| 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). |