ACORD 21 Instructions


Section Name Field Name Field and/or Section Description
The title of the form. ACORD 21, Certificate of Aircraft Insurance, is “issued as a matter of information only, and confers no rights upon the certificate holder. This certificate does not amend, extend, or alter the coverage afforded by policies”.
The above information is included in the opening statement of the form.
TITLE ACORD 21 (2009/05) Certificate of Aircraft Insurance If the receiver of the form wants to verifythat coverage exists on a policy and has no direct interest in the policy, use the certificate of insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as an additional insured, the liability policy must be amended by endorsement, to provide the appropriate coverage for the interested party prior to issuing a certificate of insurance (since the certificate confers no rights upon the holder and does not amend the policy).
TITLE Purpose of the Certificate of Insurance The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder. In a 1974 court decision (United States Pipe & Foundry Co. v United States Fidelity & Guar. Co, 505 F. 2d 88 (5th Cir. 1974), the court ruled that a certificate is not a contract between the holder and theinsurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: “The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration.” Although many companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract.

ACORD 21 (2009/05) 1 of 10

 

Section Name Field Name Field and/or Section Description
TITLE The Certificate of Aircraft Insurance is used for most casualty situations in which the insured has requested certification to a third party of issued casualty coverages. The ACORD Certificate should be issued only in compliance with company instructions. ACORD recommends that the Certificate NOT be used in the following situations: * To waive rights * To provide information to the owner of a leased motor vehicle or the lender about both liability and physical damage coverages applying to the vehicle (ACORD 23, Automobile Certificate of Insurance, should be used for this) * To quote wording from a contract * To attach to an endorsement * To quote any wording that amends a policy unless the policy itself has been amended
TITLE IMPORTANT Unlike ACORD 23, 24, 25, 27 and 28, certificates and evidence forms, ACORD 20 and 21 do not require filing since they deal exclusively with uncontrolled/unregulated inland marine insurance. Nevertheless, virtually every state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved as a policy form. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.
IDENTIFICATION SECTION Date (MM/DD/YYYY) Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
 

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name Enter text: The name of the individual at the producer’s establishment that is the primary contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext) Enter number: The producer’s contact person’s phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext) Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address Enter text: The producer’s contact person e-mail address.
IDENTIFICATION SECTION Producer Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
INSURED Name & Mailing Address Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INSURED Enter text: The named insured’s mailing address line one.
INSURED Enter text: The named insured’s mailing address line two.
INSURED Enter text: The named insured’s mailing address city name.
INSURED Enter code: The named insured’s mailing address state or province code.
INSURED Enter code: The named insured’s mailing address postal code.
INSURERS AFFORDING COVERAGE Company A Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company A % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company A NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
INSURERS AFFORDING COVERAGE Company B Enter text: The insurer’s full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company B % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company B NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
 

Section Name Field Name Field and/or Section Description
INSURERS AFFORDING COVERAGE Company C Enter text: The insurer’s full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company C % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company C NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
INSURERS AFFORDING COVERAGE Company D Enter text: The insurer’s full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company D % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company D NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
INSURERS AFFORDING COVERAGE Company E Enter text: The insurer’s full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company E % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company E NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
INSURERS AFFORDING COVERAGE Company F Enter text: The insurer’s full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name.
INSURERS AFFORDING COVERAGE Company F % Enter percentage: The percentage interest the insurer has in the policy.
INSURERS AFFORDING COVERAGE Company F NAIC # Enter code: The identification code assigned to the insurer by the NAIC.
POLICY INFORMATION Certificate Number Enter number: The producer assigned number for the certificate.
POLICY INFORMATION Revision Number Enter number: The producer assigned revision number for the certificate.
POLICY INFORMATION Industrial Aid Check the box (if applicable): Indicates the type of policy is aircraft – industrial aid.
POLICY INFORMATION Pleasure & Business Check the box (if applicable): Indicates the type of policy is aircraft – pleasure and business.
POLICY INFORMATION Commercial Check the box (if applicable): Indicates the type of policy is aircraft – commercial.
POLICY INFORMATION Non-Owned Check the box (if applicable): Indicates the type of policy is aircraft – non-owned.
 

