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ACORD 75 (2010/04) © 1993-2010 ACORD CORPORATION. All rights reserved.Page 1 of 2
INSURED
DESCRIPTION OF OPERATIONS/VEHICLES/PROPERTY (Including Location)
THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
PER EXPIRING POLICY #:
BINDER #COMPANY
CODE: SUB CODE:
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
EXPIRATION
DATE TIME
12:01 AM
NOON
PHONE
(A/C, No, Ext):
FAX
(A/C, No):
AGENCY
PM
AM
TIMEDATE
EFFECTIVE
CUSTOMER ID:
AGENCY
INSURANCE BINDER
DATE (MM/DD/YYYY)
LOAN #
LOSS PAYEE
ADDITIONAL INSUREDMORTGAGEE
NAME & ADDRESS
AUTHORIZED REPRESENTATIVE
COVERAGES LIMITS
AMOUNTCOINS %DEDUCTIBLECOVERAGE/FORMSTYPE OF INSURANCE
$
$
$
$
$
$
$
$
UNINSURED MOTORIST
PERSONAL INJURY PROT
MEDICAL PAYMENTS
PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
VEHICLE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
SCHEDULED VEHICLESALL VEHICLES ACTUAL CASH VALUE
STATED AMOUNT $
VEHICLE PHYSICAL DAMAGE
DED
COLLISION:
OTHER THAN COL:
PROPERTY
CAUSES OF LOSS
BASIC BROAD SPEC
RETRO DATE FOR CLAIMS MADE:
EACH OCCURRENCE
DAMAGE TO
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
$
$
$
$
$
$
RENTED PREMISES
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR
$
$
$
AGGREGATE
EACH ACCIDENT
OTHER THAN AUTO ONLY:
AUTO ONLY - EA ACCIDENT
GARAGE LIABILITY
ANY AUTO
WORKER'S COMPENSATION
AND
EMPLOYER'S LIABILITY
WC STATUTORY LIMITS
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
FEES
TAXES
ESTIMATED TOTAL PREMIUM
$
$
$
SPECIAL
CONDITIONS /
OTHER
COVERAGES
RETRO DATE FOR CLAIMS MADE: $
$
$
SELF-INSURED RETENTION
AGGREGATE
EACH OCCURRENCE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
AGENCY CUSTOMER ID:
This Company binds the kind(s) of insurance stipulated on the reverse side. The Insurance is subject to the terms,
conditions and limitations of the policy(ies) in current use by the Company.
This binder may be cancelled by the Insured by surrender of this binder or by written notice to the Company stating
when cancellation will be effective. This binder may be cancelled by the Company by notice to the Insured in
accordance with the policy conditions. This binder is cancelled when replaced by a policy. If this binder is not replaced
by a policy, the Company is entitled to charge a premium for the binder according to the Rules and Rates in use by the
Company.
The policy may be cancelled at any time at the request of the insured.
Applicable in Michigan
The insurer has 45 business days, commencing from the effective date of coverage to confirm eligibility for coverage
under the insurance policy.
Applicable in Maryland
This binder is effective for only ninety (90) days. Within thirty (30) days of receipt of this binder, you should request an
insurance policy or certificate (if applicable) from your agent and/or insurance company.
Applicable in the Virgin Islands
With respect to binders issued to renters of residential premises, home owners, condo unit owners and mobile home
owners, the insurer has thirty (30) business days, commencing from the effective date of coverage, to evaluate the
issuance of the insurance policy.
Applicable in Colorado
the binder is replaced by a policy or another binder in the same company.
duration of the binder exceeds 60 days. For auto insurance, the insurer must give 5 days prior notice, unless
Except for Auto Insurance coverage, no notice of cancellation or nonrenewal of a binder is required unless the
Applicable in Florida
CONDITIONS
of the form is changed from "Insurance Binder" to "Cover Note".
When this form is used to provide insurance in the amount of one million dollars ($1,000,000) or more, the title
Applicable in California
The mortgagee or Obligee of any mortgage or other instrument given for the purpose of creating a lien on real
property shall accept as evidence of insurance a written binder issued by an authorized insurer or its agent if the
binder includes or is accompanied by: the name and address of the borrower; the name and address of the lender as
loss payee; a description of the insured real property; a provision that the binder may not be canceled within the term
of the binder unless the lender and the insured borrower receive written notice of the cancellation at least ten (10)
days prior to the cancellation; except in the case of a renewal of a policy subsequent to the closing of the loan, a paid
receipt of the full amount of the applicable premium, and the amount of insurance coverage.
Chapter 21 Title 25 Paragraph 2119
Applicable in Delaware
of insurance for actual damages sustained therefrom.
required: (A) Shall be fined not more than $500.00, and (B) is liable to the party presenting the binder as proof
Any person who refuses to accept a binder which provides coverage of less than $1,000,000.00 when proof is
Applicable in Nevada
ACORD 75 (2010/04) Page 2 of 2
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