ACORD 653 (2008/04)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 653 (2008/04)
Policy Delivery Receipt
Use ACORD 653, Policy Delivery Receipt, to obtain affirmation from the insured that the
policy has been delivered and received by the insured.
IDENTIFICATION SECTION Company
Name and Address of Insurance
The name and address of Insurance Company must be inserted before this form is used.
Use the actual name of the company. Do not use group names.
APPLICANT / INSURED
Named Insured
Indicate the full name of the named insured as it appears on the policy.
APPLICANT / INSURED
Policy Number
Indicate the policy number.
APPLICANT / INSURED
Date of Delivery
Indicate the date the policy has been delivered and received by the insured.
SIGNATURE
Signature of Named Insured
Signature of named insured.
SIGNATURE
Producer Name (Please Print)
Indicate the name of the producer.
SIGNATURE
Signature of Producer
Signature of producer.
SIGNATURE
National Producer Number (if
applicable)
Provide the National Producer Number if applicable.
ACORD 653 (2008/04)
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