ACORD 653 Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 653 (2008/04) Policy Delivery Receipt Use ACORD 653, Policy Delivery Receipt, to obtain affirmation from the insured that the policy has been delivered and received by the insured.
IDENTIFICATION SECTION Name and Address ofInsurance Company The name and address of Insurance Company must be inserted before this form is used. Use the actual name of the company. Do not use group names.
APPLICANT / INSURED Named Insured Indicate the full name of the named insured as it appears on the policy.
APPLICANT / INSURED Policy Number Indicate the policy number.
APPLICANT / INSURED Date of Delivery Indicate the date the policy has been delivered and received by the insured.
SIGNATURE Signature of Named Insured Signature of named insured.
SIGNATURE Producer Name (PleasePrint) Indicate the name of the producer.
SIGNATURE Signature of Producer Signature of producer.
SIGNATURE National Producer Number (if applicable) Provide the National Producer Number if applicable.