ACORD 611 Fillable PDF – Loss Run Request Form

ACORD 611 (2015/07)

Claims History / Loss Run Request

Form Number:

ACORD 611 (2015/07)

Category:

Claims & Loss

Last Updated:

July 2015

Page Count:

01 Pages

File Format:

PDF, Fillable PDF

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ACORD 611

Insurance agencies, businesses, and companies often require a detailed record of past claims before issuing, renewing, or transferring coverage. The Acord 611, which is officially known as the “Claims History / Loss Run Request” form, is an industry-standard document used to request and authorize the release of loss run or claims history reports from an insurance carrier. It helps the insured and the agency to access accurate claims history, ensuring transparency in underwriting, the renewal process, and pricing decisions. To claim your benefits, download or fill out the form today to avoid delays in your insurance process.

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Benefits of the Acord Loss Runs Request Form

Multiple Policy Types

The Acord 611 form covers multiple policy types in a single document. Instead of submitting multiple requests, it allows you to request loss runs for property, liability, auto, workers’ compensation, inland marine, or umbrella/excess policies all at once.

Customizable

The applicant can specify exactly how many years of claims history they want, such as 3, 4, or 5, depending on the renewal or underwriting requirements.

Protects Against Disputes

Having a written, signed record of the request provides proof that the agency acted with the insured’s consent, which prevents future disputes and misunderstandings.

Key Sections of Acord 611 Fillable Form

Agency Details

This section includes the agency and insurer information, including agency name, agency code & subcode, phone number, fax number, email address, agency customer ID, etc.

Applicant Information

It describes the applicant’s name and complete address, including country, state, and ZIP code.

Carrier Information

Specifies the carrier’s name, address, and NAIC code.

Claims History/Loss Run Request Details

This section describes coverage type, policy numbers, and the number of years of claims history.

How To Complete The Loss Runs Request Form?

  1. Carrier Information: Fill out the insurance carrier’s full name, address, contact details, fax number, and NAIC code.
  2. Insured Information: Provide the applicant’s name and complete mailing address.
  3. Agency Information: Write the agency name, agency code or subcode, customer ID, policy number, etc.
  4. Request Details: Write the effective date and the number of years of claims history you want to release.
  5. Coverage Type: Select the coverage type, such as property, liability, auto, workers’ compensation, umbrella/excess, crime, or inland marine. Check all boxes that apply.
  6. Policy Number: Provide the policy number for each coverage type (if different from above).
  7. Sign & Date: The applicant must sign the form to authorize the request.
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Frequently Asked Questions

The form is used to authorize the release of loss run or claims history reports from an insurance carrier. This report helps in underwriting, renewals, or moving coverage to a new carrier.

This form allows you to specify the number of years you need. Usually, carriers provide 3 to 5 years of history.

As this form is part of the Acord standards, all insurance carriers in the United States accept it.

No, you can cover multiple policy types in a single document. Simply, check the appropriate boxes and write the policy numbers.

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