Section Name Field Name Field and/or Section Description
POLICY INFORMATION Other Checkbox Check the box (if applicable): Indicates the type of policy/perils insured is other than those listed.
POLICY INFORMATION Other Description Enter text: The description of the type of policy issued to the insured.
POLICY INFORMATION Airplane Check the box (if applicable): Indicates Airplane is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Helicopter Check the box (if applicable): Indicates Helicopter is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Mixed Fleet Check the box (if applicable): Indicates Mixed Fleet is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Excess Check the box (if applicable): Indicates Excess is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Quota Share Check the box (if applicable): Indicates Quota Share is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Liability Only Check the box (if applicable): Indicates Liability Only is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Hull & Liability Check the box (if applicable): Indicates Hull & Liability is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Hull Only Check the box (if applicable): Indicates Hull Only is the line of business subcode that further refines the line of business code.
POLICY INFORMATION Other Checkbox Check the box (if applicable): Indicates the line of business subcode that further refines the line of business code is other than those listed.
POLICY INFORMATION Other Description Enter text: The line of business subcode that further refines the line of business code.
AIRCRAFT INFORMATION ACORD 333, Aircraft Schedule Attached Check the box (if applicable): Indicates an ACORD 333, Aircraft Schedule, is attached to the certificate.
AIRCRAFT INFORMATION Year Enter year: The year of the aircraft.
AIRCRAFT INFORMATION Make Enter text: The manufacturer of the aircraft.
AIRCRAFT INFORMATION Model Enter text: The model of the aircraft.
AIRCRAFT INFORMATION Serial Number Enter identifier: The serial number of the aircraft.
AIRCRAFT INFORMATION Registration Number Enter identifier: The registration number of the aircraft (a.k.a. tail number).
AIRCRAFT INFORMATION Territory Enter text: The description of the rating territory for the aircraft.
AIRCRAFT COVERAGES Insurer Letter Enter code: The company letter of the insurer, as identified in the “Insurers Affording Coverage” form section, associated with the Aircraft Policy.
 

Section Name Field Name Field and/or Section Description
AIRCRAFT COVERAGES Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. As used here, the Aircraft policy number.
AIRCRAFT COVERAGES Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, the Aircraft policy effective date.
AIRCRAFT COVERAGES Expiration Date Enter date: The date on which the terms and conditions of the policy will expire. As used here, the Aircraft policy expiration date.
AIRCRAFT COVERAGES Additional Insured? (Y / N) Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured for any of the Aircraft policy coverages described in the certificate.
AIRCRAFT COVERAGES Aircraft Hull Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Hull Option Description Enter text: The description of the option being requested. Examples: All Risk Ground and Flight, Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT COVERAGES Aircraft Hull Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Hull Option Description Enter text: The description of the option being requested. Examples: All Risk Ground and Flight, Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT COVERAGES Aircraft Hull Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Hull Option Description Enter text: The description of the option being requested. Examples: All Risk Ground and Flight, Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT COVERAGES Aircraft Hull Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Hull Option Description Enter text: The description of the option being requested. Examples: All Risk Ground and Flight, Ground and Taxi, Ground Not in Flight, Ground Not in Motion, Ground Only, In Motion Excluding Flight, Excluding in Flight, Aircraft Storage in Hangar.
AIRCRAFT COVERAGES Aircraft Hull Limit Enter limit: The limit amount for aircraft hull coverage.
AIRCRAFT COVERAGES Aircraft Hull Limit Applies To Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT COVERAGES Aircraft Hull Limit Enter limit: The limit amount for aircraft hull coverage.
ACORD 21 (2009/05) 7 of 10

