liability extension	Text
Enter code: The liability territory for the location specified	Text
Enter amount: The premium associated with additional premises liability extension	Text
Enter number: The number of premises covered by the additional residence rented to others. This is used when you don't have the full detail about the individual locations	Text
Enter Y for a Yes response. Input N for No response. Indicates if medical payments coverage is included	Text
Enter amount: The premium for additional residence rented to others coverage	Text
Enter number: The producer assigned location number for the premises covered by additional residence rented to others	Text
Enter Y for a Yes response. Input N for No response. Indicates if medical payments coverage is included	Text
Enter number: The number of families of the additional residence rented to others	Text
Enter code: The liability territory for the location specified	Text
Enter amount: The premium for additional residence rented to others coverage	Text
Enter number: The producer assigned location number for the premises covered by additional residence rented to others	Text
Enter Y for a Yes response. Input N for No response. Indicates if medical payments coverage is included	Text
Enter number: The number of families of the additional residence rented to others	Text
Enter code: The liability territory for the location specified	Text
Enter amount: The premium for additional residence rented to others coverage	Text
Check the box (if applicable): Indicates the builders risk theft of building materials coverage is included	CheckBox
Enter limit: The limit for builders risk theft of building materials coverage	Text
Enter amount: The premium for builders risk theft of building materials coverage	Text
Check the box (if applicable): Indicates the builders risk collapse due to hydro-static pressure coverage is included	CheckBox
Enter limit: The limit for builders risk collapse due to hydro-static pressure	Text
Enter amount: The premium for builders risk collapse due to hydro-static pressure	Text
Enter limit: The aggregate limit for building ordinance or law coverage	Text
Enter limit: The increased limit for building ordinance or law coverage	Text
Check the box (if applicable): Indicates the building ordinance or law coverage is included	CheckBox
Enter percentage: The rebuild percentage for building ordinance or law coverage	Text
Enter amount: The premium for building ordinance or law coverage	Text
Check the box (if applicable): Indicates the business property at home coverage is included	CheckBox
Enter limit: The limit for business property at home coverage	Text
Enter amount: The premium for business property at home coverage	Text
Check the box (if applicable): Indicates the business property away from home coverage is included	CheckBox
Enter limit: The limit for business property away from home coverage	Text
Enter amount: The premium for business property away from home coverage	Text
Check the box (if applicable): Indicates the debris removal coverage is included	CheckBox
Enter limit: The limit for debris removal coverage	Text
Enter amount: The premium for debris removal coverage	Text
Enter percentage: The percentage deductible for earthquake coverage if the deductible is expressed as a percentage	Text
Enter deductible: The deductible amount for earthquake coverage if the deductible is expressed in dollars	Text
Enter code: The earthquake zone (territory) associated with the coverage	Text
Enter text: The type of earthquake retrofit for the residence	Text
Enter percentage: The percentage of construction that is masonry veneer	Text
Enter amount: The premium for earthquake coverage	Text
Enter limit: The limit amount for employers liability coverage	Text
Enter number: The number of employees associated with employers liability coverage	Text
Enter amount: The premium for employers liability coverage	Text
Check the box (if applicable): Indicates the equipment breakdown coverage is included. As used here, not applicable in North Carolina	CheckBox
Enter deductible: The deductible associated with equipment breakdown coverage	Text
Enter limit: The limit associated with equipment breakdown coverage	Text
Enter amount: The premium for equipment breakdown coverage	Text
Check the box (if applicable): Indicates the fire department service charge coverage is included	CheckBox
Enter amount: The premium for fire department surcharge coverage	Text
Enter limit: The building limit for flood coverage	Text
Enter limit: The contents limit for flood coverage	Text
Enter amount: The premium for flood coverage	Text
Check the box (if applicable): Indicates that liability is excluded from fungus and mold coverage	CheckBox
Check the box (if applicable): Indicates that property damage is excluded from fungus and mold coverage	CheckBox
Enter limit: The property limit for fungus and mold coverage	Text
Enter limit: The liability limit for fungus and mold coverage	Text
Enter amount: The premium for fungus and mold coverage	Text
Check the box (if applicable): Indicates the golf cart liability coverage is included	CheckBox
Enter number: The number of golf carts to be covered	Text
Enter text: The description of the golf carts	Text
Enter amount: The premium for golf cart liability coverage	Text
Enter limit: The limit for golf cart physical damage coverage	Text
Enter amount: The premium for golf cart physical damage coverage	Text
Check the box (if applicable): Indicates identity fraud expense coverage is included	CheckBox
Enter limit: The limit for identity fraud expense coverage	Text
Enter amount: The premium for identity fraud expense coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates if medical payments is included in the incidental farming personal liability coverage	Text
Enter amount: The premium for incidental farming coverage	Text
Enter limit: The total limit amount for increased coverage c special liability limit - electronic apparatus in and out of vehicle	Text
Enter limit: The increased limit amount for increased coverage c special liability limit - electronic apparatus in and out of vehicle	Text
Enter amount: The premium for increased coverage c special liability limit - electronic apparatus in and out of vehicle	Text
Enter limit: The total limit amount for increased coverage c special liability limit - electronic apparatus in vehicle	Text
Enter limit: The increased limit amount for increased coverage c special liability limit - electronic apparatus in vehicle	Text
Enter amount: The premium for increased coverage c special liability limit - electronic apparatus in vehicle	Text
Enter limit: The total limit amount for increased coverage c special liability limit - guns	Text
Enter limit: The increased limit amount for increased coverage c special liability limit - guns	Text
Enter amount: The premium for increased coverage c special liability limit - guns	Text
Enter limit: The total limit amount for increased coverage c special liability limit - money	Text
Enter limit: The increased limit amount for increased coverage c special liability limit - money	Text
Enter amount: The premium for increased coverage c special liability limit - money	Text
Enter limit: The total limit amount for increased coverage c special liability limit - securities	Text
Enter limit: The increased limit amount for increased coverage c special liability limit - securities	Text
Enter amount: The premium for increased coverage c special liability limit - securities	Text
Enter limit: The total limit amount for increased coverage c special liability limit - silverware	Text
Enter limit: The increased limit amount for increased coverage c special liability limit -silverware	Text
Enter amount: The premium for increased coverage c special liability limit -silverware	Text
