STATEMENT OF VALUES DATE (MM/DD/YYYY)
AGENCY PHONE COMPANY NAIC CODE: PAGE
(A/C, No, Ext):
FAX
(A/C, No): OF
INSURED / APPLICANT POLICY NUMBER EFFECTIVE DATE
HEADQUARTERS ADDRESS
COINS % APPLICABLE CAUSES OF LOSS
SPECIFIC AVERAGE RATE
80% BASIC EARTHQUAKE COV REQUESTED
CODE: SUBCODE: 90% BROAD FLOOD BLANKET RATE REQUESTED
AGENCY CUSTOMER ID SPRINKLER
100% SPECIAL LEAKAGE EXCL
VANDALISM EXCL
APPLICABLE FORM NUMBERS (Attach completed forms and endorsements that require completion to provide necessary information affecting rates or loss costs)
CLASS LOC BLDG ACV/ RATE OR
CODE # DESCRIPTION AND ADDRESS OF PROPERTY RC SUBJECT 100% VALUES LOSS COST PREMIUM
#
1 2 3
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
DESC:
ADDRESS:
TOTAL $ N/A $
INSTRUCTIONS SIGNATURE
1. ACV (Actual Cash Value) or RC (Replacement Cost): If other valuation basis ALL VALUES AND LOCATION INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE
applies, provide necessary information. AND BELIEF
2. SUBJECT: INSURED'S
B = Building S = Stock F = Furniture & Fixtures M = Machinery SIGNATURE
BPP = Your Business Personal Property PPO = Personal Property of Others
BI = Business Income R = Rental Income Other - specify
TITLE:
3. RATE OR LOSS COST: For class rated property, attach class rate information form
or equivalent information for each location. For specifically rated property, attach DATE:
specific rate or loss cost information if known.
ACORD 139 (2004/03) © ACORD CORPORATION 1996
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