› Supported document types › USA - ACORD Form 83 Personal Umbrella Application

USA - ACORD Form 83 Personal Umbrella Application

The Association for Cooperative Operations Research and Development (ACORD) forms are standardized documents used by the insurance industry.

This is a standardized insurance form used for commercial package insurance applications. It captures detailed information about the business, including operations, properties, and coverage needs.

This form can be machine printed or handwritten. If it is handwritten, TotalAgility must be configured to use full-page recognition using either Tungsten Clarity or Azure AI Document Intelligence.

This form starts on the first page and does not have any cover pages.

Supported versions: 2016/04

Supported fields on this form:

  • Agency

  • Date

  • Carrier

  • NAIC_Code

  • ApplicationsNameAndMailingAddress

  • ContactName

  • Phone

  • Fax

  • EmailAddress

  • Code

  • Subcode

  • AgencyCustomerID

  • Plan

  • FacilityCode

  • EffectiveDate

  • ExpirationDate

  • PolicyNumber

  • DateAtCurrentResidence

  • PrimaryPhone

  • PrimaryPhone_Home

  • PrimaryPhone_Bus

  • PrimaryPhone_Cell

  • SecondaryPhone

  • SecondaryPhone_Home

  • SecondaryPhone_Bus

  • SecondaryPhone_Cell

  • PrimaryEmailAddress

  • SecondaryEmailAddress

  • UmbrellaInfo_Coverages_PolicyAmount

  • UmbrellaInfo_Coverages_Retention

  • UmbrellaInfo_OptionalUninsuredMotorist_Limit

  • UmbrellaInfo_OptionalUnderinsuredMotorist_Limit

  • UmbrellaInfo_Code_1

  • UmbrellaInfo_Coverage_1

  • UmbrellaInfo_Limit_1

  • UmbrellaInfo_Code_2

  • UmbrellaInfo_Coverage_2

  • UmbrellaInfo_Limit_2

  • UmbrellaInfo_Premiums_Basic

  • UmbrellaInfo_Premiums_Residences

  • UmbrellaInfo_Premiums_Automobiles

  • UmbrellaInfo_Premiums_RecreationalVehicles

  • UmbrellaInfo_Premiums_UninsuredMotorist

  • UmbrellaInfo_Premiums_UnderinsuredMotorist

  • UmbrellaInfo_Premiums_Watercraft

  • UmbrellaInfo_Premiums_Others_Textbox

  • UmbrellaInfo_Premiums_Others

  • UmbrellaInfo_Premiums_Deposit

  • UmbrellaInfo_Premiums_EstimatedTotalPremium

  • UmbrellaInfo_Premiums_Calculations

  • PrimaryPolicyInfo_Auto_Company

  • PrimaryPolicyInfo_Auto_PolicyNumber

  • PrimaryPolicyInfo_Auto_Eff

  • PrimaryPolicyInfo_Auto_Exp

  • PrimaryPolicyInfo_Auto_Liability_EA_PER

  • PrimaryPolicyInfo_Auto_Liability_EA_ACCOrCSL

  • PrimaryPolicyInfo_Auto_PropertyDamage_EA_ACC

  • PrimaryPolicyInfo_Auto_UninsuredMotorists_EA_PER

  • PrimaryPolicyInfo_Auto_UninsuredMotorists_EA_ACCOrCSL

  • PrimaryPolicyInfo_Auto_Others_Text

  • PrimaryPolicyInfo_Auto_Others_PA_EA_ACC

  • PrimaryPolicyInfo_Home_Company

  • PrimaryPolicyInfo_Home_PolicyNumber

  • PrimaryPolicyInfo_Home_Eff

  • PrimaryPolicyInfo_Home_Exp

  • PrimaryPolicyInfo_Home_PersonalLiability_EA_OCC

  • PrimaryPolicyInfo_DwellingFireInclRentals_Company

  • PrimaryPolicyInfo_DwellingFireInclRentals_PolicyNumber

  • PrimaryPolicyInfo_DwellingFireInclRentals_Eff

  • PrimaryPolicyInfo_DwellingFireInclRentals_Exp

  • PrimaryPolicyInfo_DwellingFireInclRentals_PersonalLiability_EA_OCC

  • PrimaryPolicyInfo_Watercraft_Company

