Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 68 MD (2007/01)
Maryland Personal Property
Supplement
Statement Regarding Flood
Insurance
Use this form with every application for homeowners, dwelling and mobile home insurance
to comply with Maryland state law that requires that such applicants must be advised that
the policy does not cover losses caused by flood.
IDENTIFICATION SECTION Date
Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency
Producer's name and address.
IDENTIFICATION SECTION Code
Identification code assigned to the agency or brokerage firm by the insurance company
receiving this form.
IDENTIFICATION SECTION Sub Code
If the agency or brokerage uses a sub-code identification system with the company, enter
the appropriate code.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Applicant/Named 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). Provide the physical address,
not a P.O. Box, at which the first named insured is to receive all mail.
Address should include: Street number, if any; Pre-direction, if any (example: 150 N
Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.:
150 Central Ave N); City; County; State; ZIP code
If the address does not have a street number and name, provide sufficient information and
directions so that the property can be physically located. Provide legal description if
required by the mortgage holder.
IDENTIFICATION SECTION Telephone Number
Telephone number at which the applicant may be reached. Include area code and
extension, if applicable.
IDENTIFICATION SECTION Company
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 Account Number
Indicate account number, if applicable.
ACORD 68 MD (2007/01)
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Policy #
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 Check Boxes
Check if the policy is new or a renewal.
IDENTIFICATION SECTION Effective Date
Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
IDENTIFICATION SECTION Expiration Date
Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless
renewed.
ACORD 68 MD (2007/01)
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