ACORD 88 (2014/12) - Personal Insurance Application

ACORD 88 (2014/12) - Personal Insurance Application
ACORD 88, Personal Insurance Application, Applicant Information Section, is used in the underwriting process for any personal lines policy
submission using the personal lines section formats (e.g., ACORD 282, ACORD 290s).
The Applicant Information Section is the foundation on which the ACORD personal lines application program is built. This form contains
information that is not duplicated on other ACORD personal application section forms. The Applicant Information Section is a required part of every
personal lines submission using the sectional approach and no personal line application is complete without it.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer / agency.
IDENTIFICATION SECTION
Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION
Phone No.
Enter number: The producer's contact person's phone number. If applicable, include the area
code and extension.
IDENTIFICATION SECTION
Fax No.
Enter number: The fax number of the producer / agency.
IDENTIFICATION SECTION
E-Mail Address
Enter text: The producer's contact person's e-mail address.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
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.
ACORD 88 (2014/12) rev. 04-29-2014
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IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured(s)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Policy #
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
Plan
Enter code: The product code assigned by the insurer for the policy.
IDENTIFICATION SECTION
Facility Code
Enter identifier: The identification code used by assigned risk plans, FAIR plans and other
associations (only applicable in a few states). When using this field, also enter the name of the
facility in the carrier or plan field.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire. (MM/DD/YYYY)
STATUS OF TRANSACTION
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
STATUS OF TRANSACTION
Renew
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
STATUS OF TRANSACTION
Policy Change
Check the box (if applicable): Indicates the policy is being submitted for a policy change.
STATUS OF TRANSACTION
Other
Check the box (if applicable): Indicates the response expected from the company is a policy
other than those listed.
STATUS OF TRANSACTION
Other Description
Enter text: The description of the policy status (e.g. Reissue, Rewrite, etc.).
STATUS OF TRANSACTION
Policy Change Effective
Date
Enter date: The date the policy status becomes effective. This date is used for policy statuses
of bound, change, and cancel. (MM/DD/YYYY)
STATUS OF TRANSACTION
Time
Enter time: The time the policy status becomes effective. The time is used for policy statuses of
bound, change, and cancel.
STATUS OF TRANSACTION
AM
Check the box (if applicable): Indicates the effective time of the policy status is before 12:00 pm.
STATUS OF TRANSACTION
PM
Check the box (if applicable): Indicates the effective time of the policy status is 12:00 pm or
later.
INDICATE SECTIONS
ATTACHED
Personal Automobile
Check the box (if applicable): Indicates the Personal Automobile (ACORD 290) section is
attached to this application.
INDICATE SECTIONS
ATTACHED
Residential
Check the box (if applicable): Indicates ACORD 89, Residential Section, is attached to this
application. ACORD 89 must be used in conjunction with ACORD 88, Personal Insurance
Application, Applicant Information Section.
ACORD 88 (2014/12) rev. 04-29-2014
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INDICATE SECTIONS
ATTACHED
Personal Umbrella
Check the box (if applicable): Indicates the Personal Umbrella (ACORD 283) section is attached
to this application.
INDICATE SECTIONS
ATTACHED
Personal Inland Marine
Check the box (if applicable): Indicates the Personal Inland Marine (ACORD 281) section is
attached to this application.
INDICATE SECTIONS
ATTACHED
Watercraft
Check the box (if applicable): Indicates the Watercraft (ACORD 282) section is attached to this
application.
INDICATE SECTIONS
ATTACHED
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
INDICATE SECTIONS
ATTACHED
Other Description
Enter text: The type of section being attached to this application.
INDICATE SECTIONS
ATTACHED
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
INDICATE SECTIONS
ATTACHED
Other Description
Enter text: The type of section being attached to this application.
INDICATE SECTIONS
ATTACHED
Other
Check the box (if applicable): Indicates that a section other than those listed is attached to this
application.
INDICATE SECTIONS
ATTACHED
Other Description
Enter text: The type of section being attached to this application.
APPLICANT INFORMATION
Applicant's Name (First,
Middle, Last)
Enter text: The named insured's given name.
