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ACORD 36 (2007/01) 1 of 4
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 36 (2007/01) |
AGENT/BROKER OF RECORD CHANGE |
The title of the form. ACORD 36, Agent / Broker Record of Change is used to provide authorization from your customer to the customer's current insurance company. The form notifies the insurer that you have been named as the exclusive representative with respect to policies currently in force. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
New Agency |
Enter text: The full name of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. As used here, this is the new agency. |
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IDENTIFICATION SECTION |
PHONE (A/C, No, Ext) |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION SECTION |
FAX (A/C, No) |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION SECTION |
E-MAIL ADDRESS |
Enter text: The producer's contact person e-mail address. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION SECTION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter text: The named insured's mailing address line two. |
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IDENTIFICATION SECTION |
Insurance Company Name |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. |
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IDENTIFICATION SECTION |
Current Agency |
Enter text: The full name of the producer/agency. As used here, this is the current agency. |
ACORD 36 (2007/01) 2 of 4
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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IDENTIFICATION SECTION |
Current Producer |
Enter text: The name of the individual at the producer's establishment that is the primary contact. As used here, this is the current producer. |
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TABLE |
Named Insured One |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) One |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date One |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date One |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business One |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Two |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Two |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date Two |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Two |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Two |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Three |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Three |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date Three |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Three |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Three |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Four |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Four |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
ACORD 36 (2007/01) 3 of 4
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TABLE |
Effective Date Four |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Four |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Four |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Five |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Five |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date Five |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Five |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Five |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Six |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Six |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date Six |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Six |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Six |
Enter text: The line of business written by the insurer. |
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TABLE |
Named Insured Seven |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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TABLE |
Policy Number(s) Seven |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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TABLE |
Effective Date Seven |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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TABLE |
Expiration Date Seven |
Enter date: The date on which the terms and conditions of the policy will expire. |
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TABLE |
Line of Business Seven |
Enter text: The line of business written by the insurer. |
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SIGNATURE |
Producer |
Enter text: The full name of the producer/agency. |
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SIGNATURE |
Code # |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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SIGNATURE |
Date |
Enter date: The effective date the new producer has been assigned as the exclusive representative. As used here, the date which this authorization will take effect. |
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SIGNATURE |
Insured's Signature |
Sign here: Accommodates the signature of the applicant or named insured. As used here, the insured must sign this authorization form. |
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SIGNATURE |
Date |
Enter date: The date the form was signed by the named insured. |
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SIGNATURE |
Title |
Enter text: The title of the individual in the organization or his relationship to the organization. As used here, if the insured is acting as an authorized representative of another entity, list the insured's title. |
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SIGNATURE |
Company Name |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, if the insured is acting as an authorized representative of another entity, list the company name of that entity. |
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SIGNATURE |
Street Address |
Enter text: The named insured's mailing address line one. |
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SIGNATURE |
City of Insured |
Enter text: The named insured's mailing address city name. |
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SIGNATURE |
State of Insured |
Enter code: The named insured's mailing address state or province code. |
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SIGNATURE |
Zip Code of Insured |
Enter code: The named insured's mailing address postal code. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 36 (2007/01) 4 of 4
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