Enter percentage: The increase percentage for inflation guard coverage	Text
Enter amount: The premium for inflation guard coverage	Text
Enter limit: The limit amount for loss assessment coverage	Text
Enter amount: The premium for loss assessment coverage	Text
Enter limit: The limit for mine subsidence coverage	Text
Enter code: The type of construction material	Text
Enter text: The description of the property	Text
Enter amount: The premium for mine subsidence coverage	Text
Check the box (if applicable): Indicates that increased contents is required for office, professional private school, studio - residence premises coverage	CheckBox
Enter limit: The increased contents limit for office, professional private school, studio - residence premises coverage	Text
Check the box (if applicable): Indicates that increased contents is not required for office, professional private school, studio - residence premises coverage	CheckBox
Enter limit: The other structures limit for office, professional private school, studio - residence premises coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates if medical payments is included in the office, professional private school, studio - residence premises coverage	Text
Enter code: The territory for office, professional private school, studio - residence premises coverage	Text
Enter code: The type of structure for office, professional private school, studio - residence premises coverage	Text
Enter text: The description of the business or structure for office, professional private school, studio - residence premises coverage	Text
Enter amount: The premium for office, professional private school, studio - residence premises coverage	Text
Enter limit: The limit for other structures - individual structure coverage	Text
Enter text: The description of the individual structure for other structures - individual structure coverage	Text
Enter amount: The premium for other structures - individual structure coverage	Text
Check the box (if applicable): Indicates that plants, shrubs and trees coverage is included	CheckBox
Enter limit: The limit for plants, shrubs and trees coverage	Text
Enter amount: The premium for plants, shrubs and trees coverage	Text
Check the box (if applicable): Indicates that refrigerated food products coverage is included	CheckBox
Enter amount: The limit for refrigerated food products coverage	Text
Enter amount: The premium for refrigerated food products coverage	Text
Check the box (if applicable): Indicates sink hole collapse coverage is included	CheckBox
Enter amount: The premium for sink hole collapse	Text
Check the box (if applicable): Indicates unit owners additions and alterations special coverage is included	CheckBox
Enter limit: The limit for unit owners additions and alterations special coverage	Text
Enter amount: The premium for unit owners additions and alterations special coverage	Text
Enter limit: The aggregate limit for unscheduled jewelry, watches and furs coverage	Text
Enter limit: The increased limit for unscheduled jewelry, watches and furs coverage	Text
Enter amount: The premium for unscheduled jewelry, watches and furs coverage	Text
Check the box (if applicable): Indicates water backup of sewers and drains coverage is included	CheckBox
Enter limit: The limit for water backup of sewers and drains coverage	Text
Enter amount: The premium for water backup of sewers and drains coverage	Text
Enter limit: The limit for watercraft liability coverage if you are not using a Watercraft application	Text
Enter amount: The premium for watercraft liability coverage	Text
Enter limit: The limit for watercraft physical damage coverage if you are not using a Watercraft application	Text
Enter amount: The premium for watercraft physical damage coverage	Text
Check the box (if applicable): Indicates that windstorm exclusion applies. As used here, this is not applicable in Arkansas	CheckBox
Enter amount: The premium for windstorm exclusion	Text
Enter number: The number of employees associated with workers compensation full time In Servant coverage	Text
Enter amount: The premium for workers compensation full time In Servant coverage	Text
Enter code: The code associated with the type of coverage being requested	Text
Enter text: The description of the coverage	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter amount: The first limit associated with the coverage	Text
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The second limit associated with the coverage	Text
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The deductible associated with the coverage	Text
Enter code: The type of deductible (e.g. Flat, Percent, etc.)	Text
Enter code: The rating territory for the coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates a "Yes" or "No" option for the coverage, if applicable	Text
Enter amount: The premium for the coverage	Text
Enter code: The code associated with the type of coverage being requested	Text
Enter text: The description of the coverage	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter amount: The first limit associated with the coverage	Text
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The second limit associated with the coverage	Text
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The deductible associated with the coverage	Text
Enter code: The type of deductible (e.g. Flat, Percent, etc.)	Text
Enter code: The rating territory for the coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates a "Yes" or "No" option for the coverage, if applicable	Text
Enter amount: The premium for the coverage	Text
Enter code: The code associated with the type of coverage being requested	Text
Enter text: The description of the coverage	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter amount: The first limit associated with the coverage	Text
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The second limit associated with the coverage	Text
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The deductible associated with the coverage	Text
Enter code: The type of deductible (e.g. Flat, Percent, etc.)	Text
Enter code: The rating territory for the coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates a "Yes" or "No" option for the coverage, if applicable	Text
Enter amount: The premium for the coverage	Text
Enter code: The code associated with the type of coverage being requested	Text
Enter text: The description of the coverage	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter text: The description of options applicable to the coverage (e.g. Included, Excluded, Rejected, etc.)	Text
Enter amount: The first limit associated with the coverage	Text
Enter code: The code identifying what the first limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The second limit associated with the coverage	Text
Enter code: The code identifying what the second limit applies to (e.g. Per Person, Per Occurrence, etc.)	Text
Enter amount: The deductible associated with the coverage	Text
Enter code: The type of deductible (e.g. Flat, Percent, etc.)	Text
Enter code: The rating territory for the coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates a "Yes" or "No" option for the coverage, if applicable	Text
Enter amount: The premium for the coverage	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any other insurance with this company	Text
Enter code: The line of business of the other policy	Text
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols	Text
Enter code: The line of business of the other policy	Text
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any coverage declined, cancelled or non-renewed during the mandated number of years (not applicable in Missouri)?". As used here, this is not applicable for applications for auto insurance. Missouri applicant: Do not answer this question	Text