APPLICANT INFORMATION
Enter text: The named insured's other given name initial.
APPLICANT INFORMATION
Enter text: The named insured's surname.
APPLICANT INFORMATION
Date of Birth
Enter date: The date of birth of the insured. (MM/DD/YYYY)
APPLICANT INFORMATION
Social Security #
Enter identifier: The tax identifier of the named insured.
ACORD 88 (2014/12) rev. 04-29-2014
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APPLICANT INFORMATION
Marital Status / Civil Union
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* F Fianc or Fiance
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union / Registered Domestic Partner
* U Unknown
* O Other
As used here, this field may not be utilized for policyholders applying for residential property
insurance in CA.
APPLICANT INFORMATION
Applicant's Mailing Address
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Address 2
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
City
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
State
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Zip
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
APPLICANT INFORMATION
Primary Phone #
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
APPLICANT INFORMATION
Secondary Phone #
Enter number: The named insured's secondary phone number.
APPLICANT INFORMATION
Primary e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION
Secondary e-mail address
Enter text: The named insured's secondary e-mail address.
APPLICANT INFORMATION
Years At Previous Address
Enter number: The number of years at the previous address.
APPLICANT INFORMATION
Previous Address
Enter text: The first address line of the previous residence address.
APPLICANT INFORMATION
Address Continued
Enter text: The second address line of the previous residence.
APPLICANT INFORMATION
City
Enter text: The city of the previous residence.
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APPLICANT INFORMATION
State
Enter code: The state or province code of the previous residence.
APPLICANT INFORMATION
Zip
Enter code: The postal code of the previous residence.
APPLICANT INFORMATION
Check if same as mailing
Address
Check the box (if applicable): Indicates the named insured's physical address is the same as the
mailing address.
APPLICANT INFORMATION
Owned
Check the box (if applicable): Indicates if the insured owns their current residence.
APPLICANT INFORMATION
Rented
Check the box (if applicable): Indicates if the insured rents their current residence.
APPLICANT INFORMATION
Current Residence
Enter text: The named insured's physical address line one. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter text: The named insured's physical address line two. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter text: The named insured's physical address city name. As used here, this is the current
residence.
APPLICANT INFORMATION
Enter code: The named insured's physical address state or province code. As used here, this is
the current residence.
APPLICANT INFORMATION
Enter code: The named insured's physical address postal code. As used here, this is the current
residence.
APPLICANT INFORMATION
Date at Current Residence
Enter date: The date insured moved into their current residence. (MM/DD/YYYY)
APPLICANT INFORMATION
Yrs with Current Employer
Enter number: The number of years the named insured has been with their current employer.
APPLICANT INFORMATION
Applicant's Employer Name
And Address
Enter text: The employer name (business name if self-employed).
APPLICANT INFORMATION
Enter text: The first address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The second address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The city of the employer's physical address.
APPLICANT INFORMATION
Enter code: The state code of the employer's physical address.
APPLICANT INFORMATION
Enter code: The postal code of the employer's physical address.
APPLICANT INFORMATION
Applicant's Occupation
(State Nature of Business if
Self-Employed)
Enter text: The named insured's primary occupation or business activity.
APPLICANT INFORMATION
Years in Current Occupation
Enter number: The number of years the named insured has been employed in their current
occupation.
ACORD 88 (2014/12) rev. 04-29-2014
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APPLICANT INFORMATION
Years with Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
APPLICANT INFORMATION
Co-Applicant's Name (First,
Middle, Last)
Enter text: The named insured's given name.
APPLICANT INFORMATION
Enter text: The named insured's other given name initial.
APPLICANT INFORMATION
Enter text: The named insured's surname.
APPLICANT INFORMATION
Date of Birth
Enter date: The date of birth of the insured. (MM/DD/YYYY)
APPLICANT INFORMATION
Social Security #
Enter identifier: The tax identifier of the named insured.
APPLICANT INFORMATION
Marital Status / Civil Union
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* F Fianc or Fiance
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union / Registered Domestic Partner
* U Unknown
* O Other
As used here, this field may not be utilized for policyholders applying for residential property
insurance in CA.
