The Department of Defense Form 175, also known as the DD 175, is a form used by members of the United States military to document their military service. The DD 175 is used to record your name, social security number, military status and other important information about your service. The form is also used to maintain a record of your awards and decorations. If you are a member of the military, it is important to keep a copy of your DD175 up-to-date and accurate.
| Question | Answer |
|---|---|
| Form Name | Dd 175 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | fillable dd 175, dd 175 printable, dd form 175, dd175 pdf |
COMMERCIAL POLICY CHANGE REQUEST
DATE (MM/DD/YYYY)
AGENCY |
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CARRIER |
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NAIC CODE |
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ATTENTION |
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POLICY NUMBER |
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CONTACT |
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NAME: |
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PHONE |
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ACCOUNT NUMBER |
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(A/C, No, Ext): |
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FAX |
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(A/C, No): |
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EFFECTIVE DATE OF CHANGE |
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POLICY INCEPTION DATE |
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POLICY EXPIRATION DATE |
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ADDRESS: |
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CODE: |
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SUBCODE: |
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AGENCY CUSTOMER ID: |
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POLICY |
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PROPERTY |
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AUTO |
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WORKERS COMP |
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TYPE |
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NAMED INSURED |
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INLAND MARINE |
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TRUCKERS |
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UMBRELLA |
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MOTOR CARRIERS |
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INSURED'S NAME AND MAILING ADDRESS, IF CHANGED (INC ZIP+4) |
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GENERAL LIABILITY |
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BUSINESS OWNERS |
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THIS IS AN ACKNOWLEDGEMENT OF YOUR REQUEST. UPON APPROVAL, THE COMPANY'S |
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RECORDS WILL BE ADJUSTED ACCORDINGLY, AND IF A PREMIUM ADJUSTMENT IS |
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REQUIRED, IT WILL BE DONE AT PREMIUM AUDIT OR BY ENDORSEMENT. |
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SHORT DESCRIPTION OF CHANGES / REMARKS (Attach ACORD 101, Additional Remarks Schedule, if more space is required) |
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PREMISES INFORMATION |
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ADD |
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CHANGE |
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DELETE |
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LOC # |
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BLD # |
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STREET, CITY, COUNTY, STATE, ZIP+4 |
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CITY LIMITS |
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INTEREST |
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YR BUILT |
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PART OCCUPIED |
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INSIDE |
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OWNER |
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OUTSIDE |
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TENANT |
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NATURE OF BUSINESS / DESCRIPTION OF OPERATIONS BY PREMISE(S) |
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ADD |
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CHANGE |
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DELETE |
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LOC # |
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BLD # |
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POLICY LIMIT(S) CHANGED |
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ADD |
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CHANGE |
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DELETE |
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VEH # |
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YEAR |
MAKE: |
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BODY |
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VEHICLE TYPE |
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SYM / AGE |
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COLL |
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TYPE: |
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OTC SYM |
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SYM |
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MODEL: |
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V.I.N.: |
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PP |
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SPEC |
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COML |
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GARAGING |
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STREET (Required in KY) |
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CITY |
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COUNTY |
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ADDRESS |
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LIC |
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TERR |
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GVW / GCW |
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CLASS |
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SIC |
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SEAT CP |
RADIUS |
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FARTHEST TERMINAL |
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COST NEW |
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STATE |
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USE |
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COMM'L |
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FOR HIRE |
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CHECK |
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ADD'L NO- |
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UNDRINS |
F |
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LSP |
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RENT |
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DEDUCTIBLES |
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ACV |
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COMP/ |
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SPEC |
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COVERAGES |
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FAULT |
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MOTOR |
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REIMB |
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OTC |
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C OF L |
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PLEASURE |
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RETAIL |
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LIAB |
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MED PAY |
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TOWING |
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COMP/ |
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FG |
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AA |
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ST AMT |
$ |
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& LABOR |
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OTC |
