Countries and Languages
| Countries | Languages |
|---|---|
| USA | English |
Extracted Fields
Asterisk (*) indicates a required field or field group. Values cannot be empty.
Date
| Field | Description |
|---|---|
| Date | The date on which the form is completed. |
Agency
| Field | Description |
|---|---|
| Name | The full name of the insurance producer or agency. |
| Address | The address of the insurance producer or agency. |
| Contact Name | The name of the primary contact person at the producer’s establishment. |
| Phone | The phone number of the primary contact person at the producer’s establishment. |
| Fax | The fax number of the producer or agency. |
| The e-mail address of the primary contact person at the producer’s establishment. | |
| Code | The identification code assigned to the producer (for example, an agency or brokerage firm) by the insurer. |
| Subcode | The identification code assigned by the insurer to the sub-producer (for example, a natural person) within a producer’s office (for example, an agency or brokerage firm). |
| Customer ID | The identification number of the customer assigned by the producer (for example, an agency or brokerage firm). |
Carrier
| Field | Description |
|---|---|
| Name | The insurer’s full legal company name(s) as per the file copy of the policy. |
| NAIC Code | The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). |
| Company Policy or Program Name | The description of an independently filed policy or program that may be optionally available from the insurance company. |
| Program Code | The product code assigned by the insurer for the policy. |
| Underwriter | The company underwriter (or other company staff person) that this form should be directed to. |
| Underwriter Office | The company underwriting office that this application should be directed to. |
Status of Transaction
| Field | Description |
|---|---|
| Status of Transaction | |
| Quote | Indicates that the response expected from the company is a quote. |
| Issue Policy | Indicates that the response expected from the company is an issued policy. |
| Renew | Indicates that the response expected from the company is a renewed policy. |
| Bound | Indicates that the coverage has been bound. |
| Change | Indicates that the policy is being submitted for a policy change. |
| Cancel | Indicates that the policy is being submitted for cancellation. |
| Date | |
| Date | The date on which the policy status becomes effective. This date indicated for policy statuses of Bound, Change, and Cancel. The date value must be in the following format: MM/DD/YYYY. |
| Time | |
| Time | The time at which the policy status becomes effective. The time is used for policy statuses of Bound, Change, and Cancel. |
| AM | Indicates that the time specified is AM. |
| PM | Indicates that the time specified is PM. |
Sections Attached (repeating group)
| Field | Description |
|---|---|
| Selected | Indicates whether sections are attached to the application. |
| Section Name | The name of the attached section, if any. |
| Premium USD | The premium amount for the section. |
Attachments (repeating group)
| Field | Description |
|---|---|
| Selected | Indicates whether documents are attached to the application. |
| Attachment Name | The attachment’s full name, if any. |
Policy Information
| Field | Description |
|---|---|
| Proposed Effective Date | The effective date of the policy. The date on which the terms and conditions of the policy commence. The date value must be in the following format: MM/DD/YYYY. |
| Proposed Expiration Date | The date on which the terms and conditions of the policy will expire. The date value must be in the following format: MM/DD/YYYY. |
| Billing Plan | |
| Direct | Indicates whether the policy is to be billed directly. |
| Agency | Indicates whether the policy is to be billed to the producer or agency |
| Payment Plan | The payment plan for the policy. |
| Method of Payment | The method for paying the invoice. |
| Audit | The audit term for policies that are subject to periodic audit. |
| Deposit | The amount of the premium received as a deposit. |
| Minimum Premium | The minimum premium amount for the policy. |
| Policy Premium | The estimated total cost of the policy |
First Applicant
| Field | Description |
|---|---|
| Name* | Information about the first insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Address | Information about the first insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Information about the first insured (that is, the organization that has purchased the insurance coverages shown on the certificate). | |
| Business Phone | Information about the first insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Website Address | Information about the first insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| GL Code | The code identifying the general liability nature of the business of the first insured. |