  • PrimaryPolicyInfo_Watercraft_PolicyNumber

  • PrimaryPolicyInfo_Watercraft_Eff

  • PrimaryPolicyInfo_Watercraft_Exp

  • PrimaryPolicyInfo_Watercraft_Liability_EA_PER

  • PrimaryPolicyInfo_Watercraft_Liability_EA_ACCOrCSIL

  • PrimaryPolicyInfo_Watercraft_PropertyDamage_EA_ACC

  • PrimaryPolicyInfo_Watercraft_UninsuredBoaters_EA_PER

  • PrimaryPolicyInfo_Watercraft_UninsuredBoaters_EA_ACCOrCSIL

  • PrimaryPolicyInfo_Watercraft_Others_Text

  • PrimaryPolicyInfo_Watercraft_Others_PA_EA_ACC

  • PrimaryPolicyInfo_RecreationalVehicles_Company

  • PrimaryPolicyInfo_RecreationalVehicles_PolicyNumber

  • PrimaryPolicyInfo_RecreationalVehicles_Eff

  • PrimaryPolicyInfo_RecreationalVehicles_Exp

  • PrimaryPolicyInfo_RecreationalVehicles_Liability_EA_PER

  • PrimaryPolicyInfo_RecreationalVehicles_Liability_EA_ACCOrCSIL

  • PrimaryPolicyInfo_RecreationalVehicles_PropertyDamage_EA_ACC

  • PrimaryPolicyInfo_RecreationalVehicles_UninsuredBoaters_EA_PER

  • PrimaryPolicyInfo_RecreationalVehicles_UninsuredBoaters_EA_ACCOrCSIL

  • PrimaryPolicyInfo_RecreationalVehicles_Others_Text

  • PrimaryPolicyInfo_RecreationalVehicles_Others_PA_EA_ACC

  • PrimaryPolicyInfo_EmployersLiability_Company

  • PrimaryPolicyInfo_EmployersLiability_PolicyNumber

  • PrimaryPolicyInfo_EmployersLiability_Eff

  • PrimaryPolicyInfo_EmployersLiability_Exp

  • PrimaryPolicyInfo_EmployersLiability_EmployersLiability_Limit

  • PrimaryPolicyInfo_TypeOfPolicy_Other

  • PrimaryPolicyInfo_Other_Company

  • PrimaryPolicyInfo_Other_PolicyNumber

  • PrimaryPolicyInfo_Other_Eff

  • PrimaryPolicyInfo_Other_Exp

  • PrimaryPolicyInfo_Other_Other_Text

  • PrimaryPolicyInfo_Other_Other_LimitsOfLiability

  • PaymentPlan_BillingAccount

  • PaymentPlan_DepositAmount

  • PaymentPlan_EstTotalPremium

  • PaymentPlan_Billing_DirectBill_Policy

  • PaymentPlan_Billing_DirectBill_Acct

  • PaymentPlan_Billing_DirectBill_AgencyBill

  • PaymentPlan_PaymentPlan_FullPay

  • PaymentPlan_PaymentPlan_Annual

  • PaymentPlan_PaymentPlan_SemiAnnual

  • PaymentPlan_PaymentPlan_Quarterly

  • PaymentPlan_PaymentPlan_Bi_Monthly

  • PaymentPlan_PaymentPlan_Monthly

  • PaymentPlan_PaymentPlan_Others_Textbox

  • PaymentPlan_PaymentPlan_Others_Checkbox

  • PaymentPlan_PaymentMethod_Cash

  • PaymentPlan_PaymentMethod_Check

  • PaymentPlan_PaymentMethod_CreditCard

  • PaymentPlan_PaymentMethod_EFT

  • PaymentPlan_PaymentMethod_PayrollDeduction

  • PaymentPlan_PaymentMethod_PreAuthorized

  • PaymentPlan_PaymentMethod_Others_Textbox

  • PaymentPlan_PaymentMethod_Others_Checkbox

  • PaymentPlan_MailPolicyTo_Agent

  • PaymentPlan_MailPolicyTo_Insured

  • PaymentPlan_MailPolicyTo_Others_Textbox

  • PaymentPlan_MailPolicyTo_Others_Checkbox

  • PaymentPlan_Payor_Insured

  • PaymentPlan_Payor_Mortgagee

  • PaymentPlan_Payor_Others_Textbox

  • PaymentPlan_Payor_Others_Checkbox

  • PaymentPlan_PremiumFinanced

  • PaymentPlan_FinanceCompany

  • NoPriorCoverage

  • PriorCoverage_PriorCarrier

  • PriorCoverage_PriorPolicyNumber

  • PriorCoverage_ExpirationDate

  • WaterCraft_Power_Inboard_1

  • WaterCraft_Power_OutBoard_1

  • WaterCraft_Power_Inboard_OutDrive_1

