Home

 

ACORD Form 69 MD Maryland Insurance Supplement Instructions
 

 
Section Name Field Name Field and/or Section Description
TITLE ACORD 69 MD (2007/01) Maryland Insurance Supplement Notice of Underwriting Period Use this form with all applications for personal auto, homeowners, dwelling, commercial property or commercial liability insurance to comply with Maryland law that requires disclosure of a 45 day underwriting period, during which time the company may cancel the insurance if the risk does not meet the company’s underwriting requirements.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer's name and address.
Identification code assigned to the agency or brokerage firm by the insurance company
IDENTIFICATION SECTION Code receiving this form.
If the agency or brokerage uses a sub-code identification system with the company, enter
IDENTIFICATION SECTION Sub Code the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
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). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail.
Address should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.: 150 Central Ave N); City; County; State; ZIP code
IDENTIFICATION SECTION Applicant/Named Insured If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal description if required by the mortgage holder.
Telephone number at which the applicant may be reached. Include area code and
IDENTIFICATION SECTION Telephone Number extension, if applicable.
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
IDENTIFICATION SECTION Company you wish to have the policy issued.

ACORD 69 MD (2007/01) 1 of 2 ACORD 69 MD (2007/01) 2 of 2

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Account Number Indicate account number, if applicable.
IDENTIFICATION SECTION Policy # 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 Check Boxes Check if the policy is new or a renewal.
IDENTIFICATION SECTION Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
IDENTIFICATION SECTION Expiration Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless renewed.
SIGNATURE Applicant's Signature The Applicant must sign the supplement.
SIGNATURE Date Date (MM/DD/YYYY) the supplement was signed.