ACORD 38 ND (2004/10) – North Dakota Personal Insurance Supplement – Notice of Information Practices

Use ACORD 38 ND with all applications for personal insurance, to comply with North Dakota law requiring that written authorization from the insured (or in electronic form if the insured agrees) be obtained by theinsurer, prior to the disclosure of non-public personal and privileged information to non-affiliated third parties.

IDENTIFICATION SECTION

Date

Month/day/year (MM/DD/YYYY) on which the form is completed.

Agency

Producer’s name and address.

Code

Identification code assigned to your agency or brokerage firm by theinsurance company receiving this form.

Subcode

If your agency uses a subcode identification system with the company, enter the appropriate code.

Agency Customer ID

Customer’s identification number assigned by the agency.

Applicant‘s Name and Mailing Address

Applicant’s name and mailing address.

Telephone Number

Applicant’s telephone number.

Company Name

Issuing company’s name.

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.

Policy Number

Number exactly as it appears on the policy, including prefix and suffix symbols. Check if a new policy or a renewal.

Effective Date

Date on which the terms and conditions of the policy commenced.

Expiration Date

Date on which the terms and conditions of the policy will or have expire(d).

NOTICE OF INFORMATION PRACTICES

Toll-Free Telephone Number

Indicate the toll-free telephone number in which applicant may contact the insurer regarding disclosure authorization.

APPLICANT/NAMED INSURED’S SIGNATURE

Applicant/Named Insured’s Signature

All applicants/named insureds must sign this form.

Date

Enter the date the form was signed by the applicant/named insureds.