|
Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 45 (2003/04) |
Additional Interest |
The Additional Interest form is used in multiple situations to expand upon the additional interest sections within line of business applications. This form may be used for both personal and commercial accounts. The form is used to secure information on additional interests and certificate holders. |
|
IDENTIFICATION SECTION |
Date |
Month/day/year on which the form was completed. (MM/DD/YYYY) |
|
IDENTIFICATION SECTION |
Agency |
Agency’s name and address. |
|
IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Agency’s telephone number. |
|
IDENTIFICATION SECTION |
FAX |
Agency's fax number. |
|
IDENTIFICATION SECTION |
Code |
Identification code assigned to your agency or brokerage firm by the insurance company receiving this form. |
|
IDENTIFICATION SECTION |
Subcode |
If your agency uses a subcode identification system with the company, enter the appropriate code. |
|
IDENTIFICATION SECTION |
Agency Customer ID |
Customer’s identification number assigned by the agency. |
|
IDENTIFICATION SECTION |
Applicant First Named Insured |
First Named Insured as it appears on the line of business form to which this form will be attached. |
|
IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Applicant's telephone number. |
|
IDENTIFICATION SECTION |
Effective Date |
Month/day/year on which the terms and conditions of the policy commenced or will commence. |
|
IDENTIFICATION SECTION |
Expiration Date |
Month/day/year on which the terms and conditions of the policy will terminate unless renewed. |
|
IDENTIFICATION SECTION |
CO/Plan |
Name of the insurance company that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued. Also, if applicable, indicate the type of plan or policy program (Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company. |
|
IDENTIFICATION SECTION |
Policy Number |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
|
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. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Interest |
Indicate all appropriate options for the individual named. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Rank |
Primarily used for Mortgagees - indicate the ranking such as 1st, 2nd or 3rd mortgagee. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Name and Address |
Enter the complete name and address of the additional interest, including the city, state and country. If the additional interest is the owner of a motor vehicle, and the owner is different from the Named Insured, show the owner's name here. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Reference # |
Indicate the additional interests reference number for this applicant such as the loan or mortgage number. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Certificate Required |
If a Certificate of Insurance is required check this box. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Interest in Item Number |
List the item number corresponding with the application for the item of interest for this additional insured. |
|
ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Item Description |
If needed, further clarify the item of interest in this field. For a vehicle list the make, model and VIN number. For a scheduled item list the description, such as 3 carat diamond in six point setting. |
