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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 38 (2008/04) |
Notice of Information Practices (Privacy) |
"Privacy Act" statutes exist in a number of states, including the following: California -Connecticut -Georgia -Illinois -Nevada New Jersey -Rhode Island -Virginia -Washington These laws exceed the requirements of the federal Fair Credit Reporting Act or other more recent federal legislation, or they require policyholder notification at the time of renewal. They establish standards for the collection, use and disclosure of information gathered in connection with insurance transactions. In each state, disclosure of such information is limited, and applicants for insurance must be informed of their rights with respect to: * Limitation of disclosure or dissemination of information, * Credit scoring information may be used with regard to eligibility for insurance and/or the premium to be charged, and that a third party may be used in connection with the development of the credit score. * Seeing personal information collected, and * Correction of any inaccurate information. |
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With the exception of personal auto applications in California, Nevada, New Jersey and Washington, all ACORD personal lines applications have been revised to include the disclosures in ACORD 38. Use ACORD 38 with personal auto applications for insurance in California, Nevada, New Jersey and Washington. The form may also be used by insurers in connection with their company-unique applications for personal insurance lines of business. The applicant must sign the form. |
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TITLE |
Notice of Information Practices (Privacy) |
This form may also be used by insurers to provide policyholder notification at time of renewal. In most states, the applicant's signature is not required at renewal. |
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TITLE |
Notice of Information Practices (Privacy) |
Additional state-specific requirements in other states are responded to by individual supplements. These states are listed below. For specific information about the use of each of these forms, refer to the individual state form information. - Arizona: ACORD 38 AZ - Florida: ACORD 66 FL - Kansas: ACORD 38 KS - Minnesota: ACORD 38 MN - New York: ACORD 38 NY - North Carolina: ACORD 66 NC - North Dakota: ACORD 38 ND - Oregon: ACORD 38 OR - Vermont: ACORD 66 VT - West Virginia: ACORD 38 WV |
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IDENTIFICATION SECTION |
Agency Name |
Producer's name. |
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IDENTIFICATION SECTION |
Agency Address |
Producer's address. |
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IDENTIFICATION SECTION |
Contact Name |
Indicate the name of the contact within the agency. |
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IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Producer's telephone number. |
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IDENTIFICATION SECTION |
Fax No. (A/C, No, Ext) |
Producer's fax number. |
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IDENTIFICATION SECTION |
E-Mail Address |
Producer's e-mail address. |
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IDENTIFICATION SECTION |
Code |
Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. |
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IDENTIFICATION SECTION |
Subcode |
If the agency uses a sub-code identification system with the company, enter the appropriate code. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Customer's identification number assigned by the agency. |
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IDENTIFICATION SECTION |
Applicant's Name and Mailing Address |
Applicant's name and mailing address. |
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IDENTIFICATION SECTION |
Phone (A/C, No) |
Applicant's telephone number. Include area code number. |
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IDENTIFICATION SECTION |
Company Name |
Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued. |
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IDENTIFICATION SECTION |
NAIC Code |
Individual company code assigned by the NAIC. |
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IDENTIFICATION SECTION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. Check if a new policy or a renewal. |
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IDENTIFICATION SECTION |
Account Number |
If applicable, account number to be used for billing purposes. This is the Billing Number assigned by the billing entity. If agency bill, the agency assigns; if direct bill the company assigns. |
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IDENTIFICATION SECTION |
Check box - New |
Check this box if this is a new policy. |
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IDENTIFICATION SECTION |
Check box - Renewal |
Check this box if the policy is being renewed. |
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IDENTIFICATION SECTION |
Effective Date |
Date on which the terms and conditions of the policy commenced. |
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IDENTIFICATION SECTION |
Expiration Date |
Date on which the terms and conditions of the policy will or have expire(d). |
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APPLICANT / NAMED INSURED'S SIGNATURE |
Applicant / Named Insured's Signature |
All applicants / named insureds must sign this form. |
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APPLICANT / NAMED INSURED'S SIGNATURE |
Date (MM/DD/YYYY) |
Enter the date the form was signed by the applicant / named insureds. (MM/DD/YYYY) |