Enter text: An explanation of any coverage declined within the last 3 years	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past specified number of years	Text
Enter text: An explanation of any foreclosures or bankruptcies	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Has applicant had a judgment or lien during the past specified number of years	Text
Enter text: An explanation of any judgment or liens within the last 5 years	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any other residence, not listed on any application, owned, occupied or rented	Text
Enter text: An explanation of any other residence owned or occupied	Text
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage)	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Has insurance been transferred within agency	Text
Enter text: An explanation of insurance transferred within the agency	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes, ATVs, etc.), not shown on this policy	Text
Enter year: The model year of the vehicle	Text
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy)	Text
Enter text: The manufacturer's model name for the vehicle	Text
Enter code: The body type of the vehicle	Text
Enter year: The model year of the vehicle	Text
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy)	Text
Enter text: The manufacturer's model name for the vehicle	Text
Enter code: The body type of the vehicle	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "During the last five (5) years [ten (10) years in Rhode Island], has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related crime in connection with this or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)	Text
Enter text: An explanation of applicant convicted of fraud, bribery or arson	Text
Enter number: The producer assigned number of the location	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any business conducted on premises	Text
Check the box (if applicable): Indicates farming is done on the premises	CheckBox
Check the box (if applicable): Indicates an individual telecommutes from the premises	CheckBox
Check the box (if applicable): Indicates a day care is run from the premises	CheckBox
Enter number: The number of children attending the day care	Text
Check the box (if applicable): Indicates a home office or business is on the premises	CheckBox
Check the box (if applicable): Indicates business is conducted on the premises other than those listed	CheckBox
Enter text: The description of the business conducted on the premises	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any residence employees	Text
Enter number: The number of full time residence employees	Text
Enter text: The description of the type of work performed by full time residence employees	Text
Enter number: The number of part time residence employees	Text
Enter text: The description of the type of work performed by part time residence employees	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any flooding, brush, forest fire or landslide hazard	Text
Enter text: An explanation of any forest fire landslide or flooding	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Are there any animals or exotic pets on the premises	Text
Enter code: The type of animal (e.g., cat, dog, horse, etc.)	Text
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)	Text
Enter Y for a Yes response. Input N for No response. Indicates if any animal currently in the household has ever been involved in a bite incident	Text
Enter code: The type of animal (e.g., cat, dog, horse, etc.)	Text
Enter code: The breed of the animal (e.g., Doberman, German Shepherd, etc.)	Text
Enter Y for a Yes response. Input N for No response. Indicates if any animal currently in the household has ever been involved in a bite incident	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is property situated on more than 1 acre	Text
Enter number: The total area of the land in acres	Text
Enter text: The description of what the land is used for	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any uncorrected fire or building code violations	Text
Enter text: An explanation of or any uncorrected fire code violations	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is the dwelling/mobile home for sale	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is the property within 300 feet of a commercial or non-residential property	Text
Enter text: An explanation if property is within 300 ft. of a commercial property	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is there a trampoline on the premises	Text
Enter Y for a Yes response. Input N for No response. Indicates the trampoline on the premises has a safety net	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Was the structure originally built for other than a private residence and then converted	Text
Enter text: The description of the original occupancy of the building	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Any lead paint	Text
Enter text: An explanation of any lead paint on the premises	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "If a fuel tank is on premises, has other insurance been obtained for the tank	Text
Enter text: The insurer name on any other applicable insurance	Text
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)	Text
Enter limit: The other policy, coverage sub limit amount	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is the residence in a gated community	Text
Enter text: The name of the gated community	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "If building is under construction, is the applicant the general contractor	Text
Enter date: The date construction began	Text
Enter date: The estimated completion date for this construction project	Text
Enter percentage: The percentage of construction taking place in the interior of the structure	Text
Enter percentage: The percentage of construction taking place in the exterior of the structure	Text
Enter number: The total area of the addition under construction in square feet	Text
Enter number: The total area of the additional level under construction in square feet	Text
Enter Y for a Yes response. Input N for No response. Indicates if there will be structural changes as part of the construction	Text
Check the box (if applicable): Indicates materials that are not attached to the structure are included	CheckBox
Check the box (if applicable): Indicates materials that are not attached to the structure are excluded	CheckBox
Enter Y for a Yes response. Input N for No response. Indicates if the structure will be occupied during construction and renovation	Text
Enter amount: The total cost of construction of the structure	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes	Text
Enter Y for a Yes response. Input N for No response. Indicates the response to the question, " Is the named insured the owner of the property?". As used here, if no, provide the name of the owner	Text
Enter text: The additional interest's full name. As used here, this is the name of the owner of the property	Text
Enter number: The producer assigned number of the location	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is there a manager on the premises?". As used here, if yes, provide the full name of the manager and the manager's phone number, including area code. A "No" response does not require an explanation	Text
Enter text: Provide the full name of the manger. A "No" response does not require an explanation	Text
Enter number: The phone number of the manager of the structure	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is there a security attendant?". As used here, explain a "No" response to the question	Text
Enter text: An explanation if no security attendant is provided on the premises. As used here, explain a "No" response to the question	Text
