ACORD 64 NC (2008/04)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 64 NC (2008/04)
North Carolina Property
Supplement - Property Insurance
Disclosure Notice
Use ACORD 64 NC, North Carolina Property Supplement, to comply with North Carolina
regulation that requires advice to all property insurance applicants that:
- their property insurance policy does not protect them against losses from floods
- their property insurance policy does not protect them against losses from earthquakes,
mudslides, mudflows or landslides
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency
Producer's name.
IDENTIFICATION SECTION Policy Number
The number assigned by the insurance company for the policy. In general, policy numbers
will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Carrier
Name of the insurance company (or residual market plan) that will receive the application.
Do not use group names, use the actual name of the company within the group in which
you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code
The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Applicant / Named Insured(s)
Full name of the applicant as it should appear on the policy. The First Named Insured is
given certain rights and responsibilities by the policy contract language. If more than one
insured is named, be sure the one intended to receive these rights and responsibilities is
named first and any additional insureds identified as such. If joint ownership, the name
used may include both names (e.g., John and Mary Smith).
DISCLOSURE
Check Box 1 - Warning: This
property insurance policy does not
protect you against losses from
floods
Check if applicable.
DISCLOSURE
Check Box 2 - Warning: This
property insurance policy does not
protect you against losses from
earthquakes, mudslides, mudflows
or landslides
Check if applicable.
DISCLOSURE
Telephone Number of Agent
Enter the telephone number of the agent, include area code and extension (if applicable)
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DISCLOSURE
Telephone Number of Company /
Association
Enter the telephone number of the company or association, include area code and
extension (if applicable)
DISCLOSURE
Applicant / Named Insured
Signature
Applicant / Named Insured must sign the application.
DISCLOSURE
Date
Date the application was completed. (MM/DD/YYYY)
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