  • WaterCraft_Power_WaterJet_1

  • WaterCraft_Power_Sail_1

  • WaterCraft_Power_Other_Textbox_1

  • WaterCraft_Power_Other_Checkbox_1

  • WaterCraft_Power_Inboard_2

  • WaterCraft_Power_OutBoard_2

  • WaterCraft_Power_Inboard_OutDrive_2

  • WaterCraft_Power_WaterJet_2

  • WaterCraft_Power_Sail_2

  • WaterCraft_Power_Other_Textbox_2

  • WaterCraft_Power_Other_Checkbox_2

  • WaterCraft_Power_Inboard_3

  • WaterCraft_Power_OutBoard_3

  • WaterCraft_Power_Inboard_OutDrive_3

  • WaterCraft_Power_WaterJet_3

  • WaterCraft_Power_Sail_3

  • WaterCraft_Power_Other_Textbox_3

  • WaterCraft_Power_Other_Checkbox_3

  • WaterCraft_WatersNavigated_Atlantic_1

  • WaterCraft_WatersNavigated_GreatLakes_1

  • WaterCraft_WatersNavigated_InlandWaterways_1

  • WaterCraft_WatersNavigated_Pacific_1

  • WaterCraft_WatersNavigated_Rivers_1

  • WaterCraft_WatersNavigated_GulfOfMexico_1

  • WaterCraft_WatersNavigated_Others_TextBox_1

  • WaterCraft_WatersNavigated_Others_Checkbox_1

  • WaterCraft_WatersNavigated_Atlantic_2

  • WaterCraft_WatersNavigated_GreatLakes_2

  • WaterCraft_WatersNavigated_InlandWaterways_2

  • WaterCraft_WatersNavigated_Pacific_2

  • WaterCraft_WatersNavigated_Rivers_2

  • WaterCraft_WatersNavigated_GulfOfMexico_2

  • WaterCraft_WatersNavigated_Others_TextBox_2

  • WaterCraft_WatersNavigated_Others_Checkbox_2

  • WaterCraft_WatersNavigated_Atlantic_3

  • WaterCraft_WatersNavigated_GreatLakes_3

  • WaterCraft_WatersNavigated_InlandWaterways_3

  • WaterCraft_WatersNavigated_Pacifi_3

  • WaterCraft_WatersNavigated_Rivers_3

  • WaterCraft_WatersNavigated_GulfOfMexico_3

  • WaterCraft_WatersNavigated_Others_Textbox_3

  • WaterCraft_WatersNavigated_Others_Checkbox_3

  • OperatorInfo_HasAnyAutoAccidentOccurred_Yrs

  • AnyDriverHaveAPhysicalImpairment_DrvNo

  • AnyDriverHaveAPhysicalImpairment_DescriptionOfSpecialEquipmentInVehicle

  • AnyDriverUndergoneCourseOfMedicalTreatment_DrvNo

  • AnyDriverUndergoneCourseOfMedicalTreatment_Explanation

  • Employment_ApplicantsOccupation

  • Employment_ApplicantsEmployerNameAndAddress

  • Employment_Applicants_YRS_EMPL

  • Employment_CoApplicantsOccupation

  • Employment_CoApplicantsEmployerNameAndAddress

  • Employment_CoApplicants_YRS_EMPL

  • GeneralInfo_TrampolineOnThePremises_Loc1

  • GeneralInfo_TrampolineOnThePremises_SafetyNet1

  • GeneralInfo_TrampolineOnThePremises_Loc2

  • GeneralInfo_TrampolineOnThePremises_SafetyNet2

  • GeneralInfo_TrampolineOnThePremises_Loc3

  • GeneralInfo_TrampolineOnThePremises_SafetyNet3

  • GeneralInfo_TrampolineOnThePremises_Loc4

  • GeneralInfo_TrampolineOnThePremises_SafetyNet4

  • GeneralInfo_AnyAircraftOwnedorLeasedorCharteredOrFurnished_Description

  • GeneralInfo_AnyRealEstateVehicleWatercraftOrAircraftUsed_Description

  • GeneralInfo_RealEstateVehicleOwnedHiredOrRegularlyusedThatIsNotCovered_Description

  • GeneralInfo_DoYouEngageInAnyTypeOfFarmingOperation_Description

  • GeneralInfo_DoYouHoldAnyNoncompensatedPositions_Description

  • GeneralInfo_NonOwnedPropertyExceeding1000InValueInYourCareCustody_Description

  • GeneralInfo_AnyBusinessOrProfessionalActivitiesIncludedInThePrimaryPolicies_Description