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question, "Is the building entrance locked?". As used here, explain a "No" response to the question	Text
Enter text: An explanation if building entrance is not locked. As used here, explain a "No" response to the question	Text
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage)	Text
Check the box (if applicable): Indicates the interest type is an additional insured	CheckBox
Check the box (if applicable): Indicates the additional interest type is a lien holder	CheckBox
Check the box (if applicable): Indicates the additional interest type is a loss payee	CheckBox
Check the box (if applicable): Indicates the additional interest type is a mortgagee	CheckBox
Check the box (if applicable): Indicates the additional interest type is a trustee	CheckBox
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form	CheckBox
Enter text: The description of the type of interest in the item	Text
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item	Text
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance	CheckBox
Check the box (if applicable): Indicates the bill should be sent to the additional interest	CheckBox
Enter text: The additional interest's full name	Text
Enter text: The additional interest's mailing address line one	Text
Enter text: The additional interest's mailing address line two	Text
Enter text: The additional interest's mailing address city name	Text
Enter code: The additional interest's mailing address state or province code	Text
Enter code: The additional interest's mailing address postal code	Text
Enter code: The additional interest's country code	Text
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured	Text
Enter number: The producer assigned number of the location which has an additional interest	Text
Enter number: The producer assigned number of the building which has an additional interest	Text
Enter number: The producer assigned number of the vehicle which has an additional interest	Text
Enter number: The producer assigned number of the boat which has an additional interest	Text
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.)	Text
Enter number: The producer assigned number of the scheduled item which has an additional interest	Text
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting	Text
Check the box (if applicable): Indicates the interest type is an additional insured	CheckBox
Check the box (if applicable): Indicates the additional interest type is a lien holder	CheckBox
Check the box (if applicable): Indicates the additional interest type is a loss payee	CheckBox
Check the box (if applicable): Indicates the additional interest type is a mortgagee	CheckBox
Check the box (if applicable): Indicates the additional interest type is a trustee	CheckBox
Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form	CheckBox
Enter text: The description of the type of interest in the item	Text
Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item	Text
Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance	CheckBox
Check the box (if applicable): Indicates the bill should be sent to the additional interest	CheckBox
Enter text: The additional interest's full name	Text
Enter text: The additional interest's mailing address line one	Text
Enter text: The additional interest's mailing address line two	Text
Enter text: The additional interest's mailing address city name	Text
Enter code: The additional interest's mailing address state or province code	Text
Enter code: The additional interest's mailing address postal code	Text
Enter code: The additional interest's country code	Text
Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured	Text
Enter number: The producer assigned number of the location which has an additional interest	Text
Enter number: The producer assigned number of the building which has an additional interest	Text
Enter number: The producer assigned number of the vehicle which has an additional interest	Text
Enter number: The producer assigned number of the boat which has an additional interest	Text
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs, Contractors Equipment, etc.)	Text
Enter number: The producer assigned number of the scheduled item which has an additional interest	Text
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting	Text
Check the box (if applicable): Indicates an earthquake application is attached	CheckBox
Check the box (if applicable): Indicates a flood exclusion notice is attached	CheckBox
Check the box (if applicable): Indicates a lead free paint certification is attached	CheckBox
Check the box (if applicable): Indicates a mobile home supplement is attached to the policy	CheckBox
Check the box (if applicable): Indicates an inland marine application is attached	CheckBox
Check the box (if applicable): Indicates a personal umbrella section is attached to the policy	CheckBox
Check the box (if applicable): Indicates a photograph is attached	CheckBox
Check the box (if applicable): Indicates a protection device certificate is attached	CheckBox
Check the box (if applicable): Indicates a replacement cost estimate is attached	CheckBox
Check the box (if applicable): Indicates a residence based business supplement is attached	CheckBox
Check the box (if applicable): Indicates a solid fuel supplement is attached	CheckBox
Check the box (if applicable): Indicates a state supplement form is attached (if applicable)	CheckBox
Check the box (if applicable): Indicates a watercraft application is attached	CheckBox
Check the box (if applicable): Indicates a windstorm loss mitigation form is attached	CheckBox
Check the box (if applicable): Indicates there is an attachment other than those listed	CheckBox
Enter text: The description of the attachment	Text
Check the box (if applicable): Indicates there is an attachment other than those listed	CheckBox
Enter text: The description of the attachment	Text
Enter text: The general remarks associated with this line of business. Use this section to provide any additional information required for underwriting or rating. As used here, ACORD 101, Additional Remarks Schedule, may be attached if more space is required	Text
Enter date: The date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy	Text
Enter time: The time of the binder effective date that the binder becomes effective	Text
Enter date: The date on which the terms and conditions of the policy will or have expired. Certain state laws limit the terms of a binder, so this date may not coincide with the policy expiration date	Text
Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date	CheckBox
Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date	CheckBox
Check the box (if applicable): Indicates the coverage has not been bound	CheckBox
Initial here: The named insured's initials. As used here, indicates the named insured has read and understands the credit reporting information	Text
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices (ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD 38 contains CA and MA state specific language	CheckBox
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage)	Text
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states	Text
Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form	Text
Enter identifier: The State License Number of the producer	Text
Sign here: Accommodates the signature of the applicant or named insured	Text
Enter date: The date the form was signed by the named insured	Text
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number	Text
Heating System
Check the box (if applicable): Indicates the structure is new construction (builders risk)	CheckBox
Check the box (if applicable): Indicates the structure is being renovated	CheckBox
Housekeeping Condition
Excellent	CheckBox	Check this box if the property's housekeeping condition is excellent.
