ACORD 62 US (2015/01) - Insurance Supplement - Standard Fire Policy Only
ACORD 62 US (2015/01) - Insurance Supplement - Standard Fire Policy Only
ACORD 62 US, Insurance Supplement - Standard Fire Policy Only, Policyholder Disclosure, Notice of Terrorism Insurance Coverage, is used for
property coverage containing the Standard Fire Policy. The form complies with requirements of the federal Terrorism Risk Insurance Program
Reauthorization Act of 2015. This form discloses the following information:
* Coverage for losses resulting from acts of terrorism certified under the federal program must be offered;
* The applicant / insured can accept or reject the coverage; except that coverage for fire losses resulting from acts of terrorism covered under the
Standard Fire Policy would continue;
* The amount of the premium for terrorism coverage;
* The amount of the premium for terrorism (fire only) coverage (if applicable).
- Use ACORD 60 US with respect to all other lines of insurance covered by the Act.
- Use ACORD 64 US with respect to workers' compensation insurance.
IMPORTANT:
INSURERS INTENDING TO USE THIS FORM SHOULD DETERMINE IF FILINGS ARE REQUIRED IN ORDER TO COMPLY WITH INDIVIDUAL
STATE REGULATIONS.
Form Page 1
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).
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
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 National Association of
Insurance Commissioners (NAIC).
IDENTIFICATION SECTION
Applicant / Named Insured
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
ACCEPTANCE/REJECTION
I hereby elect to purchase
terrorism coverage for a
prospective premium of $
Check the box (if applicable): Indicates the named insured has elected to purchase terrorism
coverage.
ACCEPTANCE/REJECTION
Premium
Enter amount: The premium amount for terrorism coverage.
ACORD 62 US (2015/01) rev. 02-13-2015
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ACCEPTANCE/REJECTION
I hereby decline to purchase
terrorism coverage for
certified acts of terrorism. I
understand that I will have
no coverage for losses
resulting from certified acts
of terrorism.
Check the box (if applicable): Indicates the named insured has declined to purchase terrorism
coverage.
ACCEPTANCE/REJECTION
Premium for Terrorism (Fire
Only)
Enter amount: The premium amount for terrorism coverage (fire only).
SIGNATURE
Policyholder / Applicant's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Print Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SIGNATURE
Policyholder / Applicant's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Print Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SIGNATURE
Policyholder / Applicant's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Print Name
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SIGNATURE
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
ACORD 62 US (2015/01) rev. 02-13-2015
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