Field and/or Section Description
ACORD 67 (2011/07)
Illinois / Indiana / Kentucky / West
Virginia Mine Subsidence Property
ACORD 67, Illinois / Indiana / Kentucky / West Virginia Mine
Subsidence Property Insurance Supplement, is used to comply with state laws in Illinois,
Indiana, Kentucky and West Virginia which require that mine subsidence insurance
coverage must be provided to dwelling insureds located in specified counties, unless the
insured rejects coverage in writing.
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 Applicant / Named Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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 NAIC.
IDENTIFICATION SECTION Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
IDENTIFICATION SECTION Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
WAIVE MINE SUBSIDENCE Do Not Desire Mine Subsidence
Check the box (if applicable): Indicates the named insured rejects mine subsidence
coverage. As used here, indicates the named insured does not desire mine subsidence
coverage and waives any right to such coverage under this policy or any future policy
covering the property described in the Declarations, unless requested in writing.
I wish to Purchase Mine
Check the box (if applicable): Indicates the named insured accepts mine subsidence
coverage. As used here, indicates the named insured wishes to purchase mine
subsidence coverage for the structure at the limit listed below.
Enter limit: The limit for mine subsidence coverage.
Sign here: Accommodates the signature of the applicant or named insured.
Enter date: The date the form was signed by the named insured.
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 67 (2011/07) rev. 05-31-2011
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