ACORD 90 Generic Instructions
Generic Personal Auto Application
Date Month/day/year (MM/DD/YYYY) on which the form is completed. Agency Producer's name
and address. Phone No. Producer's telephone
number. (Include area code and extension if applicable) Fax No. Producer's fax
number. (Include area code) Code Identification
code assigned to the agency or brokerage firm by the insurance company receiving
this form. Sub Code If the agency
or brokerage uses a sub-code identification system with the company, enter the
appropriate code. Agency Customer ID Customer's identification
number assigned by the agency or brokerage. Applicant's Name and Mailing Address 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.
NAIC Code The identification
code assigned to the company by the NAIC. Telephone Number Telephone number
at which the applicant may be reached. Include area code and extension, if applicable. CO/Plan 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
you wish to have the policy issued. Also, if applicable, indicate the type of
plan or policy program (example: Preferred) that you wish to use when issuing
the policy. Use the specific plan name that is unique to that company. POL# 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. ACCT# Indicate account
number, if applicable. Effective Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will commence. Expiration Date Date (MM/DD/YYYY)
on which the terms and conditions of the policy will terminate unless renewed. Billing Plan Indicate whether
the agency or the company (direct) will bill the insured or other payee for
the policy. Indicate to whom the policy should be mailed. Payment Plan If direct bill,
also indicate who is to be billed, and the plan to be used for payment. RESIDENCE Owned/Rented Check the box indicating whether your home is owned or rented.
Number of years
present at the applicant's current address. Number of Years at Previous Address Number of years
present at previous address. Previous Address Physical address
of the first named insured if the applicant has been at the current address
for less than three years. GARAGE LOCATION Veh # Indicate vehicle number.
Indicate complete
address including ZIP code for any vehicle not kept at the mailing address.
Also, provide this information if the mailing address is a post office box or
rural route address, or when a driver is at school with a vehicle. VEHICLE DESCRIPTION/USE Total # Vehicles In Household All owned, leased, or regularly used vehicles in household, including non-registered and non-insured vehicles.
Indicate vehicle
number. Year Model year of
the vehicle. Make, Model and Body Type Manufacturer's
trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4
door sedan). VIN/Registered State Vehicle identification
number as it appears on the title certificate or registration. Also enter the
state where the vehicle is registered. If the vehicle is registered in a state
different from where it is garaged, provide an explanation in the Remarks section. HP/CC Horsepower, or
the number of cubic centimeters of displacement. Date Leased Indicate the
date vehicle was leased. (MM/DD/YYYY) Date Purch Year the applicant
acquired the vehicle in YYYY format. New/Used Enter "N"
if the applicant bought the vehicle new, "U" if the vehicle was used. Veh # Indicate vehicle
number. Cost New Original cost
of the vehicle. Symbol Age Grp If the vehicle
requires physical damage coverage, enter the symbol group code. Refer to rating
manual. Terr Rating territory
code where the vehicle is principally garaged. Refer to rating manual. Miles 1 Way Wk/Schl Number of miles
from the garage location to school or work. # Days Week Number of days
per week the vehicle is used to commute from the garage location to work or
school. This includes driving to and from a commuter lot or transit station. # Weeks/ Mo. Number of weeks
per month the vehicle is used to commute from the garage location to work or
school. This includes driving to and from a commuter lot or transit station. Usage Enter pleasure
(P), business (B) or farm (F). Use business (except for farming) if the vehicle
is involved in the occupation, profession or business of the applicant or any
other operator of the vehicle. Going to or from the principal place of occupation,
profession or business is considered pleasure. Perform Vehicle's performance
level. Indicate High (H), Intermediate (I) or Sport (S). Multi-Car Check box only
if multi-car credit applies. Carpool Indicate if any
vehicle is used in a car pool for travel to work or school. Garaged Indicate if the
vehicle is parked in a garage at night. If the vehicle is left on the street,
at school or some other equally exposed place, provide this information in Remarks.