APPLICANT INFORMATION
Check if same as Applicant
Check the box (if applicable): Indicates the co-named insured's mailing address is the same as
the named insured's mailing address.
APPLICANT INFORMATION
Co-Applicant's Address
Enter text: The named insured's mailing address line one.
APPLICANT INFORMATION
Enter text: The named insured's mailing address line two.
APPLICANT INFORMATION
Enter text: The named insured's mailing address city name.
APPLICANT INFORMATION
Enter code: The named insured's mailing address state or province code.
APPLICANT INFORMATION
Enter code: The named insured's mailing address postal code.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the primary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
APPLICANT INFORMATION
Primary Phone #
Enter number: The named insured's primary phone number.
APPLICANT INFORMATION
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
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APPLICANT INFORMATION
Bus
Check the box (if applicable): Indicates the secondary phone number is for a business phone.
APPLICANT INFORMATION
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
APPLICANT INFORMATION
Secondary Phone #
Enter number: The named insured's secondary phone number.
APPLICANT INFORMATION
Primary e-mail address
Enter text: The named insured's primary e-mail address.
APPLICANT INFORMATION
Secondary e-mail address
Enter text: The named insured's secondary e-mail address.
APPLICANT INFORMATION
Yrs with Current Employer
Enter number: The number of years the named insured has been with their current employer.
APPLICANT INFORMATION
Co-Applicant's Employer
Name And Address
Enter text: The employer name (business name if self-employed).
APPLICANT INFORMATION
Enter text: The first address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The second address line of the employer's physical address.
APPLICANT INFORMATION
Enter text: The city of the employer's physical address.
APPLICANT INFORMATION
Enter code: The state code of the employer's physical address.
APPLICANT INFORMATION
Enter code: The postal code of the employer's physical address.
APPLICANT INFORMATION
Co-Applicant's Occupation
(State Nature of Business if
Self-Employed)
Enter text: The named insured's primary occupation or business activity.
APPLICANT INFORMATION
Years in Current Occupation
Enter number: The number of years the named insured has been employed in their current
occupation.
APPLICANT INFORMATION
Years with Previous
Employer
Enter number: The number of years the named insured has been with their previous employer.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
LOCATION SCHEDULE
County
Enter text: The county of the physical location.
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
ACORD 88 (2014/12) rev. 04-29-2014
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LOCATION SCHEDULE
County
Enter text: The county of the physical location.
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
LOCATION SCHEDULE
Loc #
Enter number: The producer assigned number of the location.
LOCATION SCHEDULE
Street
Enter text: The first address line of the physical location.
LOCATION SCHEDULE
City
Enter text: The city of the physical location.
LOCATION SCHEDULE
County
Enter text: The county of the physical location.
LOCATION SCHEDULE
State
Enter code: The state or province of the physical location.
LOCATION SCHEDULE
Zip + 4
Enter code: The postal code of the physical location.
PRIOR COVERAGE
No Prior Coverage
Check the box (if applicable): Indicates there was no prior coverage.
PRIOR COVERAGE
Line Of Business
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
BI or CSL Limit(s) if
Applicable Per Person ($)
Enter amount: The bodily injury per person limit on the prior policy (if applicable).
PRIOR COVERAGE
Per Accident ($)
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if
applicable).
PRIOR COVERAGE
Line Of Business
Enter text: The type of policy issued to the insured. e. g., personal auto, truckers, garage liability.
PRIOR COVERAGE
Prior Carrier
Enter text: The name of the previous insurer.
PRIOR COVERAGE
Prior Policy Number
Enter identifier: The policy number of the previous coverage.
PRIOR COVERAGE
Expiration Date
Enter date: The expiration date of the previous coverage.
PRIOR COVERAGE
BI or CSL Limit(s) if
Applicable Per Person ($)
Enter amount: The bodily injury per person limit on the prior policy (if applicable).
PRIOR COVERAGE
Per Accident ($)
Enter amount: The bodily injury per accident limit or combined single limit on the prior policy (if
applicable).
