ACORD 610 (2009/04) rev. 04-30-2009 1 of 4
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 610 (2009/04) |
Premium Payment Supplement |
The title of the form. ACORD 610, Premium Payment Supplement, is a supplement to any ACORD application, to record pertinent information relating to premium payments involving bank transfers, payroll deductions, credit card deductions, and similar transactions. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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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 |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Policy Number |
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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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Carrier |
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 |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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PAYMENT PLAN |
Billing Account # |
Enter identifier: The 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 insurer assigns. If the account already exists, the agent should provide the previously assigned number. |
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PAYMENT PLAN |
Deposit Amount $ |
Enter amount: The amount of the premium received as a deposit. |
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PAYMENT PLAN |
Est Total Premium $ |
Enter amount: The estimated total cost amount of the policy. |
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PAYMENT PLAN |
Direct Bill Policy |
Check the box (if applicable): Indicates if the policy is to be direct billed. |
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PAYMENT PLAN |
Direct Bill - ACCT |
Check the box (if applicable): Indicates if the account is to be direct billed. |
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PAYMENT PLAN |
Agency Bill |
Check the box (if applicable): Indicates if the policy is to be producer/agency billed. |
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PAYMENT PLAN |
Full Pay |
Check the box (if applicable): Indicates a full payment will be made on the policy. |
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PAYMENT PLAN |
Annual |
Check the box (if applicable): Indicates the policy will be paid annually. |
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PAYMENT PLAN |
Semi-Annual |
Check the box (if applicable): Indicates the policy will be paid semi-annually. |
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PAYMENT PLAN |
Quarterly |
Check the box (if applicable): Indicates the policy will be paid quarterly. |
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PAYMENT PLAN |
Bi-Monthly |
Check the box (if applicable): Indicates the policy will be paid bi-monthly. |
ACORD 610 (2009/04) rev. 04-30-2009 2 of 4
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Section Name |
Field Name |
Field and/or Section Description |
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PAYMENT PLAN |
Monthly |
Check the box (if applicable): Indicates the policy will be paid monthly. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -Quarterly, etc.). |
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PAYMENT PLAN |
Payment Method - Cash |
Check the box (if applicable): Indicates the invoice will be paid in cash. |
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PAYMENT PLAN |
Check |
Check the box (if applicable): Indicates the invoice will be paid by check. |
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PAYMENT PLAN |
Credit Card |
Check the box (if applicable): Indicates the invoice will be paid by credit card. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
EFT |
Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer (EFT). |
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PAYMENT PLAN |
Payroll Deduction |
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction. |
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PAYMENT PLAN |
Pre-authorization Draft / Check (PAC) |
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or draft. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the invoice will be paid by a means other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter text: The method the invoice will be paid. |
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PAYMENT PLAN |
Agent |
Check the box (if applicable): Indicates if the policy paper should be sent to the producer. |
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PAYMENT PLAN |
Insured |
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the named insured. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the agent or applicant. |
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PAYMENT PLAN |
Other Description |
Enter text: The description of whom the policy paper should be mailed to. |
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PAYMENT PLAN |
Payor Insured |
Check the box (if applicable): Indicates the payor of the policy is the insured. |
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PAYMENT PLAN |
Mortgagee |
Check the box (if applicable): Indicates the payor of the policy is the mortgagee. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the payor of the policy is other than those listed. |
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PAYMENT PLAN |
Other Description |
Enter text: The description of the payor of the policy. |
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PAYMENT PLAN |
Premium Financed? Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the premium has been financed. |
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PAYMENT PLAN |
Finance Company |
Enter text: The name of the company financing the premium, if applicable. |
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PAYMENT PLAN |
For EFT, PAC Or Check Bank / ABA Number |
Enter identifier: The identifier for the bank routing number (ABA Number). |
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PAYMENT PLAN |
Account Number |
Enter identifier: The payor's bank account number where the payment will be withdrawn. |
ACORD 610 (2009/04) rev. 04-30-2009 3 of 4
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Section Name |
Field Name |
Field and/or Section Description |
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PAYMENT PLAN |
Check / Reference Number |
Enter number: The unique number imprinted on a check or draft. |
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PAYMENT PLAN |
First Payment Due Date |
Enter date: The date on which the first payment is due. |
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PAYMENT PLAN |
Day of Month Due |
Enter number: The day of the month when the payment is due. |
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PAYMENT PLAN |
For Payroll Deduction Employee is Applicant |
Check the box (if applicable): Indicates the employee making the payroll deduction is the applicant. |
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PAYMENT PLAN |
Co-Applicant |
Check the box (if applicable): Indicates the employee making the payroll deduction is the co-applicant. |
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PAYMENT PLAN |
Other (If other, complete below) |
Check the box (if applicable): Indicates the employee making the payroll deduction is other than those listed. |
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PAYMENT PLAN |
Employee ID |
Enter identifier: The employer assigned identification number for the employee. |
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PAYMENT PLAN |
Number Deductions |
Enter number: The total number of installments/deductions to be made. |
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PAYMENT PLAN |
Employee Name |
Enter text: The full name of the employee. |
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PAYMENT PLAN |
Employer Name |
Enter text: The name of the employer. |
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PAYMENT PLAN |
For Credit Cards - American Express |
Check the box (if applicable): Indicates the credit card company is American Express. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Discover |
Check the box (if applicable): Indicates the credit card company is Discover. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Visa |
Check the box (if applicable): Indicates the credit card company is Visa. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Master Card |
Check the box (if applicable): Indicates the credit card company is MasterCard. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Other |
Check the box (if applicable): Indicates the credit card company is Other than those listed. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Describe Other |
Enter text: The name of the credit card company (e.g. American Express, Visa, Etc.). As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Account Number |
Enter identifier: The credit card account number. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Expiration Date |
Enter date: The expiration date of the credit card. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
Security Verification Code |
Enter code: The security verification code of the credit card. As used here, this is not applicable in North Carolina. |
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PAYMENT PLAN |
1. Does the Payor require a physical record of this transaction? Y/N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if the payor requires a physical record of the transaction. |
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PAYMENT PLAN |
Authorized Signature |
Sign here: Accommodates the signature of the payor. |
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PAYMENT PLAN |
Date |
Enter date: The date the form was signed by the payor. |
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Section Name |
Field Name |
Field and/or Section Description |
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PAYMENT PLAN |
Authorized Signature |
Sign here: Accommodates the signature of the payor. |
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PAYMENT PLAN |
Date |
Enter date: The date the form was signed by the payor. |
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REMARKS |
Remarks |
Enter text: The remarks associated with the premium payment information. Attach ACORD 101, Additional Remarks Schedule, if more space is required. |
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REMARKS |
Producer Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states. |
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REMARKS |
Producer's Name |
Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form. |
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REMARKS |
State Producer License No |
Enter identifier: The State License Number of the producer. |
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REMARKS |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
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REMARKS |
Date |
Enter date: The date the form was signed by the named insured. |
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REMARKS |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
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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). |