Good	CheckBox	Check this box if the property's housekeeping condition is good.
Average	CheckBox	Check this box if the property's housekeeping condition is average.
Below Avg	CheckBox	Check this box if the property's housekeeping condition is below average.
Location Identifier
Location Number	Text	Enter the identifier number assigned to this location for rating and underwriting purposes.
Location Schedule Row 1
Row 1 Location Number	Text	Enter the unique identifier for the first property location on the schedule.
Row 1 Street	Text	Provide the street address of the first property location.
Row 1 City	Text	Enter the city where the first property location is situated.
Row 1 County	Text	Enter the county in which the first property location resides.
Row 1 State	Text	Provide the two-letter state abbreviation for the first property location.
Row 1 ZIP + 4	Text	Enter the five-digit ZIP code plus the four-digit extension for the first property location.
Enter number: The producer assigned number of the location	Text
Enter text: The first address line of the physical location	Text
Enter text: The city of the physical location	Text
Enter text: The county of the location	Text
Enter code: The state or province of the physical location	Text
Enter code: The postal code of the physical location	Text
Enter number: The producer assigned number of the location	Text
Enter text: The first address line of the physical location	Text
Enter text: The city of the physical location	Text
Enter text: The county of the location	Text
Enter code: The state or province of the physical location	Text
Enter code: The postal code of the physical location	Text
Loss History General
Loss History Lookback Period (Years)	Text	Enter the number of years during which any losses, whether or not paid by insurance, must be reported.
Any Losses in Lookback Period (Y/N)	Text	Select Yes if any losses, whether or not paid by insurance, occurred during the specified lookback period at this or any location; otherwise select No.
Applicant's Initials	Text	Provide the applicant’s initials to acknowledge review of the reported loss history.
In Dispute (Y/N)	Text	Select Yes if the reported loss is currently in dispute; otherwise select No. Fill only if the 'Any Losses in Lookback Period (Y/N)' is 'Yes'.
Loss History Row 1
Row 1 Loss Date	Date	Enter the date the loss occurred in MM/DD/YYYY format.
Row 1 Loss Type	Text	Specify the type or cause of the loss, such as fire, theft, or vandalism.
Row 1 Description of Loss	Text	Provide a brief description of the loss incident, including key details and circumstances.
Row 1 Catastrophe Number	Text	Enter the catastrophe event number associated with this loss, if applicable.
Row 1 Amount Paid	Number	Enter the total amount paid by the insurer for this loss in dollars.
Row 1 Entered By	Text	Enter the initials of the agent or company representative who recorded this loss information.
Row 1 In Dispute (Y/N)	Text	Indicate whether the claim is currently in dispute by entering Y for Yes or N for No.
Loss History Row 2
Row 2 Loss Date	Date	Enter the date of the second loss incident (MM/DD/YYYY). Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 Loss Type	Text	Enter the type or category of the second loss incident (e.g., Fire, Theft, Water Damage). Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 Loss Description	Text	Provide a brief description of what happened in the second loss incident. Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 Loss Category Number	Text	Enter the category number assigned to the second loss incident, if applicable. Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 Amount Paid	Number	Enter the total amount paid for the second loss incident in dollars. Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 Entered By	Text	Enter 'A' if the second loss entry was recorded by the agent or 'C' if recorded by the company. Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Row 2 In Dispute	Text	Enter 'Y' if the second loss is currently in dispute or 'N' if not. Fill only if the 'Any Losses (Y/N)' is 'Yes'.
Loss History Row 3
Row 3 Loss Date	Date	Enter the date of the third reported loss.
Row 3 Loss Type	Text	Enter the type of the third loss event (e.g., fire, theft, water damage).
Row 3 Loss Description	Text	Provide a description of the circumstances and details of the third loss.
Row 3 Category Number	Text	Enter the category number assigned to the third loss per the insurer’s classification.
Row 3 Amount Paid	Number	Enter the total dollar amount paid to resolve the third loss claim.
Row 3 Entered By	Text	Enter the initials of the agent or company representative who recorded the third loss entry.