LOSS HISTORY
Any losses, whether or not
paid by insurance, during
the last__years, at this or at
any other location?
Enter number: The number of years of loss information required by the insurer.
ACORD 88 (2014/12) rev. 04-29-2014
Page 8 of 22
LOSS HISTORY
Any losses at this or at any
other location?
Enter Y for a Yes response. Input N for No response. Indicates if there have been any losses
at any location, whether paid or not paid by insurance, in the last mandated number of years.
LOSS HISTORY
Applicant's Initials
Initial here: The named insured's initials.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
LOSS HISTORY
Line of Business
Enter text: The line of business involved in the loss (e.g. Automobile Liability, Property, General
Liability).
ACORD 88 (2014/12) rev. 04-29-2014
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LOSS HISTORY
Loss Date
Enter date: The date when the accident or incident occurred that resulted in the filing of a claim.
(MM/DD/YYYY)
LOSS HISTORY
Loss Type
Enter code: The basic coverage provided, under which the loss was incurred.
LOSS HISTORY
Description of Loss
Enter text: A brief description of the loss.
LOSS HISTORY
CAT#
Enter identifier: The Catastrophe Number that is assigned by the Insurance Services Office
Property Claims Service in cases of multiple losses due to floods, hurricanes, earthquakes, and
similar major loss events.
LOSS HISTORY
Amount Paid ($)
Enter amount: The amount that has been paid on this claim to date.
LOSS HISTORY
Entered by (A)gent
(C)ompany
Enter code: The code identifying who entered the loss (e.g. A - Agency, C - Company).
LOSS HISTORY
In Dispute (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if the claim is in dispute.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
GENERAL INFORMATION
Any other insurance with
this company?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any other insurance with this company?.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
GENERAL INFORMATION
Line of Business
Enter code: The line of business of the other policy.
GENERAL INFORMATION
Policy Number
Enter identifier: The other policy number exactly as it appears on the policy, including prefix and
suffix symbols.
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GENERAL INFORMATION
Any coverage declined,
cancelled, or non-renewed
during the last 3 years?
Not applicable for
applications for auto
insurance.
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any coverage declined, cancelled or non-renewed during the mandated number of years
(Missouri Applicants - Do not answer this question)?. As used here, this is not applicable for
applications for auto insurance.
GENERAL INFORMATION
Enter text: An explanation of any coverage declined, cancelled or non-renewed within the last
specified number of years.
GENERAL INFORMATION
Has applicant had a
foreclosure, repossession,
bankruptcy or filed for
bankruptcy during the past
five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the
past specified number of years?.
GENERAL INFORMATION
Enter text: An explanation of any foreclosures or bankruptcies in the last specified number of
years.
GENERAL INFORMATION
Has applicant had a
judgement or lien during the
past five (5) years?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has applicant had a judgement or lien during the past specified number of years?.
GENERAL INFORMATION
Enter text: An explanation of any judgement or liens during the past five (5) years.
GENERAL INFORMATION
Any other residence, not
listed on any application,
owned, occupied or rented?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Any other residence, not listed on any application, owned, occupied or rented?.
GENERAL INFORMATION
Enter text: An explanation of any other residence owned or occupied.
GENERAL INFORMATION
Has insurance been
transferred within agency?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Has insurance been transferred within agency?.
GENERAL INFORMATION
Enter text: An explanation of insurance transferred within the agency.
GENERAL INFORMATION
Does applicant own any
recreational vehicles
(snowmobiles, dune
buggies, mini bikes, ATVs,
etc.), not scheduled on this
policy?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
Does the applicant own any recreational vehicles (snow mobiles, dune buggies, mini bikes,
ATVs, etc.), not scheduled on this policy?.
GENERAL INFORMATION
Year
Enter year: The model year of the vehicle.
GENERAL INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
GENERAL INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
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GENERAL INFORMATION
Body Type
Enter code: The body type of the vehicle.
GENERAL INFORMATION
Year
Enter year: The model year of the vehicle.
