Section Name |
Field Name |
Field and/or Section Description |
|
|
Use ACORD 64 US, Insurance Supplement, for Workers’ Compensation insurance in all states. The form complies with requirements of the federal Terrorism Risk Insurance Act, as amended in 2007. |
|
|
This form discloses to applicants for new workers’ compensation insurance and to existing policyholders the following information: |
|
|
* Coverage for losses resulting from acts of terrorism certified under the federal program are included in their policy; * The applicant/insured(s) must sign the form; and * The portion of premium attributable for this coverage. |
|
|
– Use ACORD 60 US with respect to all other lines of insurance in all states. – Use ACORD 62 US for applicants/policyholders with respect to property insurance in Standard Fire Policy states. |
TITLE ACORD 64 US (2008/02) |
Insurance Supplement – Workers’ Compensation Only Policyholder Disclosure – Notice of Terrorism Coverage |
IMPORTANT: WHERE REQUIRED BY INDIVIDUAL STATE REGULATIONS, INSURERS INTENDING TO USE THIS FORM MUST FILETHE 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. |
PREMIUM |
Premium |
Enter the portion of the annual premium attributable to terrorism 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). |