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FARM |
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SERVICE |
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NO- |
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UNINS |
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SPEC |
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FTW |
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COLL |
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$ |
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$ |
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COLL |
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FAULT |
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MOTOR |
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C OF L |
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DRIVE TO |
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< 15 MILES |
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15 MILES + |
NET VEH |
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TOTAL PREM: $ |
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WORK / SCHOOL |
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DR/CR: |
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LIABILITY |
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NO FAULT |
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ADD'L NO FAULT |
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MEDICAL PAYMENTS |
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UNINSURED MOTORISTS |
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UNDERINSURED MOTORISTS |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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POLICY LIMIT(S) CHANGED |
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ADD |
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CHANGE |
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DELETE |
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VEH # |
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YEAR |
MAKE: |
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BODY |
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VEHICLE TYPE |
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SYM / AGE |
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COMP / |
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COLL |
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TYPE: |
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OTC SYM |
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SYM |
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MODEL: |
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V.I.N.: |
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PP |
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SPEC |
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COML |
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GARAGING |
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STREET (Required in KY) |
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CITY |
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COUNTY |
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STATE |
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ZIP |
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ADDRESS |
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LIC |
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TERR |
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GVW / GCW |
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CLASS |
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SIC |
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FACTOR |
SEAT CP |
RADIUS |
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FARTHEST TERMINAL |
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COST NEW |
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STATE |
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$ |
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USE |
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COMM'L |
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FOR HIRE |
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CHECK |
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ADD'L NO- |
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UNDRINS |
F |
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LSP |
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RENT |
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DEDUCTIBLES |
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ACV |
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COMP/ |
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COVERAGES |
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REIMB |
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OTC |
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C OF L |
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PLEASURE |
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RETAIL |
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LIAB |
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MED PAY |
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COMP/ |
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FG |
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AA |
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ST AMT |
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& LABOR |
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OTC |
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FARM |
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SERVICE |
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NO- |
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UNINS |
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SPEC |
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FTW |
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COLL |
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$ |
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COLL |
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FAULT |
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MOTOR |
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C OF L |
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DRIVE TO |
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< 15 MILES |
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15 MILES + |
NET VEH |
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TOTAL PREM: $ |
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WORK / SCHOOL |
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DR/CR: |
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LIABILITY |
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NO FAULT |
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ADD'L NO FAULT |
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MEDICAL PAYMENTS |
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UNINSURED MOTORISTS |
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UNDERINSURED MOTORISTS |
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$ |
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$ |
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$ |
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$ |
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$ |
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$ |
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DRIVER INFORMATION (List drivers who frequently use own vehicles) |
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ADD |
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CHANGE |
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DELETE |
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DRIVER |
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NAME (Include address, if required) |
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SEX |
MAR |
DATE OF BIRTH |
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YRS |
YEAR |
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DRIVERS LICENSE NUMBER/ |
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STATE |
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DATE |
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BROADEN. |
DOC |
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USE |
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% |
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# |
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STAT |
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EXP |
LIC |