  • GeneralInfo_DoesAnyPrimaryPolicyHaveReducedLimitsOfLiabilityOrEliminated_Description

  • GeneralInfo_AnyPendingLitigationCourtProceedingsOrJudgements_Description

  • GeneralInfo_AnyCoverageDeclinedCancelledOrNonRenewedDuringTheLast5Years_DRV

  • GeneralInfo_AnyCoverageDeclinedCancelledOrNonRenewedDuringTheLast5Years_Reason

  • GeneralInfo_HasInsuranceBeenTransferredWithinTheAgency_Description

  • UM_UIMDisclosures_ApplicableOnlyInLouisiana_ISelectUMLimits_Initials

  • UM_UIMDisclosures_ApplicableOnlyInLouisiana_IRejectUMCoverage_Initials

  • UM_UIMDisclosures_ApplicableOnlyInNewHampshire_ISelectUMLimits_Initials

  • UM_UIMDisclosures_ApplicableOnlyInNewHampshire_IRejectUMCoverag_Initials

  • UM_UIMDisclosures_ApplicableOnlyInMontana_IAcknowledgeIHaveBeenOfferedUninsuredMotorists

  • UM_UIMDisclosures_ApplicableOnlyInVermont_IAcknowledgeThatIHaveBeenOfferedUMCoverage_Sign

  • UM_UIMDisclosures_ApplicableOnlyInVermont_IAcknowledgeThatIHaveBeenOfferedUMCoverage_Date

  • NoticeOfInformationPractices_ApplicantsInitials

  • NoticeOfInformationPractices_CopyOfTheNoticeOfInformationPracticesHasBeenGiven

  • Binder_InsuranceBinder_EffDate

  • Binder_InsuranceBinder_ExpDate

  • Binder_InsuranceBinder_Time

  • Binder_InsuranceBinder_12_01AM

  • Binder_InsuranceBinder_Noon

  • Binder_InsuranceBinder_CoverageIsNotBound

  • Remarks_Attachments_StateSupplementIfApplicable

  • Remarks_Attachments_OtherCheckbox1

  • Remarks_Attachments_Other1

  • Remarks_Attachments_OtherCheckbox2

  • Remarks_Attachments_Other2

  • Remarks_Attachments

  • FraudStatementsSignature_ProducersSignature

  • FraudStatementsSignature_ProducersName

  • FraudStatementsSignature_StateProducerLicenseNo

  • FraudStatementsSignature_ApplicantsSignature

  • FraudStatementsSignature_Date

  • FraudStatementsSignature_NationalProducerNumber

  • Property_Table: A table with the following columns:

    • SerialNo

    • LocationInformation

    • Description

    • YRBuilt

    • Interest

    • Occupancy

    • Usage

  • AutomobilesAndRecreationalVehicles_Table: A table with the following columns:

    • SerialNo

    • Year

    • Make

    • Model

    • BodyType

  • Watercraft_Table: A table with the following columns:

    • SerialNo

    • Year

    • Manufacturer

    • Model

    • Length

    • HorsePower

    • MaxSpeed

  • Operators_AllMembersOfHouseHold_Table: A table with the following columns:

    • SerialNo

    • FirstName

    • MiddleName

    • LastName

    • Sex

    • MarStat

    • DateOfBirth

  • Operators_AllOperatorsOfVehicles_Table: A table with the following columns:

    • SerialNo

    • DateLIC

    • DriversLicense

    • LICState

    • SocialSecurity

    • Vehicle

    • VehiclePercentUse

    • Craft

    • CraftPercentUse

    • Other

  • OperatorInfo_HasAnyAutoAccident_Table: A table with the following columns:

    • DRV

    • Date

    • Description

    • Cost

  • Operators_AnyOperatorsConvicted_Table: A table with the following columns:

    • DRV

    • Date

    • Description

  • GeneralInfo_AnySwimmingPool_Table: A table with the following columns:

    • LOC

    • Description

    • AboveGround

    • InGround

    • ApprovedFence

    • DivingBoard

    • Slide

    • Other

  • GeneralInfo_AnyEmployees_Table: A table with the following columns:

    • LOC

    • YesOrNoFullTime

    • InsideOrOutsideFullTime

    • HrsFullTime

    • DutiesFullTime

    • YesOrNoPartTime

    • InsideOrOutsidePartTime

    • HrsPartTime

    • DutiesPartTime

    • TotalPayroll

  • GeneralInfo_AnyAnimals_Table: A table with the following columns:

    • AnimalType

    • Breed

    • BiteHistory

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