ACORD 60US Instructions


Section Name Field Name Field and/or Section Description
Use ACORD 60 US, Insurance Supplement, for all lines of insurance covered by the federal Terrorism Risk Insurance Act, as amended in 2007, in all states except for the following exceptions:
– Use ACORD 62 US for property coverage provided by the Standard Fire Policy. – Use ACORD 64 US for workers’ compensation coverage.
The form complies with requirements of the federal Terrorism Risk Insurance Act, as amended in 2007. The form discloses to applicants fornew insurance and to existing policyholders the following information:
* Coverage for losses resulting from acts of terrorism certified under the federal program must be offered; * The applicant/insured can accept or reject the coverage; * The amount of premium for this coverage.
IMPORTANT:
TITLE ACORD 60 US (2008/02) Insurance Supplement -Policyholder Disclosure – Notice of Terrorism Coverage WHERE REQUIRED BY INDIVIDUAL STATE REGULATIONS, INSURERS INTENDING TO USE THIS FORM MUST FILE THE FORM WHERE REQUIRED. ACORD CANNOT MAKE THESE FILINGS FOR INSURERS.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency Producer’s name
IDENTIFICATION SECTION Applicant/Named Insured Indicate applicant name. If named insured, name exactly as it appears on the policy.
IDENTIFICATION SECTION Policy # Number exactly as it appears on the policy, including prefix and suffix symbols.
Name of the applicableinsurance company. Do not use group names; use the actual
IDENTIFICATION SECTION Carrier name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code Enter the NAIC code of the applicable insurance company.
I hereby elect to purchase
terrorism coverage for a
ACCEPTANCE/REJECTION prospective premium of $ Check this box if terrorism coverage is elected.
ACCEPTANCE/REJECTION Premium Enter the premium for terrorism coverage.
ACCEPTANCE/REJECTION I hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I will have no coverage for losses resulting from certified acts of terrorism. Check this box if terrorism coverage is declined.
POLICYHOLDER/ APPLICANT’S SIGNATURE Policyholder/Applicant’s Signature All policyholder/applicants must sign this form if they reject terrorism coverage.
POLICYHOLDER/ APPLICANT’S SIGNATURE Print Name Print the name of the policyholder/applicant.
POLICYHOLDER/ APPLICANT’S SIGNATURE Date Enter the date the form was signed (MM/DD/YYYY).
POLICYHOLDER/ APPLICANT’S SIGNATURE Effective Date Date on which the terms and conditions of the policy commenced (MM/DD/YYYY).