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SOCIAL SECURITY NUMBER |
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LIC |
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HIRE |
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VEH # |
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USE |
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ACORD 175 (2011/03) |
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Page 1 of 2 |
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© |
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The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION RATING INFORMATION
AGENCY CUSTOMER ID:
TYPE OF CHANGE
STATE LOC
CLASS CODE
DESCR
CODE
CATEGORIES, DUTIES, CLASSIFICATIONS
#OF
EMPLOYEES FULL PART TIME TIME
ESTIMATED
ANNUAL
REMUNERATION
PROPERTY / INLAND MARINE - PREMISES INFORMATION
PREMISES #:
BUILDING #:
ADD
CHANGE
DELETE
SUBJECT OF INSURANCE
AMOUNT
COINS %
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VALUATION |
CAUSES OF LOSS |
INFLATION |
DEDUCTIBLE |
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GUARD % |
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FORMS AND CONDITIONS TO APPLY
ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CONSTRUCTION TYPE |
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DISTANCE TO |
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FIRE DISTRICT / CODE NUMBER |
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PROT CL |
# STORIES |
# BASM'TS |
|
YR BUILT |
TOTAL AREA |
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HYDRANT |
FIRE STAT |
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FT |
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MI |
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BUILDING IMPROVEMENTS |
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PLUMBING, YR: |
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BLDG CODE |
INSPECTED? |
ROOF |
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OTHER OCCUPANCIES |
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GRADE |
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Y / N |
TYPE |
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WIRING, YR: |
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HEATING, YR: |
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ROOFING, YR: |
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OTHER: |
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TAX CODE |
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RIGHT EXPOSURE & DISTANCE |
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LEFT EXPOSURE & DISTANCE |
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REAR EXPOSURE & DISTANCE |
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BURGLAR ALARM TYPE |
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CERTIFICATE # |
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EXPIRATION DATE |
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EXTENT |
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GRADE |
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CENTRAL STATION |
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WITH KEYS |
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BURGLAR ALARM INSTALLED AND SERVICED BY |
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# GUARDS/WATCHMEN |
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CLOCK HOURLY |
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PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems) |
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FIRE ALARM MANUFACTURER |
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CENTRAL STATION |
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LOCAL GONG |
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INLAND MARINE - SCHEDULED EQUIPMENT |
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% COINSURANCE: |
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ADD |
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CHANGE |
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DELETE |
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# |
MODEL |
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DESCRIPTION (TYPE, MANUFACTURER, MODEL, CAPACITY, ETC) |
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ID #/SERIAL # |
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DATE |
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NEW/USED |
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AMOUNT OF |
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YEAR |
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PURCHASED |
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INSURANCE |
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$ |
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$ |
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GENERAL LIABILITY - LIMITS |
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CHANGE |
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|||||
GENERAL AGGREGATE |
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$ |
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DAMAGE TO RENTED PREMISES |
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$ |
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PRODUCTS & COMPLETED OPERATIONS AGGREGATE |
$ |
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MEDICAL EXPENSE (Any one person) |
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$ |
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PERSONAL & ADVERTISING INJURY |
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$ |
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EMPLOYEE BENEFITS |
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$ |
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EACH OCCURRENCE |
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$ |
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$ |
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|||||
GENERAL LIABILITY - SCHEDULE OF HAZARDS
TYPE OF LOC CHANGE #
HAZ
#
CLASSIFICATION
CLASS
CODE
PREMIUM
BASIS
EXPOSURE
TERR
PREMIUM BASIS CODES
(S)GROSS SALES - PER $1,000/SALES
(P)PAYROLL - PER $1,000/PAY
(A)AREA - PER 1,000/SQ FT
(C)TOTAL COST - PER $1,000/COST
(M)ADMISSIONS - PER 1,000/ADM
(U)UNIT - PER UNIT
(T)OTHER
UMBRELLA |
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CHANGE |
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||
LIMIT OF LIABILITY |
$ |
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OTHER |
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RETAINED LIMIT |
$ |
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(DESCRIBE) |
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ADDITIONAL INTEREST |
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INTEREST |
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NAME AND ADDRESS RANK: |
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EVIDENCE: |
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CERTIFICATE |
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INTEREST IN ITEM NUMBER |
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ADDITIONAL |
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MORTGAGEE |
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LOCATION: |
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BUILDING: |
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INSURED |
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EMPLOYEE |
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OWNER |
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VEHICLE: |
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BOAT: |
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AS LESSOR |
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LIENHOLDER |
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REGISTRANT |
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AIRPORT: |
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LOSS PAYEE |
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ITEM CLASS: |
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ITEM: |
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ITEM DESCRIPTION |
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REFERENCE / LOAN #:
SIGNATURE (Any deletion or reduction in coverage requires the Insured's signature)
PRODUCER'S SIGNATURE
PRODUCER'S NAME (Please Print)
STATE PRODUCER LICENSE NO (Required in Florida)
INSURED'S SIGNATURE
DATE
NATIONAL PRODUCER NUMBER
ACORD 175 (2011/03) |
Page 2 of 2 |