Transcription of STATEMENT OF VALUES DATE (MM/DD/YYYY) …
1 ACV/RCRATE ORLOSS COST13 date (MM/DD/ yyyy )PHONE(A/C, No, Ext):AGENCYCOMPANYPAGENAIC CODE:FAX(A/C, No): policy NUMBERINSURED / APPLICANTEFFECTIVE DATEHEADQUARTERS ADDRESSCOINS %APPLICABLE CAUSES OF LOSSCODE:SUBCODE:AGENCY CUSTOMER IDAPPLICABLE FORM NUMBERS (Attach completed forms and endorsements that require completion to provide necessary information affecting rates or loss costs)CLASS CODELOC# DESCRIPTION AND ADDRESS OF PROPERTYSUBJECT100% VALUESPREMIUMBLDG#N/AALL VALUES AND LOCATION INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGEAND BELIEFOFSPECIFIC AVERAGE RATEREQUESTED80%BASICEARTHQUAKE COV90%BROADFLOODBLANKET RATE REQUESTEDSPRINKLERLEAKAGE EXCL100%SPECIALVANDALISM EXCLDESC:ADDRESS:DESC:ADDRESS:DESC:ADDRE SS:DESC:ADDRESS:DESC:ADDRESS:DESC:ADDRES S:DESC:ADDRESS:DESC:ADDRESS:DESC:ADDRESS :DESC:ADDRESS:DESC:ADDRESS:ACV (Actual Cash value ) or RC (Replacement Cost): If other valuation basisapplies, provide necessary ' :B = Building S = Stock F = Furniture & Fixtures M = MachineryBPP = Your Business Personal Property PPO = Personal Property of Others BI = Business Income R = Rental Income Other - :RATE OR LOSS COST: For class rated property, attach class rate information formor equivalent information for each location.
2 For specifically rated property, attachspecific rate or loss cost information if $INSTRUCTIONSSIGNATUREACORD 139 (2004/03) ACORD CORPORATION 1996 STATEMENT OF VALUES2$
