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ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL
PENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied)
IN FLORIDA, 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.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
ANOTHER 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
MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
ACORD 140 (2007/09)
AGENCY CUSTOMER ID:
CLOCK HOURLY
# GUARDS/WATCHMENBURGLAR ALARM INSTALLED AND SERVICED BY
WITH KEYS
CENTRAL STATION
GRADEEXTENT
EXPIRATION DATECERTIFICATE #BURGLAR ALARM TYPE
YR:
BUILDING IMPROVEMENTS
WIRING, YR:
ROOFING, YR:
OTHER:
PLUMBING, YR:
HEATING, YR:
FIRE ALARM MANUFACTURER
PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)
LOCAL GONG
CENTRAL STATION
% SPRNK
HEATING BOILER ON PREMISES? (Y/N)
IF YES, IS INSURANCE PLACED ELSEWHERE? (Y/N)
WIND CLASS
RESISTIVE
SEMI- RESISTIVE
BLDG CODE
GRADE
TAX CODE ROOF TYPE OTHER OCCUPANCIES
TOTAL AREAYR BUILT# BASM'TS# STORIESPROT CLFIRE DISTRICT/CODE NUMBER
MIFT
FIRE STATHYDRANT
DISTANCE TO
CONSTRUCTION TYPE
#
BLKT
FORMS AND CONDITIONS TO APPLYDED
GUARD %
INFLATION
CAUSES OF LOSSCOINS %AMOUNTSUBJECT OF INSURANCE
ADDITIONAL INFORMATION BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810 VALUE REPORTING INFORMATION - Attach ACORD 811
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION
SPOILAGE COVERAGE
(Y/N)
DESCRIPTION OF PROPERTY COVERED LIMIT
$
DEDUCTIBLE
$
REFRIG MAINT AGREEMENT
(Y/N)
OPTIONS
FRONT EXPOSURE & DISTANCE
REAR EXPOSURE & DISTANCELEFT EXPOSURE & DISTANCERIGHT EXPOSURE & DISTANCE
ATION
VALU-
# OF OPEN SIDES ON STRUCTURE:
PREMISES INFORMATION
BUILDING #:
PREMISES #:
STREET ADDRESS:
BLDG DESCRIPTION:
ADDITIONAL INTERESTS
ITEM DESCRIPTION:
OTHER:
SCHEDULED ITEM NUMBER:
BUILDING:LOCATION:
INTEREST IN ITEM NUMBER
NAME AND ADDRESS: REFERENCE #: CERTIFICATE REQUIRED
GAGEE
MORT-
PAYEE
LOSS
INTEREST
RANK:
