Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 60 (2010/04)
Flood Insurance Notice / Rejection
ACORD 60, Flood Insurance Selection / Rejection, is used to explain
to applicants for property insurance the value of purchasing flood insurance coverage, and
to record the signature of the applicant if flood insurance coverage is selected or rejected.
This form contains advisory text provided by the Federal Emergency Management Agency
(FEMA).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION
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 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 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
Applicant / Named Insured(s)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
NFIP Building Coverage - Accept
Check the box (if applicable): Indicates NFIP Building coverage is accepted by the
applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
NFIP Building Coverage - Reject
Check the box (if applicable): Indicates NFIP Building coverage is rejected by the
applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
NFIP Contents / Personal Property -
Accept
Check the box (if applicable): Indicates NFIP Contents / Personal Property coverage is
accepted by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
NFIP Contents / Personal Property -
Reject
Check the box (if applicable): Indicates NFIP Contents / Personal Property coverage is
rejected by the applicant / named insured.
ACORD 60 (2010/04) rev. 04-30-2010
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Section Name
Field Name
Field and/or Section Description
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Excess Building Coverage -
Accept
Check the box (if applicable): Indicates Excess Building coverage is accepted by the
applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Excess Building Coverage - Reject
Check the box (if applicable): Indicates Excess Building coverage is rejected by the
applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Excess Contents / Personal
Property Coverage - Accept
Check the box (if applicable): Indicates Excess Contents / Personal Property coverage is
accepted by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Excess Contents / Personal
Property Coverage - Reject
Check the box (if applicable): Indicates Excess Contents / Personal Property coverage is
rejected by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Primary
Building Coverage - Accept
Check the box (if applicable): Indicates the alternative market primary building coverage is
accepted by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Primary
Building Coverage - Reject
Check the box (if applicable): Indicates the alternative market primary building coverage is
rejected by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Primary
Contents Coverage - Accept
Check the box (if applicable): Indicates the alternative market primary contents coverage
is accepted by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Primary
Contents Coverage - Reject
Check the box (if applicable): Indicates the alternative market primary contents coverage
is rejected by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Loss of Income
or Additional Living Expense -
Accept
Check the box (if applicable): Indicates Loss Of Income or Additional Living Expense
coverage is accepted by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Alternative Market Loss of Income
or Additional Living Expense -
Reject
Check the box (if applicable): Indicates Loss Of Income or Additional Living Expense
coverage is rejected by the applicant / named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Date
Enter date: The date the form was signed by the named insured.
ACORD 60 (2010/04) rev. 04-30-2010
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Section Name
Field Name
Field and/or Section Description
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Address of Property
Enter text: The first address line of the physical location. As used here, this is the physical
address of the property for which flood insurance coverage is available but has been
rejected by the applicant/first named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Address of Property
Enter text: The city of the physical location. As used here, this is the physical address of
the property for which flood insurance coverage is available but has been rejected by the
applicant/first named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Address of Property
Enter code: The state or province of the physical location. As used here, this is the
physical address of the property for which flood insurance coverage is available but has
been rejected by the applicant/first named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Address of Property
Enter code: The postal code of the physical location. As used here, this is the physical
address of the property for which flood insurance coverage is available but has been
rejected by the applicant/first named insured.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g. producer,
agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SELECTION / REJECTION
OF FLOOD INSURANCE
COVERAGE
Date
Enter date: The date the producer signed the form.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
ACORD 60 (2010/04) rev. 04-30-2010
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