DATE (MM/DD/YYYY)
EVIDENCE OF COMMERCIAL PROPERTY INSURANCE
LOAN NUMBER POLICY NUMBER
POLICY TYPE
NAIC NO:
COMPANY NAME AND ADDRESS
IF MULTIPLE COMPANIES, COMPLETE SEPARATE FORM FOR EACH
CONTINUED UNTIL
TERMINATED IF CHECKED
THIS REPLACES PRIOR EVIDENCE DATED:
EFFECTIVE DATE EXPIRATION DATE
CONTACT PERSON AND ADDRESS
PRODUCER NAME,
(A/C, No):
FAX
PHONE
(A/C, No, Ext):
ADDRESS:
E-MAIL
THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON
THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE DOES NOT AMEND, EXTEND OR ALTER
THE COVERAGE AFFORDED BY THE POLICIES BELOW.
SUB CODE:
CUSTOMER ID #:
AGENCY
CODE:
NAMED INSURED AND ADDRESS
ADDITIONAL NAMED INSURED(S)
BUSINESS PERSONAL PROPERTY
BUILDING OR
PROPERTY INFORMATION (Use REMARKS on page 2, if more space is required)
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY
BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS
OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LOCATION/DESCRIPTION
LENDERS LOSS PAYABLE
MORTGAGEE
CONTRACT OF SALE
LENDER SERVICING AGENT NAME AND ADDRESS
NAME AND ADDRESS
ADDITIONAL INTEREST
AUTHORIZED REPRESENTATIVE
If YES, LIMIT:
Actual Loss Sustained; # of months:If YES, LIMIT:
BUSINESS INCOME
If YES, indicate value(s) reported on property identified above: $
DED:
DED:
DED:
DED:
DED:
- Coverage for loss to undamaged portion of bldg
- Incr. Cost of Construction
- Demolition Costs
SPECIALBROADBASICPERILS INSURED
DED:COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE:
DED:
%If YES,
PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE
HOLDER PRIOR TO LOSS
FLOOD (If Applicable)
COVERAGE INFORMATION
NOYES
BLANKET COVERAGE
TERRORISM COVERAGE Attach Disclosure Notice / DEC
IS THERE A TERRORISM-SPECIFIC EXCLUSION?
IS DOMESTIC TERRORISM EXCLUDED?
DED:
REPLACEMENT COST
AGREED VALUE
COINSURANCE
EQUIPMENT BREAKDOWN (If Applicable)
ORDINANCE OR LAW
WIND / HAIL (If Subject to Different Provisions)
EARTH MOVEMENT (If Applicable)
$
LIMITED FUNGUS COVERAGE
FUNGUS EXCLUSION (If "YES", specify organization's form used)
N/A
RENTAL VALUE
If YES, LIMIT:
If YES, LIMIT:
If YES, LIMIT:
If YES, LIMIT:
If YES, LIMIT:
If YES, LIMIT:
MAIL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO
DAYS WRITTEN NOTICE TO THE ADDITIONAL INTEREST NAMED BELOW, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
CANCELLATION
© ACORD CORPORATION 2003-2006. All rights reserved.
ACORD 28 (2006/07)
The ACORD name and logo are registered marks of ACORD
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