ACORD 67 CA (2011/07)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 67 CA (2011/07)
California Residential Property
Insurance Disclosure
ACORD 67 CA California Residential Property Disclosure, complies
with California law which requires that the named insured for each policy of residential
property insurance be provided a copy of the California Residential Property Insurance
Disclosure statement contained in the law.
Use ACORD 67 CA with ACORD 80, Homeowners Application or ACORD 89, Residential
Section. ACORD 89 must be used in conjunction with ACORD 88, Personal Insurance
Application, Applicant Information Section.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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 Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
COVERAGES
Actual Cash Value Coverage
Check the box (if applicable): Indicates actual cash value will be used to determine the
amount paid on a claim.
COVERAGES
Replacement Cost Coverage
Check the box (if applicable): Indicates that replacement cost - dwelling coverage is
included.
COVERAGES
Extended Replacement Cost
Coverage
Check the box (if applicable): Indicates extended replacement cost will be used to
determine the amount paid on a claim.
COVERAGES
Guaranteed Replacement Cost
Coverage
Check the box (if applicable): Indicates that replacement cost full value coverage is
included.
COVERAGES
Building Code Upgrade Coverage
Check the box (if applicable): Indicates the building ordinance or law coverage is included.
COVERAGES
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
ACORD 67 CA (2011/07) rev. 05-31-2011
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Section Name
Field Name
Field and/or Section Description
Edition
Edition
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 67 CA (2011/07) rev. 05-31-2011
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