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Section Name |
Field Name |
Field and/or Section Description |
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Use ACORD 38 MN with all applications for insurance, to comply with a new law requiring that all applicants for insurance must be told that credit-related information may be requested from Credit Bureaus or other organizations providing personal or privileged information in connection with the application. |
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TITLE |
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This information will be used for the purpose of making underwriting decisions which may include determinations to grant or deny coverage and/or the rates to be charged. |
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ACORD 38 MN (2005/08) |
Minnesota Authorization |
This authorization is required pursuant to Minnesota Statute 72A.501. |
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IDENTIFICATION SECTION |
Agency |
Producer’s name and address. |
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Identification code assigned to your agency or brokerage firm by the insurance company |
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IDENTIFICATION SECTION |
Code |
receiving this form. |
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If your agency uses a subcode identification system with the company, enter the |
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IDENTIFICATION SECTION |
Subcode |
appropriate code. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Customer’s identification number assigned by the agency. |
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Applicant's Name and Mailing |
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IDENTIFICATION SECTION |
Address |
Applicant's name and mailing address. |
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IDENTIFICATION SECTION |
Telephone Number |
Applicant's telephone number. |
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IDENTIFICATION SECTION |
Company Name |
Issuing company’s name. |
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If applicable, account number to be used for billing purposes. This is the Billing Number |
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assigned by the billing entity. If agency bill, the agency assigns; if direct bill the company |
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IDENTIFICATION SECTION |
Account Number |
assigns. |
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APPLICANT/NAMED |
Applicant/Named Insured's |
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INSURED'S SIGNATURE |
Signature |
All applicants/named insureds must sign this form. |
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APPLICANT/NAMED |
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INSURED'S SIGNATURE |
Date |
Enter the date the form was signed by the applicant/named insureds. |