ACORD 65 IA (2008/01)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 65 IA (2008/01)
Iowa Auto Supplement - Notice -
Payment for Aftermarket Crash
Parts
This disclosure form must be used with all applications for auto physical damage
insurance, when the insurer will require the use of aftermarket parts rather than original
equipment manufacturer parts. The Iowa Insurance Division provided the text for the form.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency
Producer's name.
IDENTIFICATION SECTION Applicant/Named Insured
Full name of the applicant as it should appear on the policy. The First Named Insured is
given certain rights and responsibilities by the policy contract language. If more than one
insured is named, be sure the one intended to receive these rights and responsibilities is
named first and any additional insureds identified as such. If joint ownership, the name
used may include both names (e.g., John and Mary Smith).
IDENTIFICATION SECTION Policy Number
The number assigned by the insurance company for the policy. In general, policy numbers
will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier
Name of the insurance company (or residual market plan) that will receive the application.
Do not use group names, use the actual name of the company within the group in which
you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code
The identification code assigned to the company by the NAIC.
ACORD 65 IA (2008/01)
1 of 1