GENERAL INFORMATION
Make
Enter text: The manufacturer of the vehicle (e.g., Ford, Chevy).
GENERAL INFORMATION
Model
Enter text: The manufacturer's model name for the vehicle.
GENERAL INFORMATION
Body Type
Enter code: The body type of the vehicle.
GENERAL INFORMATION
During the last five (5) years
[ten (10) in Rhode Island],
has any applicant been
indicted for or convicted of
any degree of the crime of
fraud, bribery, arson or any
other arson-related crime in
connection with this or any
other property?
Enter Y for a Yes response. Input N for No response. Indicates the answer to the question,
During the last five (5) years [ten (10) years in Rhode Island], has any applicant been indicted
for or convicted of any degree of the crime of fraud, bribery, arson or any other arson related
crime in connection with this or any other property? (In RI, failure to disclose the existence of an
arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of
imprisonment.).
GENERAL INFORMATION
Enter text: An explanation as to whether any applicant has been convicted of fraud, bribery or
arson in the last specified number of years.
PAYMENT PLAN
Billing Account #
Enter identifier: The account number to be used for billing purposes. This is the billing number
assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns.
If the account already exists, the agent should provide the previously assigned number.
PAYMENT PLAN
Deposit Amount $
Enter amount: The amount of the premium received as a deposit.
PAYMENT PLAN
Est Total Premium $
Enter amount: The estimated total cost amount of the policy.
PAYMENT PLAN
Direct Bill - Policy
Check the box (if applicable): Indicates if the policy is to be direct billed.
PAYMENT PLAN
Direct Bill - Acct
Check the box (if applicable): Indicates if the account is to be direct billed.
PAYMENT PLAN
Agency Bill
Check the box (if applicable): Indicates if the policy is to be producer / agency billed.
PAYMENT PLAN
Full Pay
Check the box (if applicable): Indicates a full payment will be made on the policy.
PAYMENT PLAN
Annual
Check the box (if applicable): Indicates the policy will be paid annually.
PAYMENT PLAN
Semi-Annual
Check the box (if applicable): Indicates the policy will be paid semi-annually.
PAYMENT PLAN
Quarterly
Check the box (if applicable): Indicates the policy will be paid quarterly.
PAYMENT PLAN
Bi-Monthly
Check the box (if applicable): Indicates the policy will be paid bi-monthly.
PAYMENT PLAN
Monthly
Check the box (if applicable): Indicates the policy will be paid monthly.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the policy will be paid in a frequency other than those
listed.
ACORD 88 (2014/12) rev. 04-29-2014
Page 12 of 22
PAYMENT PLAN
Other Description
Enter code: The payment plan for the policy (i.e., AN - Annual, MO - Monthly, QT - Quarterly,
etc.).
PAYMENT PLAN
Payment Method - Cash
Check the box (if applicable): Indicates the invoice will be paid in cash.
PAYMENT PLAN
Check
Check the box (if applicable): Indicates the invoice will be paid by check.
PAYMENT PLAN
Credit Card
Check the box (if applicable): Indicates the invoice will be paid by credit card.
PAYMENT PLAN
EFT
Check the box (if applicable): Indicates the invoice will be paid using electronic funds transfer
(EFT).
PAYMENT PLAN
Payroll Deduction
Check the box (if applicable): Indicates the invoice will be paid by payroll deduction.
PAYMENT PLAN
Pre-authorization Draft /
Check (PAC)
Check the box (if applicable): Indicates the invoice will be paid by a pre-authorized check or
draft.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the invoice will be paid by a means other than those
listed.
PAYMENT PLAN
Other Description
Enter text: The method the invoice will be paid.
PAYMENT PLAN
Agent
Check the box (if applicable): Indicates if the policy paper should be sent to the producer.
PAYMENT PLAN
Insured
Check the box (if applicable): Indicates if the policy paper should be mailed directly to the
named insured.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates if the policy paper should be mailed to other than the
agent or applicant.
PAYMENT PLAN
Other Description
Enter text: The description to whom the policy paper should be mailed.
PAYMENT PLAN
Payor Insured
Check the box (if applicable): Indicates the payor of the policy is the insured.