Row 3 In Dispute	Text	Specify whether the third loss is in dispute by entering Y for Yes or N for No.
Loss History Row 4
Row 4 Loss Date	Date	Enter the date of the loss for Loss History row 4 in MM/DD/YYYY format.
Row 4 Loss Type	Text	Enter the type of loss (e.g., fire, theft, water damage) for Loss History row 4.
Row 4 Loss Description	Text	Provide a brief description of the loss event for Loss History row 4.
Row 4 Category Number	Text	Enter the category number associated with the loss for Loss History row 4.
Row 4 Amount Paid	Number	Enter the total amount paid by insurance or otherwise for the loss in Loss History row 4.
Row 4 Entered By	Text	Indicate who entered the information for Loss History row 4 by entering ‘A’ for Agent or ‘C’ for Company.
Loss of Use Coverage Row
Actual Loss Sustained	CheckBox	Check this box if you want Loss of Use coverage on an Actual Loss Sustained basis.
Loss of Use Premium	Number	Enter the annual premium amount for Loss of Use coverage.
Loss of Use Coverage Option	Text	Enter the coverage option for Loss of Use (for example, Included or Excluded).
Loss of Use Coverage Limit	Number	Enter the limit for Loss of Use coverage as a dollar amount or percentage based on the selected option.
Loss of Use Option Premium	Number	Enter the premium amount corresponding to the selected Loss of Use coverage option.
Mail Policy Recipient
Agent	CheckBox	Check this box to have the policy mailed to the agent.
Insured	CheckBox	Check this box to have the policy mailed to the insured.
Other	CheckBox	Check this box to have the policy mailed to another recipient.
Mail Policy Recipient Address	Text	Enter the full mailing address (street, city, state, ZIP) for the policy recipient selected under “Mail Policy To:”.
Medical Payments Coverage Row
Blanket Coverage Premium	Number	Enter the annual premium amount charged for the blanket coverage combining dwelling, other structures, personal property, and loss of use.
Personal Liability Each Occurrence Limit	Number	Enter the maximum liability limit per occurrence for personal liability coverage.
Medical Payments Each Person Limit	Number	Enter the maximum amount payable per person under medical payments coverage.
Medical Payments Each Person Premium	Number	Enter the annual premium charged for medical payments coverage per person.
Occupancy Type
Occupancy – Owner	Text	Enter Yes if the dwelling at this location is occupied by the owner; otherwise enter No.
Check the box (if applicable): Indicates the siding on the structure is stucco	CheckBox
Occupancy – Tenant	Text	Enter Yes if the dwelling at this location is occupied by a tenant; otherwise enter No.
Other Structures Coverage Row
Other Structures Coverage Limit	Number	Enter the dollar amount representing the maximum coverage limit for Other Structures on the property (e.g., detached garages, sheds, fences).
Other Structures Coverage Premium	Number	Enter the dollar premium charged for the selected Other Structures coverage limit.
Payer Specification
Insured	CheckBox	Check this box when the insured is paying the policy premium.
Mortgagee	CheckBox	Check this box when the mortgagee is paying the policy premium.
Other	CheckBox	Check this box when an entity other than the insured or mortgagee will pay the policy premium.
Payment Method Options
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those listed	CheckBox
Monthly Payment Plan Selection	Text	Enter 'X' to select the monthly payment plan option.
Cash	CheckBox	Check this box if you will pay the premium by cash.
Check	CheckBox	Check this box if you will pay the premium by check.
Credit Card	CheckBox	Check this box if you will pay the premium by credit card.
EFT	CheckBox	Check this box if you will pay the premium via electronic funds transfer (EFT).
Payroll Deduction	CheckBox	Check this box if you will pay the premium through payroll deduction.
Pre-Authorized Draft/Check (PAC)	CheckBox	Check this box if you will pay the premium by pre-authorized draft/check (PAC).
Check the box (if applicable): Indicates the invoice will be paid by a means other than those listed	CheckBox
PAC Payment Account Information	Text	Enter the bank routing and account details for pre-authorized draft/check (PAC) payments. Fill only if the 'Pre-Authorized Draft/Check (PAC)' is 'Yes'.
Payment Plan Frequency
Full Pay	CheckBox	Check this box if you will pay the premium in a single lump-sum payment.
Annual	CheckBox	Check this box if you will pay your premium once per year.
Semi-Annual	CheckBox	Check this box if you will split your premium into two payments per year.
Quarterly	CheckBox	Check this box if you will split your premium into four payments per year.
Bi-Monthly	CheckBox	Check this box if you will split your premium into six payments every two months.
Monthly	CheckBox	Check this box if you will split your premium into twelve monthly payments.
Personal Liability Coverage Row
Loss of Use Premium	Number	Enter the premium amount charged for the Loss of Use coverage (Actual Loss Sustained).
Blanket Coverage Limit	Number	Enter the blanket coverage limit that applies to dwelling, other structures, personal property, and loss of use combined.
Personal Liability Each Occurrence Premium	Number	Enter the premium amount charged for the Personal Liability (Each Occurrence) coverage.
Personal Property Coverage Row
Personal Property Coverage Limit	Number	Enter the dollar amount representing the limit of coverage for personal property.
Personal Property Coverage Premium	Number	Enter the dollar premium charged for personal property coverage.
