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ACORD 38 NY Instructions
 

 
Section Name Field Name Field and/or Section Description
TITLE ACORD 38 NY (2005/04) New York Personal Insurance Supplement - Notice of Information Practices Use ACORD 38 NY with all personal lines insurance applications, to comply with New York insurance law (Article 28) and Regulation 182. Applicants are required to be notified, in a form separate from the application, that a credit report might be obtained and credit-based scoring used in connection with the insurance being applied for. The name and address of the insurance company, the company's toll free telephone number and the name of the consumer reporting agency must be entered on the form.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer’s name and address.
Identification code assigned to your agency or brokerage firm by the insurance company
IDENTIFICATION SECTION Code receiving this form.
If your agency uses a subcode identification system with the company, enter the
IDENTIFICATION SECTION Subcode appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency.
Applicant's Name and Mailing
IDENTIFICATION SECTION Address Applicant's name and mailing address.
IDENTIFICATION SECTION Telephone Number Applicant's telephone number.
IDENTIFICATION SECTION Company Name and Address Issuing company’s name and address.
If applicable, account number to be used for billing purposes. This is the Billing Number
assigned by the billing entity. If agency bill, the agency assigns; if direct bill the company
IDENTIFICATION SECTION Account Number assigns.
IDENTIFICATION SECTION Toll Free Telephone Number Issuing company’s toll free telephone number.
Number exactly as it appears on the policy, including prefix and suffix symbols. Check if a
IDENTIFICATION SECTION Policy Number new policy or a renewal.
IDENTIFICATION SECTION Effective Date Date on which the terms and conditions of the policy commenced.
IDENTIFICATION SECTION Expiration Date Date on which the terms and conditions of the policy will or have expire(d).

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Section Name Field Name Field and/or Section Description
APPLICANT/NAMED INSURED'S SIGNATURE Consumer Reporting Agency Insert the name of the consumer reporting agency.
APPLICANT/NAMED INSURED'S SIGNATURE Applicant/Named Insured's Signature All applicants/named insureds must sign this form.
APPLICANT/NAMED INSURED'S SIGNATURE Date Enter the date the form was signed by the applicant/named insureds.