ACORD 851 MD (2008/11)

Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 851 MD (2008/11)
Maryland Personal Property
Supplement
ACORD 851 MD, Maryland Personal Property Supplement, complies with Maryland law,
which requires that the named insured for each policy of residential property insurance be
offered coverage for loss from water and sewer backup.
Use this form with ACORD 89, Residential Section, when applying for residential property
insurance. This form may also be used at the time of insurance renewal.
IDENTIFICATION SECTION Agency Customer ID
Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Agency
The producer's full name.
IDENTIFICATION SECTION Policy Number
Provide the policy number if a policy has already been issued.
IDENTIFICATION SECTION Effective Date
Enter the effective date (MM/DD/YYYY) on which the terms and conditions of the policy
will commence.
IDENTIFICATION SECTION Named Insured(s)
Full name of the applicant as it should appear on the policy. If coverage will include real
property enter the names of all persons named in the deed for the property.
IDENTIFICATION SECTION Carrier
Name of the applicable insurance company. 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
Individual company code assigned by the NAIC.
WATER AND SEWER
BACKUP COVERAGE
Initials - Accept
Applicant must intial the application if they accept water and sewer backup coverage.
WATER AND SEWER
BACKUP COVERAGE
Initials - Reject
Applicant must intial the application if they reject water and sewer backup coverage.
SIGNATURE
Applicant's Signature
The applicant should read and understand the information on the form before personally
signing the application.
SIGNATURE
Date
Date (MM/DD/YYYY) the form was signed.
ACORD 851 MD (2008/11)
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