| SIC | The Standard Industry Classification code assigned to the business activity of the first insured. |
| NAICS | The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity of the first insured. |
| FEIN or SSN | The tax identifier of the first insured. |
| Business Type | |
| Corporation | Indicates the legal entity code of the first insured. |
| Individual | Indicates the legal entity code of the first insured. |
| Joint Venture | Indicates the legal entity code of the first insured. |
| LLC | Indicates the legal entity code of the first insured. |
| Not for Profit Organization | Indicates the legal entity code of the first insured. |
| Partnership | Indicates the legal entity code of the first insured. |
| Subchapter S Corporation | Indicates the legal entity code of the first insured. |
| Trust | Indicates the legal entity code of the first insured. |
| Other | Indicates the legal entity code of the first insured. |
| LLC No of Members | The number of members and managers of the limited liability corporation. |
| Business Type Other | The description of the other type of legal entity. |
Non-First Applicant (repeating group)
| Field | Description |
|---|---|
| Name | Information about the insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Address | Information about the insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Information about the insured (that is, the organization that has purchased the insurance coverages shown on the certificate). | |
| Business Phone | Information about the insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| Website Address | Information about the insured (that is, the organization that has purchased the insurance coverages shown on the certificate). |
| GL Code | The code identifying the general liability nature of the business of the insured. |
| SIC | The Standard Industry Classification code assigned to the business activity of the insured. |
| NAICS | The North American Industry Classification System (NAICS) 6-digit industry code assigned to the business activity of the insured. |
| FEIN or SSN | The tax identifier of the insured. |
| Business Type | |
| Corporation | Indicates the legal entity code of the insured. |
| Individual | Indicates the legal entity code of the insured. |
| Joint Venture | Indicates the legal entity code of the insured. |
| LLC | Indicates the legal entity code of the insured. |
| Not for Profit Organization | Indicates the legal entity code of the insured. |
| Partnership | Indicates the legal entity code of the insured. |
| Subchapter S Corporation | Indicates the legal entity code of the insured. |
| Trust | Indicates the legal entity code of the insured. |
| Other | Indicates the legal entity code of the insured. |
| LLC No of Members | The number of members and managers of the limited liability corporation. |
| Business Type Other | The description of the other type of legal entity. |
Contact Information (repeating group)
| Field | Description |
|---|---|
| Contact Type | The customer’s identification number assigned by the producer (for example, an agency or brokerage firm). |
| Contact Name | The full name of the contact. |
| Primary Phone | |
| Phone | The primary phone number of the contact. |
| Home | Indicates that the primary phone number is for a home phone. |
| Business | Indicates that the primary phone number is for a business phone. |
| Cell | Indicates that the primary phone number is for a cell phone. |
| Secondary Phone | |
| Phone | The secondary phone number of the contact. |
| Home | Indicates that the secondary phone number is for a home phone. |
| Business | Indicates that the secondary phone number is for a business phone. |
| Cell | Indicates that the secondary phone number is for a cell phone. |
| Primary E-mail Address | The primary e-mail address of the contact. |
| Secondary E-mail Address | The secondary e-mail address of the contact. |
Premises Information (repeating group)
| Field | Description |
|---|---|
| Location Number | The address of the premises. |
| Building Number | The address of the premises. |
| Street | The address of the premises. |
| City | The address of the premises. |
| County | The address of the premises. |
| State | The address of the premises. |
| ZIP | The address of the premises. |
| City Limits | |
| Inside | Indicates that the building is within the city limits. |
| Outside | Indicates that the building is outside the city limits. |
| Other | Indicates that neither of the above applies. For example, for buildings in unincorporated areas. |
| City Limits Other | The description of the risk location if not inside or outside the city limits. |
| Interest | |
| Owner | Indicates that the insured’s interest in the building is as its owner. |
| Tenant | Indicates that the insured’s interest in the building is as its tenant. |
| Other | Indicates that the insured’s interest in the building is other than those listed. |
| Interest Other | The description of the insured’s interest in the building when it is other than those listed. |
