DED
TYPEAMOUNTBLKT #TYPEAMOUNTBLKT #
LIMIT: $REJECT COVERAGEACCEPT COVERAGEMINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV)
TYPE
DED
BLANKET SUMMARY
REFERENCE / LOAN #:
EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS
ACORD 45 attached for additional names
ADDITIONAL INTEREST
ITEM:
CLASS:
ITEM
ITEM DESCRIPTION
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
MORTGAGEE
LOSS PAYEE
INTEREST
PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK
Y / N
SOLID FUELBOILER
SECONDARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N
SOLID FUELBOILER
PRIMARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?
GONG
LOCAL
STATION
CODE NUMBERFIRE DISTRICT
# OF OPEN SIDES ON STRUCTURE:
VALU-
ATION
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BREAKDOWN OR CONTAMINATION
SELLING
PRICE
POWER OUTAGE
LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)
OPTIONS
REFRIG MAINT
AGREEMENT
(Y / N)
$
DEDUCTIBLE
$
LIMITDESCRIPTION OF PROPERTY COVERED
SPOILAGE
COVERAGE
(Y / N)
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION
SUBJECT OF INSURANCE
AMOUNT
COINS %
CAUSES OF LOSS
INFLATION
GUARD %
FORMS AND CONDITIONS TO APPLY
BLKT
#
CONSTRUCTION TYPE
DISTANCE TO
HYDRANT FIRE STAT
FT MI
PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA
OTHER OCCUPANCIESROOF TYPETAX CODE
GRADE
BLDG CODE
SEMI- RESISTIVE
RESISTIVE
WIND CLASS
INSTALLED:
DATE
MANUFACTURER:
STOVE OR FIREPLACE INSERT
HEATING SOURCE INCL WOODBURNING
% SPRNK
CENTRAL STATION
LOCAL GONG
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems)
FIRE ALARM MANUFACTURER
HEATING, YR:
PLUMBING, YR:
OTHER:
ROOFING, YR:
WIRING, YR:
BUILDING IMPROVEMENTS
YR:
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
EXTENT GRADE
CENTRAL
WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN
CLOCK HOURLY
EFFECTIVE DATE
NAIC CODE
CARRIER
POLICY NUMBER
NAMED INSURED(S)
AGENCY NAME
AGENCY CUSTOMER ID:
© 1985-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD 140 (2016/03)
BLDG DESCRIPTION:
STREET ADDRESS:PREMISES #:
BUILDING #:
PREMISES INFORMATION
DATE (MM/DD/YYYY)
PROPERTY SECTION
LENDER'S LOSS PAYABLE
Attach to ACORD 125
REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
LIMIT: $REJECT COVERAGEACCEPT COVERAGEMINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV)
TYPE
DEDVALU-
ATION
SUBJECT OF INSURANCE AMOUNT COINS % CAUSES OF LOSS
INFLATION
GUARD %
DED
FORMS AND CONDITIONS TO APPLY
BLKT
#
REFERENCE / LOAN #:
EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS
ACORD 45 attached for additional names
ADDITIONAL INTEREST
ITEM:
CLASS:
ITEM
ITEM DESCRIPTION
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
MORTGAGEE
LOSS PAYEE
INTEREST
PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK
Y / N
SOLID FUELBOILER
SECONDARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N
SOLID FUELBOILER
PRIMARY HEAT
IF BOILER, IS INSURANCE PLACED ELSEWHERE?
GONG
LOCAL
STATION
CODE NUMBERFIRE DISTRICT
# OF OPEN SIDES ON STRUCTURE:
RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCE
FRONT EXPOSURE & DISTANCE
BREAKDOWN OR CONTAMINATION
SELLING
PRICE
POWER OUTAGE
LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)
OPTIONS
REFRIG MAINT
AGREEMENT
(Y / N)
$
DEDUCTIBLE
$
LIMITDESCRIPTION OF PROPERTY COVERED
SPOILAGE
COVERAGE
(Y / N)
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION
CONSTRUCTION TYPE
DISTANCE TO
HYDRANT FIRE STAT
FT MI
PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA
OTHER OCCUPANCIESROOF TYPETAX CODE
GRADE
BLDG CODE
SEMI- RESISTIVE
RESISTIVE
WIND CLASS
INSTALLED:
DATE
MANUFACTURER:
STOVE OR FIREPLACE INSERT
HEATING SOURCE INCL WOODBURNING
% SPRNK
CENTRAL STATION
LOCAL GONG
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems)
FIRE ALARM MANUFACTURER
HEATING, YR:
PLUMBING, YR:
OTHER:
ROOFING, YR:
WIRING, YR:
BUILDING IMPROVEMENTS
YR:
BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE
EXTENT GRADE
CENTRAL
WITH KEYS
BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN
CLOCK HOURLY
AGENCY CUSTOMER ID:
BLDG DESCRIPTION:
STREET ADDRESS:PREMISES #:
BUILDING #:
ADDITIONAL
PREMISES INFORMATION
ACORD 140 (2016/03) Page 2 of 3
LENDER'S LOSS PAYABLE
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.
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 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.
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 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 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 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 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 CO
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.
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 AL, AR, DC, LA, MD, NM, RI and WV
NATIONAL PRODUCER NUMBER
(Required in Florida)
PRODUCER'S SIGNATURE
DATEAPPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO
SIGNATURE
AGENCY CUSTOMER ID:
ACORD 140 (2016/03) Page 3 of 3
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