ACORD 69 MD (2013/10) - Maryland Insurance Supplement
ACORD 69 MD (2013/10) - Maryland Insurance Supplement
ACORD 69 MD, Maryland Insurance Supplement Notice of Underwriting Period, should be used 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 companys underwriting requirements,
or recalculate the premium if the insurer discovers a material risk factor during this period.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed.
IDENTIFICATION SECTION
Producer Name
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Address Line 1
Enter text: The mailing address line one of the producer / agency.
IDENTIFICATION SECTION
Address Line 2
Enter text: The mailing address line two of the producer / agency.
IDENTIFICATION SECTION
City
Enter text: The mailing address city name of the producer / agency.
IDENTIFICATION SECTION
State
Enter code: The mailing address state or province code of the producer / agency.
IDENTIFICATION SECTION
Zip
Enter code: The mailing address postal code of the producer / agency.
IDENTIFICATION SECTION
Code
Enter code: The identification code assigned to the producer (e.g., agency or brokerage firm) by
the insurer.
IDENTIFICATION SECTION
Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g., person)
within a producer's office (e.g., agency or brokerage).
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Named Insured/Applicant's
Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION
Address Line 1
Enter text: The named insured's mailing address line one.
IDENTIFICATION SECTION
Address Line 2
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
City
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
County
Enter text: The applicant's physical address county name.
IDENTIFICATION SECTION
State
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Zip
Enter code: The named insured's mailing address postal code.
IDENTIFICATION SECTION
Phone Number
Enter number: The named insured's primary phone number.
ACORD 69 MD (2013/10) rev. 07-31-2013
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IDENTIFICATION SECTION
Company
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
Account Number
Enter identifier: The account number to be used for billing purposes. This is the billing number
assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns.
If the account already exists, the agent should provide the previously assigned number.
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
New
Check the box (if applicable): Indicates the response expected from the company is a new
issued policy.
IDENTIFICATION SECTION
Renewal
Check the box (if applicable): Indicates the response expected from the company is a renewed
policy.
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
Expiration Date
Enter date: The date on which the terms and conditions of the policy will expire.
SIGNATURE
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
ACORD 69 MD (2013/10)
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