ACORD 861 CA (2011/07)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 861 CA (2011/07)
California Residential Property
Insurance Bill of Rights
ACORD 861 CA, California Residential Property Insurance Bill of
Rights, must be provided to every applicant for residential property insurance. The
content of the form follows the language in California law effective July 1, 2011.
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 Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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.
CONTACT INFORMATION
Name(s)
Enter text: The full name of the person who may be contacted by the applicant to obtain a
report from a claims information database.
CONTACT INFORMATION
Toll-Free Telephone Number(s)
Enter number: The toll-free telephone number of the person who may be contacted by the
applicant to obtain a report from a claims information database.
CONTACT INFORMATION
Internet Web Site Address(es)
Enter text: The internet web site address of the person who may be contacted by the
applicant to obtain a report from a claims information database (if applicable).
CONTACT INFORMATION
Name(s)
Enter text: The full name of the person who may be contacted by the applicant to obtain a
report from a claims information database.
CONTACT INFORMATION
Toll-Free Telephone Number(s)
Enter number: The toll-free telephone number of the person who may be contacted by the
applicant to obtain a report from a claims information database.
CONTACT INFORMATION
Internet Web Site Address(es)
Enter text: The internet web site address of the person who may be contacted by the
applicant to obtain a report from a claims information database (if applicable).
CONTACT INFORMATION
Name(s)
Enter text: The full name of the person who may be contacted by the applicant to obtain a
report from a claims information database.
CONTACT INFORMATION
Toll-Free Telephone Number(s)
Enter number: The toll-free telephone number of the person who may be contacted by the
applicant to obtain a report from a claims information database.
ACORD 861 CA (2011/07) rev. 05-31-2011
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Section Name
Field Name
Field and/or Section Description
CONTACT INFORMATION
Internet Web Site Address(es)
Enter text: The internet web site address of the person who may be contacted by the
applicant to obtain a report from a claims information database (if applicable).
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
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 861 CA (2011/07) rev. 05-31-2011
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