ACORD 67 Instructions

Section Name Field Name Field and/or Section Description
State laws in Illinois, Kentucky and West Virginia require that mine subsidence insurance coverage must be provided to dwelling insureds located in specified counties, unless the insured rejects coverage in writing.
Indiana law requires that Mine Subsidence Coverage be made available in specified counties. Inaddition, Illinois, and West Virginia law requires that mine subsidence insurance be made available, on an optional basis, to dwelling insureds in the other counties.
TITLE ACORD 67 (2008/04) Illinois / Indiana / Kentucky / West Virginia Mine SubsidenceProperty InsuranceSupplement Use ACORD 67 with ACORD 88, Residential Section, to comply with the laws mentioned above.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification numberassigned by the agency or brokerage.
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.
IDENTIFICATION SECTION Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless
IDENTIFICATION SECTION Expiration Date renewed.
Check this box if the applicant/named insured does not desire Mine Subsidence Coverage
and waives any right to such coverage under this policy or any future policy covering the
REJECTION/SELECTION Check Box property described in the Declarations, unless requested in writing.
Check this box if the applicant/named insured does wish to purchase Mine Subsidence
REJECTION/SELECTION Limit Enter the desired limit.
SIGNATURE Applicant Signature Applicant must sign the supplement.