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ACORD Form 861 CA California Residential Property Insurance Bill Of Rights Instructions
 

 
Section Name Field Name Field and/or Section Description
TITLE California Residential Property This form must be provided to every applicant for residential property insurance. The
ACORD 861 CA (2006/07) Insurance Bill of Rights content of the form follows the language in California law effective July 1, 2006.
IDENTIFICATION SECTION Agency Agency'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.
IDENTIFICATION SECTION Named Insured/Applicant's Name and Mailing Address 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
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.
IDENTIFICATION SECTION Account Number Indicate account number, if applicable.
IDENTIFICATION SECTION New Check this box if this is a new policy.
IDENTIFICATION SECTION Renewal Check this box if this is a renewal of an existing policy.
The number assigned by the insurance company for the policy. In general, policy numbers
IDENTIFICATION SECTION Policy Number will not appear on new business applications since they are not known at that point in time.

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Section Name Field Name Field and/or Section Description
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.
CLAIMS INFORMATION DATABASE Name Indicate the name of the person who may be contacted by the applicant to obtain a report from a claims information database.
CLAIMS INFORMATION DATABASE Toll-free Telephone Number Indicate the toll-free telephone number of the person who may be contacted by the applicant to obtain a report from a claims information database.
CLAIMS INFORMATION DATABASE Internet Web Site Address Indicate the internet web site address (if applicable).
SIGNATURE Applicant's Signature The applicant should read and understand the notice and any other disclosure information on the form before personally signing the application.
SIGNATURE Date Date the form was signed.