ACORD 38VA Instructions


Section Name Field Name Field and/or Section Description
The title of the form. ACORD 38, Notice of Information Practices (Privacy), is used to satisfy the “Privacy Act” statutes that exist in a number of states, including the following:
California -Connecticut -Georgia -Illinois -Nevada New Jersey -Rhode Island -Virginia -Washington
TITLE ACORD 38 VA (2009/10) Virginia Notice of Information Practices (Privacy) These laws exceed the requirements of the federal Fair Credit Reporting Act or other more recent federal legislation, or they require policyholder notification at the time of renewal. They establish standards for the collection, use and disclosure of information gathered in connection with insurance transactions.
TITLE In each state, disclosure of suchinformation is limited, and applicants for insurance must be informed of their rights with respect to: * Limitation of disclosure or dissemination of information, * Credit scoringinformation may be used with regard to eligibility for insurance and/or the premium to be charged, and that a third party may be used in connection with the development of thecredit score. * Seeing personal information collected, and * Correction of any inaccurate information. With the exception of personal auto applications in California, Nevada, New Jersey and Washington, all ACORD personal lines applications have been revised to include the disclosures in ACORD 38. Use ACORD 38 with personal auto applications for insurance in California, Nevada, New Jersey and Washington. The form may also be used by insurers in connection with their company-unique applications for personal insurance lines of business. The applicant must sign the form.
TITLE This form may also be used by insurers to provide policyholder notification at time of renewal. In most states, the applicant’s signature is not required at renewal. Additional state-specific requirements in other states are responded to by individual supplements. These states are listed below. For specific information about the use of each of these forms, refer to the individual state form information. – Arizona: ACORD 38 AZ – Florida: ACORD 66 FL – Kansas: ACORD 38 KS – Minnesota: ACORD 38 MN – New York: ACORD 38 NY – North Carolina: ACORD 66 NC – North Dakota: ACORD 38 ND – Oregon: ACORD 38 OR – Vermont: ACORD 66 VT – West Virginia: ACORD 38 WV
IDENTIFICATION SECTION Agency Name Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Agency Address 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.
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 Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
IDENTIFICATION SECTION Subcode Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer’s office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Applicant’s Name and Mailing Address Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address city name.
IDENTIFICATION SECTION Enter text: The applicant’s physical address county name.
IDENTIFICATION SECTION Enter code: The named insured’s mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured’s mailing address postal code.
IDENTIFICATION SECTION Phone (A/C, No) Enter number: The named insured’s primary phone number.
IDENTIFICATION SECTION Company Name 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.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION 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.
IDENTIFICATION SECTION Account Number Enter identifier: The 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 insurer assigns. If the account already exists, the agent should provide the previously assigned number.
IDENTIFICATION SECTION Check box – New Check the box (if applicable): Indicates the response expected from the company is a new issued policy.
IDENTIFICATION SECTION Check box – Renewal Check the box (if applicable): Indicates the response expected from the company is a renewed policy.
IDENTIFICATION SECTION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
APPLICANT / NAMED INSURED’S SIGNATURE Applicant / Named Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Date (MM/DD/YYYY) Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Applicant / Named Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Date (MM/DD/YYYY) Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Applicant / Named Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Date (MM/DD/YYYY) Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Applicant / Named Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED INSURED’S SIGNATURE Date (MM/DD/YYYY) Enter date: The date the form was signed by the named insured.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).