Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 39 MD (2003/05)
Maryland Application Supplement
ACORD 39 MD, Maryland Application Supplement, is used to satisfy
a new Maryland law effective October 1, 2002, that requires that applicants be advised
that their credit history will be used as a factor in determining the premium the applicant
will be charged for their insurance. If the applicant's premium is adversely affected, the
applicant may request a review of their credit history at any time upon request. Credit
history information that occurred more than five (5) years prior to the issuance of the policy
may not be used.
This supplement must be used with all applications for personal insurance except ACORD
auto applications, which contain the required disclosure.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
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 Applicant/Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Company
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 Policy #
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.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Homeowners Insurance
Check the box (if applicable): Indicates the type of policy is homeowners.
IDENTIFICATION SECTION Personal Inland Marine Insurance
Check the box (if applicable): Indicates the type of policy is inland marine.
IDENTIFICATION SECTION Watercraft Insurance
Check the box (if applicable): Indicates the type of policy is watercraft.
IDENTIFICATION SECTION Personal Umbrella Insurance
Check the box (if applicable): Indicates the type of policy is umbrella.
ACORD 39 MD (2003/05) rev. 05-08-2009
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Dwelling Insurance
Check the box (if applicable): Indicates the type of policy is dwelling fire.
IDENTIFICATION SECTION Mobile Home Insurance
Check the box (if applicable): Indicates the type of policy is mobile home.
IDENTIFICATION SECTION Personal Lines Package Insurance
Check the box (if applicable): Indicates the type of policy is a personal lines package.
IDENTIFICATION SECTION Signature of Applicant
Sign here: Accommodates the signature of the applicant or named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 39 MD (2003/05) rev. 05-08-2009
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