Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 38 (2011/05)
Notice of Information Practices
(Privacy)
ACORD 38, Notice of Information Practices (Privacy), is used to
satisfy the Privacy Act statutes that exist in a number of states, including the following:
California - Connecticut - Georgia - Illinois - Nevada - New Jersey - Rhode Island -
Washington
These laws exceed the requirements of the federal Fair Credit Reporting Act or other
more recent federal legislation, or they require policyholder notification at the time of
renewal. They establish standards for the collection, use and disclosure of information
gathered in connection with insurance transactions.
In each state, disclosure of such information is limited, and applicants for insurance must
be informed of their rights with respect to:
* Limitation of disclosure or dissemination of information
* Credit scoring information may be used with regard to eligibility for insurance and/or the
premium to be charged, and that a third party may be used in connection with the
development of the credit score. Additionally, certain states now require the disclosure of
information regarding Extraordinary Life Circumstances and their affect on the credit
score.
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Section Name
Field Name
Field and/or Section Description
TITLE
This form may also be used by insurers to provide policyholder notification at time of
renewal. In most states, the applicant's signature is not required at renewal. Additional
state-specific requirements in other states are responded to by individual supplements.
These states are listed below. For specific information about the use of each of these
forms, refer to the individual state form information.
- Arizona: ACORD 38 AZ
- Connecticut: ACORD 62 CT
- Florida: ACORD 66 FL
- Kansas: ACORD 38 KS
- Minnesota: ACORD 38 MN
- New York: ACORD 38 NY
- North Carolina: ACORD 66 NC
- North Dakota: ACORD 38 ND
- Oregon: ACORD 38 OR
- Vermont: ACORD 66 VT
- Virginia: ACORD 38 VA
- West Virginia: ACORD 38 WV
IDENTIFICATION SECTION Agency Name
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Agency Address
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext)
Enter number: The fax number of the producer/agency.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Address
Applicant's Name and Mailing
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION Phone (A/C, No)
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION Company Name
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.
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 Account Number
Enter identifier: The account number to be used for billing purposes. This is the billing
number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the
insurer assigns. If the account already exists, the agent should provide the previously
assigned number.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Check box - New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION Check box - Renewal
Check the box (if applicable): Indicates the response expected from the company is a
renewed policy.
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 Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
IDENTIFICATION SECTION Other Jurisdiction
Enter code: The state or province code which laws govern the policy.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
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Section Name
Field Name
Field and/or Section Description
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT / NAMED
INSURED'S SIGNATURE
Date (MM/DD/YYYY)
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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