ACORD 36 Instructions


Section Name Field Name Field and/or Section Description
Use ACORD 36 to provide authorization from your customer to the customer’s current
TITLE insurance company. The form notifies the insurer that you have been named as the
ACORD 36 (2007/01) Agent / Broker of Record Change exclusive representative with respect to policies currently in force.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
Name and address of the new Agency to be represented by the producer named in the
IDENTIFICATION SECTION Agency authorization form as the exclusive representative.
Identification code assigned to the agency or brokerage firm bythe insurance company
IDENTIFICATION SECTION Code receiving this form.
If the agency or brokerage uses a sub-code identification system with the company, enter
IDENTIFICATION SECTION Sub Code the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
Name of the insurance company that will receive the authorization form. Do not use group
IDENTIFICATION SECTION Insurance Company Name names, use the actual name of the company within the group that issued the policy.
IDENTIFICATION SECTION Current Agency Indicate the name of the currentinsurance agency.
IDENTIFICATION SECTION Current Producer Indicate the name of the current producer.
Named Insured (as it appears on
TABLE policy) Indicate the named insured exactly as it appears on the policy.
The number assigned by the insurance company for the policy. In general, policy numbers
TABLE Policy Number will not appear on new business applications since they are not known at that point in time.
TABLE Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless
TABLE Expiration Date renewed.
TABLE Line of Business Line of business covered by the policy.
TABLE Producer Name Name of the producer designated as the exclusive representative of the insured.
TABLE Code # Identification code assigned to the producer by the agency.
TABLE Date Date (MM/DD/YYYY) on which this authorization will take effect.
SIGNATURE Insured’s Signature The insured must sign this authorization form.
SIGNATURE Date The date the insured signed the authorization form.
SIGNATURE Title (If Applicable) If the insured is acting as an authorized representative of another entity, list the insured’s title.
SIGNATURE Company Name (If Applicable) If the insured is acting as an authorized representative of another entity, list the company name of that entity.
SIGNATURE Street Address of Insured Indicate the street address of the insured.
SIGNATURE City of Insured Indicate the city of the insured.
SIGNATURE State of Insured Indicate the state of the insured.
SIGNATURE Zip Code of Insured Indicate the zip code of the insured.