ACORD 65 WV (2006/05)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 65 WV (2006/05)
West Virginia Personal and
Commercial Umbrella Liability
Supplement
Uninsured/Underinsured Motor
Vehicle Coverage Important Notice
Use this form with all personal and commercial umbrella applications, to comply with
requirements set by the WV DOI.
This form is an important notice regarding the opportunity to obtain optional excess
UNinsured motor vehicle coverage and/or obtain optional excess UNDERinsured motor
vehicle coverage. The form should be given to the applicant, together with either ACORD
66 WV (Offer of Split Limits), or ACORD 68 WV (Offer of Single Limits).
IDENTIFICATION SECTION Agency
Agency's name and address.
IDENTIFICATION SECTION Code
Identification code assigned to the agency or brokerage firm by the insurance company
receiving this form.
IDENTIFICATION SECTION Sub Code
If the agency or brokerage uses a sub-code identification system with the company, enter
the appropriate code.
IDENTIFICATION SECTION Company
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 Personal Umbrella Check Box
Check the applicable box.
IDENTIFICATION SECTION Commercial Umbrella Check Box
Check the applicable box.
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 Effective Date
Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
IMPORTANT NOTICE
Proposed Policyholder (Applicant)
Provide Proposed Policyholder (Applicant) name.
IMPORTANT NOTICE
Present Policyholder
Provide Present Policyholder name.
ACORD 65 WV (2006/05)
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