AGRICULTURE PROPERTY SECTION SCHEDULED AND UNSCHEDULED FARM PERSONAL PROPERTY CARRIER
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1 AGENCY AGRICULTURE PROPERTY SECTION SCHEDULED AND UNSCHEDULED FARM PERSONAL PROPERTY CARRIER DATE (MM/DD/YYYY) NAIC CODE POLICY NUMBER NAMED INSURED(S) ACCOUNT NUMBER GENERAL INFORMATION 1. IS ANY PROPERTY KEPT ON A LOCATION(S) THAN AN INSURED LOCATION? (Y / N) IF YES, WHERE IS IT KEPT? 5. IS EQUIPMENT WELL MAINTAINED? (Y / N) (A) DURING FARMING SEASON? (B) DURING OFF SEASON? 2. WHAT IS MAXIMUM OF EQUIPMENT AT ANY ONE LOCATION? (A) DURING FARMING SEASON? (B) DURING OFF SEASON? 4. WHAT IS RADIUS OF OPERATIONS OF EQUIPMENT? MILES INSIDE NEW RNWL EFFECTIVE DATE 3. IS THERE ANY EQUIPMENT LOANED OR RENTED TO/FROM S? (Y / N) IF YES, FOR BORROWED OR RENTED EQUIPMENT: TRANSIT TRANSIT PEAK SEASON DESCRIPTION FROM TIME PERIOD (MM/DD/YYYY) COINS % TO CAUSES OF LOSS (PERILS) APPLIES TO SCHD / UNSCHD IN OPEN UCTIBLE EXPIRATION DATE ADDITIONAL INTEREST TOTAL INTEREST RANK: INTEREST RANK: INTEREST RANK: Page 1 of 5 ' ACORD CORPORATION. All rights reserved. Attach to ACORD 401 The ACORD name and logo are registered marks of ACORD
2 MISCELLANEOUS COINS % (PERILS) UCTIBLE MISCELLANEOUS AGRICULTURAL MACHINERY AND IMPLEMENTS NOT EXCEEDING PER ITEM MISCELLANEOUS TOOLS, EQUIPMENT AND SUPPLIES NOT EXCEEDING PER ITEM TOTAL SCHEDULED FARM PERSONAL PROPERTY DESCRIPTION - EQUIPMENT YEAR MAKE MODEL SERIAL (PERILS) UCTIBLE DESCRIPTION - NON-EQUIPMENT (LIVESTOCK INFO, FEED, HAY, ETC.) (PERILS) UCTIBLE Page 2 of 5
3 AGRICULTURE UNSCHEDULED FARM PERSONAL PROPERTY Use ACORD 406 to itemize individual category items with multiple units (i.e., Tractors, etc.). AGRICULTURAL PRODUCE AGRICULTURAL MACHINERY AND IMPLEMENTS BARLEY TILLAGE: CORN TRACTORS FODDER DISCS FRUIT HARROWS GROUND FEED PLOWS HAY MFG STK FEED NUTS OATS SILAGE CULTIVATING: SOYBEANS CULTIPACKERS STRAW CULTIVATORS WHEAT DRILLS PLANTERS ROTARY HOES SEEDERS SPREADERS SPRAYERS TOTAL : POULTRY HARVESTING: AUGERS CHICKENS BLOWERS TURKEYS CHOPPERS COMBINES CORN PICKERS COTTON PCKRS DRIERS TOTAL : ELEVAT (PORT) LIVESTOCK FORAGE: DAIRY COWS GRAIN CLNRS DAIRY HEIFERS GRAIN HEADS DAIRY CALVES GRAPE: BEEF COWS BEEF CALVES HAY BALERS FEEDER CATTLE MOWERS BULLS NUTSHAKERS SOWS & GILTS RAKES BOARS RICE HARVSTRS FEEDER PIGS SILO BLOWERS EWES SILO UNLOADRS RAMS TOMATO: LAMBS HORSES WAGONS PONIES MULES TOTAL : TOTAL : Page 3 of 5
4 AGRICULTURE UNSCHEDULED FARM PERSONAL PROPERTY AGRIC TOOLS, EQUIPMENT AND SUPPLIES OF IRRIGATION EQUIPMENT OF AGRICULT CHEM: CNTR PIVOT IRR FERTILIZERS DRIP HERBICIDES HANDSET INSECTICIDES LTRL MOVE IRR PESTICIDES PUMPS AIR COMPRESSORS SOLID SET BINS BOXES & BOX SHOOK WHEEL-LINE ELECTRIC MOTORS FARM LUBRICANTS FENCING & POSTS GAS/DIESEL FUEL HAND TOOLS MATERIALS & SUPP MILKING EQUIP TOTAL : ADDITIONAL ITEMS OF OFFICE EQUIP PAINTS PICKING EQUIP POULTRY EQUIP POWER TOOLS SADDLES & TACK SPARE PARTS TIRES VET SUPPLIES WELDRS & TRCHES TOTAL : SUMMARY SCHEDULED FARM PERSONAL PROPERTY : : TOTAL : SUMMARY UNSCHEDULED FARM PERSONAL PROPERTY TOTAL ALL CATEGORIES: : : IF EXCLUSION OF PROPERTY FROM BLANKET COVERAGE IS DESIRED, PLEASE LIST THE SPECIFIC ITEMS PROPERTY CLASS PROP SUB-CLASS ITEMS Page 4 of 5
5 SIGNATURE Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only. Applicable in KS Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA and WA It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars (5,000) and not more than ten thousand dollars (10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER S SIGNATURE PRODUCER S NAME (Please Print) STATE PRODUCER LICENSE NO (Required in Florida) APPLICANT S SIGNATURE DATE NATIONAL PRODUCER NUMBER Page 5 of 5
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DIRECTIONS: 1. Fill in the application by filling in the blue fields on all pages. 1. 2. Please Complete fill in the all application enrollment the fields with form (all the pages) (all correct pages)
EMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE
EMPLOYEE STOCK OWNERSHIP PLAN QUESTIONNAIRE Name of Insurance Company to which application is made COMPLETION OF THIS QUESTIONNAIRE IS REQUIRED WHEN SEEKING COVERAGE FOR A STANDALONE EMPLOYEE STOCK OWNERSHIP
FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application)
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone: (800) 752-8402 Fax: (317) 776-6891 www.roushins.com Email: quote@roushins.com FORECLOSURE/EVICTION CLEANUP SUPPLEMENTAL APPLICATION
MACHINE SHOP SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD Application)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
Claim submissions made easy
VISION OUT-OF-NETWORK CLAIM FORM Claim submissions made easy WENT OUT-OF-NETWORK? NO PROBLEM, LET S WALK THROUGH IT If you saw an out-of-network eye doctor and you have out-of-network benefits, your next
Please fill in your Agency information below so we have a way to contact you.
Please fill in your Agency information below so we have a way to contact you. Producer Agency Code Phone Email Fax FAX this page along with your completed application to us at 1-888-815-6122 FARM/RANCH
Sun Life Assurance Company of Canada Customized Disability Claim Attending Physician Statement
Sun Life Assurance Company of Canada Customized Disability Claim Attending Physician Statement Plan administrator instructions The Attending Physician must: Complete, sign and date the Attending Physician
AMATEUR SPORTS ASSOCIATION INSURANCE APPLICATION
AMATEUR SPORTS ASSOCIATION INSURANCE APPLICATION SUBMISSION REQUIREMENTS Completed signed / dated Supplemental Applications Completed ACORD Applications (Property, Auto and Umbrella Liability) if coverages
APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD BOND NO. 15, FOR MORTGAGE BANKERS AND INVESTMENT COMPANIES
Underwritten by National Casualty Company Home Office: Columbus, Ohio 43215 Administrative Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 APPLICATION FOR A FINANCIAL INSTITUTION BOND,
AXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
PART I POLICYHOLDER S REPORT
1. PLEASE FULLY COMPLETE THIS FORM 2. ATTACH ITEMIZED BILLS 3. MAIL TO HSR E-mail : UBAclaims@hsri.com HSR Plaza II 4100 Medical Parkway Carrollton, Texas 75007 Phone: (972) 512-5600 Fax: (972) 512-5820
Pertinent Information About This Account: Agency Name: City, State Zipcode: Agency Contact: Address: Phone Number: Fax Number: Insured Name:
Agency Name: City, State Zipcode: Agency Contact: Email Address: Phone Number: Fax Number: Insured Name: Effective Date: Date Quote Needed: Expiring Premium: Expiring Carrier Name: Has Policy Been Cancelled
WAREHOUSE PROGRAM SUPPLEMENTAL APPLICATION
WAREHOUSE PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to ACORD General Liability Application) Applicant s Name: Agency Name: Agent No.: Mailing Address: Phone No.: PROPOSED EFFECTIVE DATE: From
Telephone: (913) Facsimile: (913) Miscellaneous Professional Liability Application
Specialty Global Insurance Services 8500 Shawnee Mission Parkway, L2 a division of MPP Company, Inc. Shawnee Mission, KS 66202 Telephone: (913) 564-0777 Facsimile: (913) 564-0603 E-mail: submissions@specialtyglobal.com
Accidental Death Claim Instructions
Phone : 1-877-722-1959 Fax: 443-279-2901 Accidental Death Claim Instructions The Claimant/ Insured should complete and sign the Accidental Death Insurance claim form in full and return it with the documentation
AXIS Insurance Telephone: (678) S. Wacker Dr., Ste Toll-Free: (866) Chicago, IL Facsimile: (678)
AXIS Insurance Telephone: (678) 746-9000 111 S. Wacker Dr., Ste. 3500 Toll-Free: (866) 259-5435 Chicago, IL 60606 Facsimile: (678) 746-9315 Website: www.axiscapital.com/en-us/insurance/us#professional-lines
m I am a new account m I am renewing my coverage
Complete all information requested below. Please print clearly. APPLICATION FOR NRPA-SPONSORED TEAM SPORTS COMBINED LIABILITY AND ACCIDENT INSURANCE COVERAGE The effective date for this insurance the day
m I am a new account m I am renewing my coverage
APPLICATION FOR NRPA-SPONSORED BLANKET RECREATIONAL ACTIVITIES ACCIDENT INSURANCE COVERAGE Application is hereby made to Nationwide Life Insurance Company for coverage. The effective date for this insurance