Section Name Field Name Field and/or Section Description
AIRCRAFT COVERAGES Aircraft Hull Limit Applies To Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT COVERAGES Aircraft Hull Limit Enter limit: The limit amount for aircraft hull coverage.
AIRCRAFT COVERAGES Aircraft Hull Limit Applies To Enter code: The code identifying what the limit applies to. Examples: Total Aircraft, Aircraft while on Floats, Aircraft while on Skis, Floats, Skis.
AIRCRAFT COVERAGES Aircraft Liability Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Liability Option Description Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only, Total Limit.
AIRCRAFT COVERAGES Aircraft Liability Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Liability Option Description Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only, Total Limit.
AIRCRAFT COVERAGES Aircraft Liability Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Liability Option Description Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only, Total Limit.
AIRCRAFT COVERAGES Aircraft Liability Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Aircraft Liability Option Description Enter text: The description of the option being requested. Examples: Adjacent Fields/CBT, BI Only, Chemical BI, Chemical BI and PD, Chemical PD, CSL BI and PD, CSL BI and PD Excluding Passengers, CSL BI and PD Including Passengers, Excluding Chemicals, PD Only, Total Limit.
AIRCRAFT COVERAGES Aircraft Liability Ea Occ Enter limit: The each occurrence limit amount for aircraft liability coverage.
AIRCRAFT COVERAGES Aircraft Liability Ea Pass Enter limit: The each passenger limit amount for aircraft liability coverage.
AIRCRAFT COVERAGES Aircraft Liability Ea Per Enter limit: The each person limit amount for aircraft liability coverage.
AIRCRAFT COVERAGES Aircraft Liability Aggr Enter limit: The aggregate limit amount for aircraft liability coverage.
AIRCRAFT COVERAGES Medical Payments Including Crew Check the box (if applicable): Indicates the crew is included in the medical payments coverage.
 

Section Name Field Name Field and/or Section Description
AIRCRAFT COVERAGES Medical Payments Excluding Crew Check the box (if applicable): Indicates the crew is excluded from the medical payments coverage.
AIRCRAFT COVERAGES Medical Payments Ea Per Enter limit: The each person limit amount for medical payments coverage.
AIRCRAFT COVERAGES Coverage Code Enter code: The code for the coverage.
AIRCRAFT COVERAGES Coverage Description Enter text: The description of other coverage (not the limit) on the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Coverage Code Enter code: The code for the coverage.
AIRCRAFT COVERAGES Coverage Description Enter text: The description of other coverage (not the limit) on the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
 

Section Name Field Name Field and/or Section Description
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Coverage Code Enter code: The code for the coverage.
AIRCRAFT COVERAGES Coverage Description Enter text: The description of other coverage (not the limit) on the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Coverage Code Enter code: The code for the coverage.
AIRCRAFT COVERAGES Coverage Description Enter text: The description of other coverage (not the limit) on the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s)
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
 

Section Name Field Name Field and/or Section Description
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Option Checkbox Check the box (if applicable): Indicates a coverage option applies to the coverage.
AIRCRAFT COVERAGES Option Description Enter text: The description of the option being requested.
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
AIRCRAFT COVERAGES Limit Enter limit: The limit amount for the coverage.
AIRCRAFT COVERAGES Applies To Enter code: The code identifying what the limit applies to (i.e. per occurrence).
DESCRIPTION OF OPERATIONS / REMARKS (Attach ACORD 101, Additional Remarks Schedule if more space is required) Description of Operations / Remarks Enter text: The Certificate Of Aircraft Insurance general remarks including the description of operations. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
CERTIFICATE HOLDER Certificate Holder Name & Address Enter text: The certificate holder’s full name.
CERTIFICATE HOLDER Enter text: The certificate holder’s mailing address line one.
CERTIFICATE HOLDER Enter text: The certificate holder’s mailing address line two.
CERTIFICATE HOLDER Enter text: The certificate holder’s mailing address city name.
CERTIFICATE HOLDER Enter code: The certificate holder’s mailing address state or province code.
CERTIFICATE HOLDER Enter code: The certificate holder’s mailing address postal code.
CANCELLATION Days to Cancel Enter number: The number of days in which the insurer will endeavor to mail a written cancellation notice. This amount is subject to approval by the insurer(s).
CANCELLATION Authorized Representative Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. As used here, the authorized representative by all companies to issue Certificates.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).