PAYMENT PLAN
Mortgagee
Check the box (if applicable): Indicates the payor of the policy is the mortgagee.
PAYMENT PLAN
Other
Check the box (if applicable): Indicates the payor of the policy is other than those listed.
PAYMENT PLAN
Other Description
Enter text: The description of the payor of the policy.
PAYMENT PLAN
Premium Financed? Y / N
Enter Y for a Yes response. Input N for No response. Indicates if the premium has been
financed.
PAYMENT PLAN
Finance Company
Enter text: The name of the company financing the premium, if applicable.
ADDITIONAL INTEREST
Interest - Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ACORD 88 (2014/12) rev. 04-29-2014
Page 13 of 22
ADDITIONAL INTEREST
Trustee
Check the box (if applicable): Indicates the additional interest type is a trustee.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Rank:
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Certificate Required
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST
Send Bill
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST
Name and Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Enter code: The additional interest's country code.
ADDITIONAL INTEREST
Reference / Loan #:
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Interest in Item Number
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle:
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat:
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Item Class:
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST
Item:
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ADDITIONAL INTEREST
Item Description:
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
ADDITIONAL INTEREST
Interest - Additional Insured
Check the box (if applicable): Indicates the additional interest type is an additional insured.
ACORD 88 (2014/12) rev. 04-29-2014
Page 14 of 22
ADDITIONAL INTEREST
Lienholder
Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST
Loss Payee
Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST
Mortgagee
Check the box (if applicable): Indicates the additional interest type is a mortgagee.
ADDITIONAL INTEREST
Trustee
Check the box (if applicable): Indicates the additional interest type is a trustee.
ADDITIONAL INTEREST
Other
Check the box (if applicable): Indicates the additional interest is other than those listed.
ADDITIONAL INTEREST
Other Description
Enter text: The description of the other type of additional interest.
ADDITIONAL INTEREST
Rank:
Enter number: The ranking of 'this' additional interest when multiple additional interests are
associated with the same item.
ADDITIONAL INTEREST
Certificate Required
Check the box (if applicable): Indicates if the additional interest requires a Certificate of
Insurance.
ADDITIONAL INTEREST
Send Bill
Check the box (if applicable): Indicates the bill should be sent to the additional interest.
ADDITIONAL INTEREST
Name and Address
Enter text: The additional interest's full name.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line one.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address line two.
ADDITIONAL INTEREST
Enter text: The additional interest's mailing address city name.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address state or province code.
ADDITIONAL INTEREST
Enter code: The additional interest's mailing address postal code.
ADDITIONAL INTEREST
Enter code: The additional interest's country code.
ADDITIONAL INTEREST
Reference / Loan #:
Enter identifier: The loan number, account number or other controlling number that the
additional interest may have assigned the insured.
ADDITIONAL INTEREST
Interest in Item Number
Location:
Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST
Building:
Enter number: The producer assigned number of the building which has an additional interest.
ADDITIONAL INTEREST
Vehicle:
Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST
Boat:
Enter number: The producer assigned number of the boat which has an additional interest.
ADDITIONAL INTEREST
Item Class:
Enter code: The description of the property class of the scheduled item (i.e. Jewelry, Furs,
Contractors Equipment, etc.).
ADDITIONAL INTEREST
Item:
Enter number: The producer assigned number of the scheduled item which has an additional
interest.
ACORD 88 (2014/12) rev. 04-29-2014
Page 15 of 22
ADDITIONAL INTEREST
Item Description:
Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list
the make, model and VIN number. For a scheduled item, list the description, such as three
carat diamond in six point setting.
REMARKS / ATTACHMENTS Flood Exclusion Notice
Check the box (if applicable): Indicates a flood exclusion notice is attached.
REMARKS / ATTACHMENTS Lead Free Paint Certification
Check the box (if applicable): Indicates a lead free paint certification is attached.
REMARKS / ATTACHMENTS Mobile Home Supplement
Check the box (if applicable): Indicates a mobile home supplement is attached to the
application.
