ACORD 65 MN (2012/04)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 65 MN (2012/04)
Minnesota Insurance Guaranty
Association Notice - Notice
Concerning Policyholder Rights in
an Insolvency under the
Minnesota Insurance Guaranty
Association Law
ACORD 65 MN, Minnesota Insurance Guaranty Association Notice,
complies with Minnesota regulations, which require that all applicants for insurance in
Minnesota must be provided with information with respect to their rights in case of an
insurer insolvency under the Guaranty Association laws.
SIGNATURE SECTION
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE SECTION
Applicant / Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 65 MN (2012/04) rev. 04-30-2012
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