Universal wording updates to improve clarity and intent were made to all FIG text for this form on 04/30/2009.
Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 38 NY (2005/04)
New York Personal Insurance
Supplement - Notice of Information
Practices
ACORD 38 NY, New York Personal Insurance Supplement - Notice
of Information Practices, is used with all personal lines insurance applications, to comply
with New York insurance law (Article 28) and Regulation 182. Applicants are required to
be notified, in a form separate from the application, that a credit report might be obtained
and credit-based scoring used in connection with the insurance being applied for. The
name and address of the insurance company, the company's toll free telephone number
and the name of the consumer reporting agency must be entered on the form.
IDENTIFICATION SECTION Date
Enter date: The month/day/year 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 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.
ACORD 38 NY (2005/04)
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Section Name
Field Name
Field and/or Section Description
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 Telephone Number
Enter number: The named insured's primary phone number.
IDENTIFICATION SECTION Company Name and Address
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
Enter text: The first line of the insurer's mailing address.
IDENTIFICATION SECTION
Enter text: The second line of the insurer's mailing address.
IDENTIFICATION SECTION
Enter text: The city of the insurer's mailing address.
IDENTIFICATION SECTION
Enter code: The state or province of the insurer's mailing address.
IDENTIFICATION SECTION
Enter code: The postal code of the insurer's mailing address.
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 Toll Free Telephone Number
Enter number: The toll-free telephone number in which named insured may contact the
insurer regarding disclosure authorization.
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 New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION Renewal
Check the box (if applicable): Indicates the response expected from the company is a
renewed policy.
ACORD 38 NY (2005/04)
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Section Name
Field Name
Field and/or Section Description
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/NAMED
INSURED'S SIGNATURE
Consumer Reporting Agency
Enter text: The code identifies an external source that may be used to provide financial or
credit information. For example, a Dun and Bradstreet Number, TRW number, Equifax,
Trans-Union, etc.
APPLICANT/NAMED
INSURED'S SIGNATURE
Applicant/Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Applicant/Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Applicant/Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
APPLICANT/NAMED
INSURED'S SIGNATURE
Applicant/Named Insured's
Signature
Sign here: Accommodates the signature of the applicant or named insured.
APPLICANT/NAMED
INSURED'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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