Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 38 MN (2011/05)
Minnesota Authorization
ACORD 38 MN, Minnesota Authorization, is used with all applications
for insurance, to comply with Minnesota law requiring that all applicants for insurance
must be told that credit-related information may be requested from Credit Bureaus or
other organizations providing personal or privileged information in connection with the
application.
This information will be used for the purpose of making underwriting decisions which may
include determinations to grant or deny coverage and/or the rates to be charged.
This authorization is required pursuant to Minnesota Statute 72A.501.
Additionally, the Applicant is advised that they have the right to request in writing that
Extraordinary Life Circumstances be considered with the development of their credit
score.
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Agency Address
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 (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION Fax No. (A/C, No, Ext)
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
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Section Name
Field Name
Field and/or Section Description
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 Address
Applicant's Name and Mailing
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION Phone (A/C, No.)
Enter number: The named insured's primary phone 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 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 Account Number
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.
IDENTIFICATION SECTION New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Renewal
Check the box (if applicable): Indicates the response expected from the company is a
renewed policy.
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 Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
APPLICANT / APPLICANT'S
AUTHORIZED
REPRESENTATIVE'S
SIGNATURE
Applicant / Applicant's Authorized
Representative's Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here,
this is the named insured or named insured representative.
APPLICANT / APPLICANT'S
AUTHORIZED
REPRESENTATIVE'S
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
APPLICANT / APPLICANT'S
AUTHORIZED
REPRESENTATIVE'S
SIGNATURE
Applicant / Applicant's Authorized
Representative's Signature
Sign here: Accommodates the signature of the applicant or named insured. As used here,
this is the named insured or named insured representative.
APPLICANT / APPLICANT'S
AUTHORIZED
REPRESENTATIVE'S
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).
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