ACORD 62US Instructions


Section Name Field Name Field and/or Section Description
Use ACORD 62 US, Insurance Supplement, for property coverage containing the Standard Fire Policy. The form complies with requirements of the federal Terrorism Risk Insurance Act, as amended in 2007. This 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; except that coverage for fire losses resulting from acts of terrorism covered under the Standard Fire Policy would continue; * The amount of the premium for terrorism coverage; * The amount of the premium for terrorism (fire only) coverage (if applicable).
– Use ACORD 60 US for applicants/policyholders with respect to all other lines of insurance.
– Use ACORD 64 US for applicants/policyholders with respect to workers’ compensation insurance.
TITLE ACORD 62 US (2008/02) Insurance Supplement – Standard Fire Policy Only Notice – Policyholder Disclosure -Notice of Terrorism Coverage IMPORTANT: 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.
ACCEPTANCE/REJECTION I hereby elect topurchase terrorism coverage for a 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 an exclusion of certain terrorism losses will be made part of the policy. Check this box if terrorism coverage is declined.
ACCEPTANCE/REJECTION If you decline this offer, the premium for terrorism (fire only) coverage is $ Enter the annual premium for terrorism (fire only) coverage
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).