| Number of Full Time Employees | Specifies the number of full time employees. |
| Number of Part Time Employees | Specifies the number of part time employees. |
| Annual Revenues USD | The annual revenue amount for this location. |
| Occupied Area SQ FT | The area, in square feet, of the space in the building that is occupied by the insured. |
| Open to Public Area SQ FT | The area, in square feet, of the building that is open to the public |
| Total Building Area SQ FT | The number of square feet of the building or area occupied at this location for which insurance is being requested. |
| Any Area Leased to Others | The field indicates whether the insured has any area that is leased to others. Possible values: Yes, No |
| Yes | Indicates that the insured has area leased to others. |
| No | Indicates that the insured does not have area leased to others. |
| Description of Operations | The description of the business operations each applicant performs and the way they are conducted by premises. |
Nature of Business
| Field | Description |
|---|---|
| Date Business Started | The date on which the business was started. |
| Nature of Business | Indicates the nature of the business. |
| Apartments | Indicates the nature of the business. |
| Condominiums | Indicates the nature of the business. |
| Contractor | Indicates the nature of the business. |
| Institutional | Indicates the nature of the business. |
| Manufacturing | Indicates the nature of the business. |
| Office | Indicates the nature of the business. |
| Restaurant | Indicates the nature of the business. |
| Retail | Indicates the nature of the business. |
| Service | Indicates the nature of the business. |
| Wholesale | Indicates the nature of the business. |
| Other | Indicates the nature of the business. |
| Nature of Business Other | The description of the other nature of the business. |
| Description of Primary Operations | The description of the primary operations of the business. |
| Retail Stores or Service Operations of Total Sales | |
| Installation or Service or Repair Work | The percentage of total sales of a retail store or service operation attributed to installation, service, or repair work. |
| Off Premises Installation or Service or Repair Work | The percentage of total sales of a retail store or service operation attributed to installation, service, or repair work completed off premises. |
| Description of Operations of Other Named Insureds | The description of the operations of the other insureds. |
Additional Interest
| Field | Description |
|---|---|
| Interest | Indicates the additional interest type. |
| Additional Insured | Indicates the additional interest type. |
| Breach of Warranty | Indicates the additional interest type. |
| Co-owner | Indicates the additional interest type. |
| Employee as Lessor | Indicates the additional interest type. |
| Leaseback Owner | Indicates the additional interest type. |
| Lien Holder | Indicates the additional interest type. |
| Loss Payee | Indicates the additional interest type. |
| Morgagee | Indicates the additional interest type. |
| Owner | Indicates the additional interest type. |
| Registrant | Indicates the additional interest type. |
| Trustee | Indicates the additional interest type. |
| Other | Indicates the additional interest type. |
| Interest Other | The description of the other type of additional interest. |
| Reason for Interest | The reason for including the additional interest. |
| Name | The additional interest’s full name. |
| Address | The additional interest’s mailing address. |
| Rank | The ranking of “this” additional interest when multiple additional interests are associated with the same item. |
| Evidence Document | |
| Evidence | Indicates whether the additional interest requires evidence of insurance. |
| Certificate | Indicates whether the additional interest requires a Certificate of Insurance. |
| Policy | Indicates whether additional interest requires a copy of the policy. |
| Reference or Loan Number | The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
| Lien Amount | The amount of the loan. |
| Interest End Date | The date the interest holder’s interest terminates. |
| Phone | The primary phone number of the additional interest. |
| Fax | The primary fax number of the additional interest. |
| The primary e-mail address for the additional interest. |
Key Fields
- Date
- Agency/Name
- Carrier/Name
- Carrier/Underwriter
- Policy Information/Proposed Effective Date
- First Applicant/Name
Validation Rules
| Rule | Description |
|---|---|
| Business Type Checkmark Check | Checks that only one field from the Business Type group is filled in. If more than one field is filled in, displays an error message. |
| Nature of Business Checkmark Check | Checks that only one field from the Nature of Business group is filled in. If more than one field is filled in, displays an error message. |
