ACORD 64US Instructions


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).