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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 66 IA (2006/07) |
Iowa Personal Insurance Supplement - Disclosure Use of Claims History |
Use this form, as required by Iowa law, with all applications for personal insurance, except personal auto. The form discloses to an applicant that claims history will be considered in determining whether to decline, cancel, nonrenew or surcharge a policy that is being applied for. |
|
IDENTIFICATION SECTION |
Agency |
Producer’s name and address. |
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Identification code assigned to your agency or brokerage firm by the insurance company |
|
IDENTIFICATION SECTION |
Code |
receiving this form. |
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If your agency uses a subcode identification system with the company, enter the |
|
IDENTIFICATION SECTION |
Subcode |
appropriate code. |
|
IDENTIFICATION SECTION |
Applicant/Named Insured |
Indicate applicant name. If named insured, name exactly as it appears on the policy. |
|
IDENTIFICATION SECTION |
Company |
Issuing company's name. |
|
IDENTIFICATION SECTION |
Policy # |
Number exactly as it appears on the policy, including prefix and suffix symbols. |
|
IDENTIFICATION SECTION |
Effective Date |
Date on which the terms and conditions of the policy commenced. |
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SIGNATURE |
Applicant Signature |
Applicant must sign the supplement. |
|
SIGNATURE |
Date |
Indicate the date the supplement was signed in MM/DD/YYYY format. |