REMARKS / ATTACHMENTS Photograph
Check the box (if applicable): Indicates a photograph is attached.
REMARKS / ATTACHMENTS Protection Device Certificate
Check the box (if applicable): Indicates a protection device certificate is attached.
REMARKS / ATTACHMENTS Recreational Vehicle App
Check the box (if applicable): Indicates a recreational vehicle application is attached.
REMARKS / ATTACHMENTS Replacement Cost Estimate
Check the box (if applicable): Indicates a replacement cost estimate is attached.
REMARKS / ATTACHMENTS
Residence Based
Businesses Supp
Check the box (if applicable): Indicates a residence based business supplement is attached.
REMARKS / ATTACHMENTS Solid Fuel Supplement
Check the box (if applicable): Indicates a solid fuel supplement is attached.
REMARKS / ATTACHMENTS State Supplement
Check the box (if applicable): Indicates a state supplement form is attached (if applicable).
REMARKS / ATTACHMENTS Windstorm Loss Mitigation
Check the box (if applicable): Indicates a windstorm loss mitigation form is attached.
REMARKS / ATTACHMENTS Other
Check the box (if applicable): Indicates there is an attachment other than those listed.
REMARKS / ATTACHMENTS Other Description
Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Remarks
Enter text: The remarks associated with the personal lines policy.
Form Page 3
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
ACORD 88 (2014/12) rev. 04-29-2014
Page 16 of 22
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
ACORD 88 (2014/12) rev. 04-29-2014
Page 17 of 22
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
ACORD 88 (2014/12) rev. 04-29-2014
Page 18 of 22
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
ACORD 88 (2014/12) rev. 04-29-2014
Page 19 of 22
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
ACORD 88 (2014/12) rev. 04-29-2014
Page 20 of 22
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
FORMS AND
ENDORSEMENTS
Loc #
Enter number: The producer assigned identifier for the location associated with this form.
FORMS AND
ENDORSEMENTS
Veh #
Enter number: The producer assigned identifier for the vehicle associated with this form.
FORMS AND
ENDORSEMENTS
Boat #
Enter number: The producer assigned identifier for the boat associated with this form.
FORMS AND
ENDORSEMENTS
Item #
Enter number: The producer assigned identifier for the item associated with this form.
FORMS AND
ENDORSEMENTS
Form Number
Enter identifier: The number used by the insurer for this form.
FORMS AND
ENDORSEMENTS
Form Name
Enter text: The name of the form.
FORMS AND
ENDORSEMENTS
Edition Date
Enter date: The edition date of the form.
FORMS AND
ENDORSEMENTS
Copyright Owner Code
Enter code: Indicates the entity that has copyright ownership of the form.
REMARKS
Remarks
Enter text: The remarks associated with the personal lines policy.
NOTICE OF INFORMATION
PRACTICES
Applicant's Initials
Initial here: The named insured's initials. As used here, indicates the named insured has read
and understands the credit reporting information.
NOTICE OF INFORMATION
PRACTICES
Copy of the Notice of
Information Practices
Privacy has been given to
the applicant. Not required
in all states, contact your
agent or broker for your
state's requirements.
Check the box (if applicable): Indicates that a copy of the Notice of Information Practices
(ACORD 38 or state specific ACORD 38) has been given to the applicant. State specific 38s
are available for applicants in AZ, DE, KS, MN, ND, NY, OR, VA, and WV. In addition, ACORD
38 contains CA and MA state specific language.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
ACORD 88 (2014/12) rev. 04-29-2014
Page 21 of 22
FRAUD STATEMENTS /
SIGNATURE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
FRAUD STATEMENTS /
SIGNATURE
Producer's Name (Please
Print)
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
FRAUD STATEMENTS /
SIGNATURE
State Producer License No
(Required in FL)
Enter identifier: The State License Number of the producer.
FRAUD STATEMENTS /
SIGNATURE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
FRAUD STATEMENTS /
SIGNATURE
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
FRAUD STATEMENTS /
SIGNATURE
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
ACORD 88 (2014/12) rev. 04-29-2014
Page 22 of 22