ACORD 64 US (2015/01) - Insurance Supplement - Workers Compensation Only
ACORD 64 US (2015/01) - Insurance Supplement - Workers Compensation Only
ACORD 64 US, Insurance Supplement - Workers' Compensation Only, Policyholder Disclosure, Notice of Terrorism Insurance Coverage, may be
used as permitted by state law. 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 are included in the policy;
* The applicant / insured(s) must sign the form; and
* The portion of premium attributable for this coverage.
- Use ACORD 60 US with respect to other lines of insurance covered by the Act.
- Use ACORD 62 US with respect to property insurance in Standard Fire Policy states.
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.
DISCLOSURE OF PREMIUM
Premium ($)
Enter amount: The premium amount applicable to terrorism coverage.
SIGNATURE
Applicant / Named Insured'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.
ACORD 64 US (2015/01) rev. 02-13-2015
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SIGNATURE
Date
Enter date: The date the form was signed by the applicant or named insured. (MM/DD/YYYY)
SIGNATURE
Applicant / Named Insured'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
Applicant / Named Insured'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 64 US (2015/01) rev. 02-13-2015
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