ACORD 63 (2013/09) - FRAUD STATEMENTS

ACORD 63 (2013/09) - FRAUD STATEMENTS
ACORD 63, Fraud Statements, is a stand alone copy of the fraud warnings applicable in all states. This should not be used for loss notices or
workers compensation applications.
In the case of claimants, the back of each ACORD loss notice contains the required fraud warning in compliance with state laws and regulations.
With respect to applications, all ACORD applications include the required fraud warning or ACORD 63 must be attached.
With respect to Sections, the ACORD 63 must be attached in all states.
NOTE: When a risk is located in more than one state, the applicable law is the law in effect for the state in which the insurance policy is written, or
the insurance claim is made.
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
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence.
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
Applicant / Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
GENERAL STATEMENT
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
GENERAL STATEMENT
Date
Enter date: The date the form was signed by the named insured.
ACORD 63 (2013/09) rev. 07-31-2013 P age 1 of 1