ACORD 610 (2009/04)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 610 (2009/04)
Premium Payment Supplement
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.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
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.
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 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.
IDENTIFICATION SECTION NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
PAYMENT PLAN
Deposit Amount $
Enter amount: The amount of the premium received as a deposit.
PAYMENT PLAN
Est Total Premium $
Enter amount: The estimated total cost amount of the policy.
PAYMENT PLAN
Direct Bill Policy
Check the box (if applicable): Indicates if the policy is to be direct billed.
PAYMENT PLAN
Direct Bill - ACCT
Check the box (if applicable): Indicates if the account is to be direct billed.
PAYMENT PLAN
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer/agency billed.
PAYMENT PLAN
Full Pay
Check the box (if applicable): Indicates a full payment will be made on the policy.
PAYMENT PLAN
Annual
Check the box (if applicable): Indicates the policy will be paid annually.
PAYMENT PLAN
Semi-Annual
Check the box (if applicable): Indicates the policy will be paid semi-annually.
PAYMENT PLAN
Quarterly
Check the box (if applicable): Indicates the policy will be paid quarterly.
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
1 of 4
Section Name
Field Name
Field and/or Section Description
PAYMENT PLAN
Monthly
Check the box (if applicable): Indicates the policy will be paid monthly.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the policy will be paid in a frequency other than
those listed.
PAYMENT PLAN
Other Description
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT -
Quarterly, etc.).
PAYMENT PLAN
Payment Method - Cash
Check the box (if applicable): Indicates the invoice will be paid in cash.
PAYMENT PLAN
Check
Check the box (if applicable): Indicates the invoice will be paid by check.
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.
PAYMENT PLAN
EFT
Check the box (if applicable): Indicates the invoice will be paid using electronic funds
transfer (EFT).
PAYMENT PLAN
Payroll Deduction
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction.
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.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the invoice will be paid by a means other than
those listed.
PAYMENT PLAN
Other Description
Enter text: The method the invoice will be paid.
PAYMENT PLAN
Agent
Check the box (if applicable): Indicates if the policy paper should be sent to the producer.
PAYMENT PLAN
Insured
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the
named insured.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates if the policy paper should be mailed to other than
the agent or applicant.
PAYMENT PLAN
Other Description
Enter text: The description of whom the policy paper should be mailed to.
PAYMENT PLAN
Payor Insured
Check the box (if applicable): Indicates the payor of the policy is the insured.
PAYMENT PLAN
Mortgagee
Check the box (if applicable): Indicates the payor of the policy is the mortgagee.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the payor of the policy is other than those listed.
PAYMENT PLAN
Other Description
Enter text: The description of the payor of the policy.
PAYMENT PLAN
Premium Financed? Y/N
Enter Y for a Yes response. Input N for No response. Indicates if the premium has
been financed.
PAYMENT PLAN
Finance Company
Enter text: The name of the company financing the premium, if applicable.
PAYMENT PLAN
For EFT, PAC Or Check Bank /
ABA Number
Enter identifier: The identifier for the bank routing number (ABA Number).
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
2 of 4
Section Name
Field Name
Field and/or Section Description
PAYMENT PLAN
Check / Reference Number
Enter number: The unique number imprinted on a check or draft.
PAYMENT PLAN
First Payment Due Date
Enter date: The date on which the first payment is due.
PAYMENT PLAN
Day of Month Due
Enter number: The day of the month when the payment is due.
PAYMENT PLAN
For Payroll Deduction Employee is
Applicant
Check the box (if applicable): Indicates the employee making the payroll deduction is the
applicant.
PAYMENT PLAN
Co-Applicant
Check the box (if applicable): Indicates the employee making the payroll deduction is the
co-applicant.
PAYMENT PLAN
Other (If other, complete below)
Check the box (if applicable): Indicates the employee making the payroll deduction is other
than those listed.
PAYMENT PLAN
Employee ID
Enter identifier: The employer assigned identification number for the employee.
PAYMENT PLAN
Number Deductions
Enter number: The total number of installments/deductions to be made.
PAYMENT PLAN
Employee Name
Enter text: The full name of the employee.
PAYMENT PLAN
Employer Name
Enter text: The name of the employer.
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.
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.
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.
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.
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.
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.
PAYMENT PLAN
Account Number
Enter identifier: The credit card account number. As used here, this is not applicable in
North Carolina.
PAYMENT PLAN
Expiration Date
Enter date: The expiration date of the credit card. As used here, this is not applicable in
North Carolina.
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.
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.
PAYMENT PLAN
Authorized Signature
Sign here: Accommodates the signature of the payor.
PAYMENT PLAN
Date
Enter date: The date the form was signed by the payor.
ACORD 610 (2009/04) rev. 04-30-2009
3 of 4
Section Name
Field Name
Field and/or Section Description
PAYMENT PLAN
Authorized Signature
Sign here: Accommodates the signature of the payor.
PAYMENT PLAN
Date
Enter date: The date the form was signed by the payor.
REMARKS
Remarks
Enter text: The remarks associated with the premium payment information. Attach
ACORD 101, Additional Remarks Schedule, if more space is required.
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.
REMARKS
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or
broker that signed the form.
REMARKS
State Producer License No
Enter identifier: The State License Number of the producer.
REMARKS
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
REMARKS
Date
Enter date: The date the form was signed by the named insured.
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.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 610 (2009/04) rev. 04-30-2009
4 of 4