ACORD 38 KS (2013/12) - Kansas Personal Insurance Supplement

ACORD 38 KS (2013/12) - Kansas Personal Insurance Supplement

ACORD 38 KS, Kansas Personal Insurance Supplement - Notice of Insurance Information Practices, is used with all applications for personal

insurance, to comply with a law requiring that all applicants for insurance must be told that credit reports or other investigative reports may be

requested in connection with the application, and that credit scoring information may be used to determine eligibility or the premium charged.

Additionally, the Applicant is advised that they have the right to request in writing that Extraordinary Life Circumstances be considered with the

development of their credit score. Applicant is also advised that they have the right to correct any information that may be wrong and that there is a

specific appeal process.

Form Page 1

Section Name

Field Name

Description

IDENTIFICATION SECTION

Date

Enter date: The date on which the form is completed.

IDENTIFICATION SECTION

Agency

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.

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

Applicant's Name and

Mailing Address

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.

ACORD 38 KS (2013/12) rev. 10-31-2013

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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

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.

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.

IDENTIFICATION SECTION

New

Check the box (if applicable): Indicates the response expected from the company is a new

issued policy.

IDENTIFICATION SECTION

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.

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

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

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.

ACORD 38 KS (2013/12)

Page 2 of 3

APPLICANT / NAMED

INSURED'S SIGNATURE

Date

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

Enter date: The date the form was signed by the named insured.

Form Page 2

Section Name

Field Name

Description

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

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

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

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

Enter date: The date the form was signed by the named insured.

ACORD 38 KS (2013/12)

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