Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 36 (2007/01)
AGENT/BROKER OF RECORD
CHANGE
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.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION New Agency
Enter text: The full name of the producer/agency. As used here, this is the new agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency. As used here, this is the
new agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency. As used here, this is the
new agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency. As used here, this is
the new agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency. As used
here, this is the new agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency. As used here, this is
the new agency.
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.
IDENTIFICATION SECTION FAX (A/C, No)
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-MAIL ADDRESS
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
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).
IDENTIFICATION SECTION Agency Customer ID
Enter text: The named insured's mailing address line two.
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.
IDENTIFICATION SECTION Current Agency
Enter text: The full name of the producer/agency. As used here, this is the current agency.
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
ACORD 36 (2007/01)
1 of 4
Section Name
Field Name
Field and/or Section Description
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
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.
TABLE
Named Insured One
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date One
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date One
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business One
Enter text: The line of business written by the insurer.
TABLE
Named Insured Two
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date Two
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Two
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Two
Enter text: The line of business written by the insurer.
TABLE
Named Insured Three
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date Three
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Three
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Three
Enter text: The line of business written by the insurer.
TABLE
Named Insured Four
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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)
2 of 4
Section Name
Field Name
Field and/or Section Description
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
TABLE
Effective Date Four
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Four
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Four
Enter text: The line of business written by the insurer.
TABLE
Named Insured Five
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date Five
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Five
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Five
Enter text: The line of business written by the insurer.
TABLE
Named Insured Six
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date Six
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Six
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Six
Enter text: The line of business written by the insurer.
TABLE
Named Insured Seven
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
TABLE
Effective Date Seven
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
TABLE
Expiration Date Seven
Enter date: The date on which the terms and conditions of the policy will expire.
TABLE
Line of Business Seven
Enter text: The line of business written by the insurer.
SIGNATURE
Producer
Enter text: The full name of the producer/agency.
SIGNATURE
Code #
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
ACORD 36 (2007/01)
3 of 4
Section Name
Field Name
Field and/or Section Description
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009.
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.
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.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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.
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.
SIGNATURE
Street Address
Enter text: The named insured's mailing address line one.
SIGNATURE
City of Insured
Enter text: The named insured's mailing address city name.
SIGNATURE
State of Insured
Enter code: The named insured's mailing address state or province code.
SIGNATURE
Zip Code of Insured
Enter code: The named insured's mailing address postal code.
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