Plumbing Condition and Known Leaks
Plumbing Condition - Excellent	CheckBox	Check this box if the plumbing condition of the property is excellent.
Plumbing Condition - Good	CheckBox	Check this box if the plumbing condition of the property is good.
Plumbing Condition - Average	CheckBox	Check this box if the plumbing condition of the property is average.
Plumbing Condition - Below Average	CheckBox	Check this box if the plumbing condition of the property is below average.
Any Known Leaks (Y/N)	Text	Enter 'Y' if there are any known leaks in the plumbing system or 'N' if there are none.
Premium Financing
Other Payor	Text	Enter the name of the payor responsible for premium payment if it is neither the insured nor the mortgagee.
Premium Financed	Text	Indicate whether the premium is financed by entering Y for Yes or N for No.
Finance Company	Text	Provide the name of the finance company arranging the premium financing. Fill only if the 'Premium Financed' is 'Yes'.
Prior Coverage
No Prior Coverage	CheckBox	Check this box if the applicant has had no prior insurance coverage.
Prior Carrier	Text	Enter the name of the prior insurance company that provided coverage.
Prior Policy Number	Text	Enter the policy number of the prior insurance policy.
Expiration Date	Date	Enter the expiration date of the prior policy in MM/DD/YYYY format.
Prior Carrier	Text	Enter the name of the prior insurance company that provided coverage.
Prior Policy Number	Text	Enter the policy number of the prior insurance policy.
Expiration Date	Date	Enter the expiration date of the prior policy in MM/DD/YYYY format.
Protection Device Type
System	Text	Enter the type of protection system installed at the residence (for example, central station or local alarm).
Check the box (if applicable): Indicates the structure is visible from the road	CheckBox
Check the box (if applicable): Indicates the structure is visible from another dwelling that is occupied during the day	CheckBox
Check the box (if applicable): Indicates the residence usually has an adult home during the day	CheckBox
Central Smoke	CheckBox	Check this box if the residence is equipped with a centrally monitored smoke detection device.
Central Temp	CheckBox	Check this box if the residence is equipped with a centrally monitored temperature detection device.
Central Burg	CheckBox	Check this box if the residence is equipped with a centrally monitored burglary detection device.
Direct System	CheckBox	Check this box if the property’s protection system is a direct connection without central station monitoring.
Purchase Price
Purchase Price	Number	Enter the total amount paid for the property in US dollars.
Renovations
Check the box (if applicable): Indicates there is no fuel storage tank on the premises	CheckBox
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground on a masonry floor	CheckBox
Check the box (if applicable): Indicates the fuel storage tank is located indoors, above ground not on a masonry floor	CheckBox
Check the box (if applicable): Indicates the fuel storage tank is outdoors and above ground	CheckBox
Check the box (if applicable): Indicates the fuel storage tank is outdoors and below ground	CheckBox
Check the box (if applicable): Indicates the fuel line is underground	CheckBox
Check the box (if applicable): Indicates the fuel line goes through the foundation	CheckBox
Partial Wiring Renovation	CheckBox	Check this box if renovations to the wiring are only partially completed.
Complete Plumbing Renovation	CheckBox	Check this box if renovations to the plumbing have been fully completed.
Wiring Renovation Year	Text	Enter the year the wiring renovation was completed.
Replacement Cost Options
Include Dwelling Replacement Cost – Full Value	CheckBox	Check this box if you want replacement cost coverage for the dwelling at full value.
Dwelling Replacement Cost Percentage Limit	Number	Enter the percentage limit that applies to the dwelling replacement cost full value coverage option.
Dwelling Replacement Cost Premium	Number	Enter the premium amount in dollars for the dwelling replacement cost full value coverage option.
Include Other Structures Replacement Cost – Dwelling	CheckBox	Check this box if you want replacement cost coverage for other structures based on dwelling cost.
Other Structures Replacement Cost Premium	Number	Enter the premium amount in dollars for the other structures replacement cost (dwelling) coverage option.
Include Personal Property Replacement Cost – Contents	CheckBox	Check this box if you want replacement cost coverage for personal property contents.
Personal Property Replacement Cost Premium	Number	Enter the premium amount in dollars for the personal property replacement cost contents coverage option.
Roof Condition
Excellent	CheckBox	Check this box if the roof condition is excellent.
Good	CheckBox	Check this box if the roof condition is good.
Average	CheckBox	Check this box if the roof condition is average.
Below Avg	CheckBox	Check this box if the roof condition is below average.
Roof Construction
Vinyl Siding / Plastic	CheckBox	Check this box if the dwelling’s exterior walls are covered with vinyl siding or plastic siding.
Vinyl Siding/Plastic Percentage	Number	Enter the percentage of the dwelling’s exterior siding composed of vinyl or plastic.
Cedar, Wood, Shingle	CheckBox	Check this box if the dwelling’s exterior walls are covered with cedar, wood, or shingle siding.
Cedar/Wood Shingle Siding Percentage	Number	Enter the percentage of the dwelling’s exterior siding composed of cedar, wood, or shingle.
EIFSCB (on cinder block)	CheckBox	Check this box if the dwelling’s exterior walls are covered with EIFSCB (exterior insulation and finish system) applied on cinder block.
Roof Material	Text	Specify the primary material used to construct the roof (for example, asphalt shingle, metal, or tile).
Rooms and Families
Number of Rooms	Text	Enter the total number of rooms in the dwelling.
