Transcription of UMBRELLA / EXCESS SECTION DATE (MM/DD/YYYY)
{{id}} {{{paragraph}}}
Example: dental hygienist
UMBRELLA / EXCESS SECTION DATE (MM/DD/YYYY)
acord 131 (2016/04)$$VOLUNTARYA ttach to acord 125 IMPORTANT - If CLAIMS MADE is checked in the POLICY INFORMATION SECTION below, this is an application for a claims-made all provisions of the policy DATENAMED INSURED(S)POLICY NUMBERNAIC CODECARRIERAGENCYAGENCY CUSTOMER ID:NAME OF BENEFIT PROGRAM$$$RETROACTIVE DATE FOR EBLRETAINED LIMIT FOR EBLAGGREGATE LIMIT FOR EBLLIMIT OF INSURANCE (Ea Employee)EMPLOYEE BENEFITS LIABILITYUMBRELLAEXCESSNEWRENEWALPOLICY INFORMATION$EXPIRING POL #:FIRST DOLLARDEFENSE (Y / N)EA OCC$TRANSACTION TYPELIMIT OF LIABILITYRETAINED LIMITRETROACTIVE DATEPROPOSEDOCCURRENCECLAIMS MADECURRENTThe acord name and logo are registered marks of ACORDPage 1 of 5 1991-2016 acord CORPORATION.
ACORD 131 (2016/04) SIGNATURE 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,
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: