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.
Month/day/year (MM/DD/YYYY) on which the form is completed.
Producer’s name and address.
Identification code assigned to your agency or brokerage firm by theinsurance company receiving this form.
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.
Applicant’s telephone number.
Issuing company’s name.
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.
Number exactly as it appears on the policy, including prefix and suffix symbols. Check if a new policy or a renewal.
Date on which the terms and conditions of the policy commenced.
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.
Enter the date the form was signed by the applicant/named insureds.