Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 65 FL (2007/08)
Florida Residential Property
Supplement
ACORD 65 FL, Florida Residential Property Supplement, complies with Florida law, which
requires that every applicant applying for a homeowners, mobile home or condominium
unit policy, must be given the option to exclude windstorm coverage. Their selection must
be written in their own handwriting and signed by them and every other named insured on
the policy.
The form also provides instructions for other than individuals (e.g., corporations), to
exclude windstorm coverage.
The application also provides the option for applicants applying for a homeowners or
mobile home policy to exclude coverage for the contents of the structure. Their selection
must be written in their own handwriting and signed by them and every other named
insured on the policy.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Date
Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency
Producer's name.
IDENTIFICATION SECTION Applicant (First Name Insured)
Full name of the applicant as it should appear on the policy. The First Named Insured is
given certain rights and responsibilities by the policy contract language. If more than one
insured is named, be sure the one intended to receive these rights and responsibilities is
named first and any additional insureds identified as such. If joint ownership, the name
used may include both names (e.g., John and Mary Smith).
IDENTIFICATION SECTION Policy Number
The number assigned by the insurance company for the policy. In general, policy numbers
will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier
Name of the insurance company (or residual market plan) that will receive the application.
Do not use group names, use the actual name of the company within the group in which
you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code
The identification code assigned to the company by the NAIC.
WINDSTORM EXCLUSION
I do not want the insurance on my
home to pay for damage from
windstorms
Applicant/Named Insured must write his/her selection in his own handwriting.
ACORD 65 FL (2007/08)
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Section Name
Field Name
Field and/or Section Description
WINDSTORM EXCLUSION
I do not want the insurance on my
mobile home to pay for damage
from windstorms
Applicant/Named Insured must write his/her selection in his own handwriting.
WINDSTORM EXCLUSION
I do not want the insurance on my
condminium unit to pay for
damage from windstorms
Applicant/Named Insured must write his/her selection in his own handwriting.
SIGNATURE
Applicant's Signature
Every Applicant/Named Insured must sign the application.
SIGNATURE
Date
Date the application was completed. (MM/DD/YYYY)
SIGNATURE
Effective Date
Enter the effective date of the windstorm exclusion.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
CONTENTS EXCLUSION
I do not want the insurance on my
home to pay for the costs to repair
or replace any contents that are
damaged.
Applicant/Named Insured must write his/her selection in his own handwriting.
CONTENTS EXCLUSION
I do not want the insurance on my
mobile home to pay for the costs
to repair or replace any contents
that are damaged.
Applicant/Named Insured must write his/her selection in his own handwriting.
SIGNATURE
Applicant's Signature
Every Applicant/Named Insured must sign the application.
SIGNATURE
Date
Date the application was completed. (MM/DD/YYYY)
SIGNATURE
Effective Date
Enter the effective date of the exclusion of coverage for contents.
ACORD 65 FL (2007/08)
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