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ACORD Form 817 P & C Producer Appointment Form - Appointment Section Instructions

 

 
Section Name Field Name Field and/or Section Description
ACORD 817 (2007/08) Producer Appointment Form, Appointment Section ACORD 817 is a standard Producer Appointment Form designed for P&C/Surety appointments and accepted by multiple insurers. In this case, the producer is a person. This form is to be completed by a Producer and then sent to the insurer. The 817 is comprised of the data content needed for new PCS producer appointments. Related to the ACORD 817 is the ACORD 818 - Background Questions form, an optional form that serves as an attachment to the 817 for those insurers who require background question information.
IDENTIFICATION SECTION Date The date the form is completed.
IDENTIFICATION SECTION Carrier The full name of the insurance company to whom the appointment form/request is being submitted.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
AGENCY INFORMATION Name And Address The full name of the agency and address at which the producer (person) is employed with regards to this appointment request.
AGENCY INFORMATION FEIN: The FEIN tax ID of the agency.
AGENCY INFORMATION Licensing Contact: The name of the licensing contact person within the agency. Contact this person if there are any questions about the appointment form.
AGENCY INFORMATION Contact Phone (A/C, No, Ext): The licensing contact person's business phone number.
AGENCY INFORMATION Contact Fax (A/C, No): The licensing contact person's fax number.
AGENCY INFORMATION Contact E-Mail: The licensing contact person's email address.
PRODUCER INFORMATION Full Legal Name - Prefix Any phrase to precede the name which is not part of the actual name, such as Dr. or Mrs.
PRODUCER INFORMATION Full Legal Name - First Name The person's "first name".
PRODUCER INFORMATION Full Legal Name - Middle Name The person's "middle name".
PRODUCER INFORMATION Full Legal Name - Surname This is the family's or individual's surname, also known in the USA as "Last Name".
PRODUCER INFORMATION Full Legal Name - Suffix Name Suffix. For example, "Jr.", or "III".
PRODUCER INFORMATION Position / Title in Agency The title of the producer/person/applicant within the agency.
PRODUCER INFORMATION Birth Date (MM/DD/YYYY) The birth date of the producer/person/applicant.
PRODUCER INFORMATION National Producer # The identifier assigned to an individual producer/agent/broker/agency by the NAIC. This is known as the National Producer Number.
PRODUCER INFORMATION Social Security # The tax ID of the producer/person/applicant (i.e. SSN).
PRODUCER INFORMATION Residence Address Residence address of the producer/person/applicant.
PRODUCER INFORMATION Business Phone (A/C, No, Ext): The business phone of the producer/person/applicant.
PRODUCER INFORMATION Business E-Mail Address The business email of the producer/person/applicant.
PRODUCER INFORMATION Other Names Used - Prefix Any phrase to precede the name which is not part of the actual name, such as Dr. or Mrs.
PRODUCER INFORMATION Other Names Used - First Name The person's "first name".
PRODUCER INFORMATION Other Names Used - Middle Name The person's "middle name".
PRODUCER INFORMATION Other Names Used - Surname This is the family's or individual's surname, also known in the USA as "Last Name".
PRODUCER INFORMATION Other Names Used - Suffix Name Suffix. For example, "Jr.", or "III".
PRODUCER INFORMATION Name Type: Alias (checkbox)
PRODUCER INFORMATION Maiden (checkbox)
PRODUCER INFORMATION Previous (checkbox)
PRODUCER INFORMATION Other Names Used - Prefix Any phrase to precede the name which is not part of the actual name, such as Dr. or Mrs.
PRODUCER INFORMATION Other Names Used - First Name The person's "first name".
PRODUCER INFORMATION Other Names Used - Middle Name The person's "middle name".
PRODUCER INFORMATION Other Names Used - Surname This is the family's or individual's surname, also known in the USA as "Last Name".
PRODUCER INFORMATION Other Names Used - Suffix Name Suffix. For example, "Jr.", or "III".
PRODUCER INFORMATION Alias (checkbox)
PRODUCER INFORMATION Maiden (checkbox)
PRODUCER INFORMATION Previous (checkbox)
PRODUCER INFORMATION Other Names Used - Prefix Any phrase to precede the name which is not part of the actual name, such as Dr. or Mrs.
PRODUCER INFORMATION Other Names Used - First Name The person's "first name".
PRODUCER INFORMATION Other Names Used - Middle Name The person's "middle name".
PRODUCER INFORMATION Other Names Used - Surname This is the family's or individual's surname, also known in the USA as "Last Name".
PRODUCER INFORMATION Other Names Used - Suffix Name Suffix. For example, "Jr.", or "III".
PRODUCER INFORMATION Alias (checkbox)
PRODUCER INFORMATION Maiden (checkbox)
PRODUCER INFORMATION Previous (checkbox)
STATES(S) & U.S. TERRITORIES APPLICABLE States/Territories: All States (checkbox) Indicate the states for which the appointment or termination applies. Check all that apply.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE For California, Minnesota and Washington Applicants Only
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE Company Name Indicate the name of the company providing the consumer credit report.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE Street Address Indicate the street address of the company providing the consumer credit report.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE City Indicate the city of the company providing the consumer credit report.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE State Indicate the state of the company providing the consumer credit report.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE Zip Code Indicate the zip code of the company providing the consumer credit report.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE If a consumer credit report is obtained, I understand that I am entitled to receive a copy. I have indicted below whether I would like a copy. Yes (Initials) Applicant must initial his/her option.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE If a consumer credit report is obtained, I understand that I am entitled to receive a copy. I have indicted below whether I would like a copy. No (Initials) Applicant must initial his/her option.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE If an investigative consumer report and/or consumer report is processed, I understand that I am entitled to receive a copy. I have indicated below whether I would like a copy. Yes (Initials) Applicant must initial his/her option.
NOTICE OF BACKGROUND CHECK AND FAIR CREDIT REPORTING ACT DISCLOSURE If an investigative consumer report and/or consumer report is processed, I understand that I am entitled to receive a copy. I have indicated below whether I would like a copy. No (Initials) Applicant must initial his/her option.
PRINT NAME Print Print or type the name of the applicant.
SIGNATURE Signature Applicant must sign the form.
SIGNATURE DATE Date (MM/DD/YYYY) Date the form was signed.