Number of Apartments	Text	Enter the total number of distinct apartment units on the premises.
Number of Weeks Rented	Text	Indicate the total number of weeks the property was rented during the past 12 months.
Number of Families	Text	Enter the number of separate families occupying the dwelling.
Sprinkler
Sprinkler – Partial	CheckBox	Check this box if the property has a partial sprinkler system installed.
Sprinkler – Full	CheckBox	Check this box if the property has a full sprinkler system installed.
Enter number: The distance in feet from the nearest hydrant that supports the protection class used	Text
Swimming Pool
Check the box (if applicable): Indicates the structure is being reconstructed	CheckBox
Check the box (if applicable): Indicates the residence is occupied by the owner	CheckBox
Check the box (if applicable): Indicates the residence is occupied by tenants	CheckBox
Check the box (if applicable): Indicates the residence is unoccupied	CheckBox
Check the box (if applicable): Indicates the residence is vacant	CheckBox
Check the box (if applicable): Indicates the residence is occupied by other than those listed	CheckBox
Enter text: The description of the inhabitants of the residence	Text
Check the box (if applicable): Indicates the type of residence being insured is a dwelling	CheckBox
Swimming Pool Notes
Above Ground	CheckBox	Check this box if the property has an above ground swimming pool.
In Ground	CheckBox	Check this box if the property has an in ground swimming pool.
Approved Fence	CheckBox	Check this box if the swimming pool is enclosed by an approved fence.
Diving Board	CheckBox	Check this box if the swimming pool is equipped with a diving board.
Slide	CheckBox	Check this box if the swimming pool has a slide.
Number of Slides	Text	Enter the number of slides installed in the swimming pool.
Tax Code
Basement Area Inspected	Text	Enter ‘Y’ if the basement area has been inspected or ‘N’ if it has not.
Territory Codes
Distance to Fire Station (Miles)	Number	Enter the distance from the property to the nearest fire station in miles.
Number of Fire Divisions	Text	Enter the total number of fire divisions that serve the property.
Number of Fire Units per Division	Text	Enter the number of fire units available in each fire division serving the property.
Door Lock – Deadbolt	CheckBox	Check this box if the exterior door is secured by a deadbolt lock.
Door Lock – Spring Latch	CheckBox	Check this box if the exterior door is secured by a spring-latch lock.
Door Lock – Other	CheckBox	Check this box if the exterior door uses a lock type other than deadbolt or spring latch.
Door Lock – Spring Latch Indicator	Text	Enter 'Yes' or 'No' to indicate whether the main entry door is secured with a spring-latch lock.
Sprinkler – Partial	CheckBox	Check this box if only a portion of the premises is equipped with a sprinkler system.
Transaction Details
New	CheckBox	Check this box if this is a new policy transaction.
Renew	CheckBox	Check this box if this is a policy renewal transaction.
Policy Change	CheckBox	Check this box if this is a transaction to change an existing policy.
Other (specify)	CheckBox	Check this box if the transaction status is other than New, Renew, or Policy Change.
Policy Change Details	Text	Enter a brief description of the policy change transaction.
Policy Change Effective Date	Date	Enter the effective date of the policy change in MM/DD/YYYY format.
Policy Change Time	Time	Enter the time at which the policy change takes effect (HH:MM).
AM	CheckBox	Check this box if the policy change effective time is in the morning (AM).
PM	CheckBox	Check this box if the policy change effective time is in the afternoon or evening (PM).
Date Agent Last Inspected Property	Date	Enter the date when the agent last inspected the property in MM/DD/YYYY format.
Length of Relationship with Applicant	Text	Provide the length of time you have known the applicant (for example, in years or months).
Weeks Rented
Weeks Rented	Text	Enter the total number of weeks the dwelling is expected to be rented during the policy period.
Windstorm Protection
Wind Class – Resistive	CheckBox	Check if the property’s wind class is classified as Resistive.
Wind Class Rating	Text	Enter the windstorm protection class rating for the property (for example, Class I, II, III, or IV).
Storm Shutters – A	CheckBox	Check if storm shutters are installed at location A for windstorm protection.
Storm Shutters – B	CheckBox	Check if storm shutters are installed at location B for windstorm protection.
Hurricane Resistive Glass – A	CheckBox	Check if hurricane resistive glass is installed at location A for windstorm protection.
Hurricane Resistive Glass	Text	Provide information about any hurricane-resistive glass installed on the property, such as type and coverage extent.
Hurricane Resistive Glass – B	CheckBox	Check if hurricane resistive glass is installed at location B for windstorm protection.
Year Built and Areas
Year Built	Text	Enter the calendar year in which the dwelling was originally constructed.
Market Value	Number	Enter the current market value of the dwelling in U.S. dollars.
Replacement Cost	Number	Enter the estimated cost to replace the dwelling in U.S. dollars.
Total Living Area	Number	Enter the total square footage of all above-grade living space in the dwelling.
Basement Area	Number	Enter the total square footage of the basement area, finished or unfinished.
Garage Area	Number	Enter the total square footage of the garage space attached to the dwelling.
Breezeway Area	Number	Enter the total square footage of any breezeway connecting structures.
Year EIFS Installed
Year EIFS Installed	Text	Enter the year the exterior insulation and finish system (EIFS) was installed on the dwelling.

ACORD 80, Homeowner Application Instructions