ACORD 66 IA (2006/07)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 66 IA (2006/07)
Iowa Personal Insurance
Supplement - Disclosure Use of
Claims History
Use this form, as required by Iowa law, with all applications for personal insurance, except
personal auto. The form discloses to an applicant that claims history will be considered in
determining whether to decline, cancel, nonrenew or surcharge a policy that is being
applied for.
IDENTIFICATION SECTION Agency
Producers name and address.
IDENTIFICATION SECTION Code
Identification code assigned to your agency or brokerage firm by the insurance company
receiving this form.
IDENTIFICATION SECTION Subcode
If your agency uses a subcode identification system with the company, enter the
appropriate code.
IDENTIFICATION SECTION Applicant/Named Insured
Indicate applicant name. If named insured, name exactly as it appears on the policy.
IDENTIFICATION SECTION Company
Issuing company's name.
IDENTIFICATION SECTION Policy #
Number exactly as it appears on the policy, including prefix and suffix symbols.
IDENTIFICATION SECTION Effective Date
Date on which the terms and conditions of the policy commenced.
SIGNATURE
Applicant Signature
Applicant must sign the supplement.
SIGNATURE
Date
Indicate the date the supplement was signed in MM/DD/YYYY format.
ACORD 66 IA (2006/07)
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