SCHEDULE OF PROPERTY LIMITS DATE (MM/DD/YYYY)

AGENCY PHONE COMPANY PAGE

(A/C, No, Ext): NAIC CODE:
FAX
(A/C, No): OF
INSURED / APPLICANT POLICY NUMBER EFFECTIVE DATE

HEADQUARTERS ADDRESS

COINS % APPLICABLE CAUSES OF LOSS

BASIC SPECIAL EARTHQUAKE SPRINKLER

CODE: SUBCODE: 80% 100% COVERAGE LEAKAGE EXCL
AGENCY CUSTOMER ID 90% BROAD FLOOD VANDALISM EXCL

CLASS LOC BLDG LIMITS OF INSURANCE

CODE # DESCRIPTION AND ADDRESS OF PROPERTY SUBJECT
# 1

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

DESC:

ADDRESS:

TOTAL $

INSTRUCTIONS - If a blanket rate is desired, use ACORD 139.

1. SUBJECT: B = Building F = Furniture & Fixtures BPP = Your Business Personal Property Other - specify
S = Stock M = Machinery PPO = Personal Property of Others
ACORD 159 (2004/03) © ACORD CORPORATION 1996
ACORDs provided by Forms Boss. www.FormsBoss.com; (c) Impressive Publishing 800-208-1977