Examples of exposures are: Odometer Reading Current number
of miles on the odometer. Annual Mileage Total estimated
annual mileage for each vehicle. Govern Driver Driver to be
assigned to each vehicle for rating purposes. Driver Use % Percentage that
each driver uses each vehicle. Each vehicle should total 100 percent. If any
driver has 0 percent use for all vehicles, indicate why in the Remarks section. Class Rate classification
for each vehicle. Refer to manual; some companies determine class automatically
from information provided in Vehicle Use and Driver Information sections. Veh # Indicate vehicle
number. Passive Seat Belt Check the box
if the vehicle is equipped with automatic seat belts. Air Bag Drv/Both Indicate "D"
for driver side air bag, "B" for vehicle equipped with air bag for
both front driver and passenger. Anti-Lock Brakes 2/4 For vehicles with
anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel
anti-lock braking system. Anti-Theft Devices If vehicle is
equipped with an anti-theft device, indicate type. Credits and Surcharges Enter any other
credits and/or surcharges that are to apply to any or all vehicles. Veh # Indicate vehicle
number. Passive Seat Belt Check the box
if the vehicle is equipped with automatic seat belts. Air Bag Drv/Both Indicate "D"
for driver side air bag, "B" for vehicle equipped with air bag for
both front driver and passenger. Anti-Lock Brakes 2/4 For vehicles with
anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel
anti-lock braking system. Anti-Theft Devices If vehicle is
equipped with an anti-theft device, indicate type. Credits and Surcharges Enter any other
credits and/or surcharges that are to apply to any or all vehicles. COVERAGES/PREMIUMS For information relating to each state's unique coverages, refer to the State forms section in this guide, and your company's rating manual.
The desired limit
of both bodily injury and property damage. If an entry is made in this field,
leave the separate Bodily Injury and Property Damage fields blank, except be
sure to show a property damage deductible if applicable. Bodily Injury The desired per
person and per accident limits. Property Damage The limit desired
include applicable property damage deductible. Medical Payments The desired per
person limit. Uninsured Motorists The bodily injury
(per person and per accident) limits. For COMBINED SINGLE LIMIT (CSL), enter
the limit in the BI per accident area for combined single limits. Comprehensive/OTC The comprehensive
(Other Than Collision) coverage deductible for each vehicle. Collision The collision
coverage deductible for each vehicle if applicable. Some companies provide a
verbal limit. Consult company manuals for cases in which a verbal limits applies.
ACV unless Amount Stated If stated amount
applies for the type of vehicle being insured, enter the amount and indicate
the vehicle to which it applies. Towing & Labor The amount per
disablement for each vehicle if applicable. Some companies provide a verbal
limit. Consult company manuals for cases in which a verbal limit applies. Transportation Expenses/Rental Reimbursements The desired per
day limit and maximum amount. Additional miscellaneous coverages can be included
in the blank line or the additional line or the Additional Coverages/Endorsements
Section. Additional Coverages/Endorsements Indicate any
additional coverages and endorsements. Include limits, deductible and premium. Policy Fee Enter any applicable
policy fee permitted by law. Total Per Vehicle The estimated
total premium for each vehicle. Estimated Total The estimate
total premium for all vehicles on policy. Include all coverages, credits and
surcharges. Deposit The amount of
premium submitted with the application. Balance Due Estimated total
premium minus deposit. DRIVER INFORMATION Number (#) Number all licensed operators. Show the applicant as driver #1, even if not an operator.
Name of each licensed
operator (resident or not) as it appears on their drivers licenses, and every
resident of the household regardless of age. Enter the surname only if different
from the applicant's. Show the applicant as driver #1, even if not an operator.
Use the REMARKS section or additional sheets if the number of individuals exceeds
the space provided. Sex Enter F for female,
M for male. Mar Stat Enter the marital
status of each listed driver. Examples: Relation to Applicant Driver's relationship
to the applicant. Examples: Date of Birth Date of birth
of each driver and household resident (MM/DD/YYYY) (e.g., March 7, 1944 should
be 03/07/1944). Occupation Occupation of
each operator. Date Lic Date (MM/YYYY)
each driver was permanently licensed. Stdt > 100 Indicate if any
youthful driver is residing at a school over 100 road miles from the principal
place of garaging. Show name of institution and address in the Remarks section. Good Stdt Indicate if any
driver qualifies for a good student credit (verify that company offers this
credit). Complete and attach a Good Student Certificate (ACORD 91) for each
operator who qualifies. Drv Train Indicate if driver
training credit applies to the driver, if required by the company. Refer to
the company's manual to verify if a credit or surcharge should be applied. Attach
a Driver Training Certificate for any operator under age 21 who has successfully
completed this training and qualifies for the credit. Acc Prev Cse Date on which
the driver successfully completed an approved motor vehicle accident prevention
course (or a similarly recognized defensive driving course). Attach a completion
certificate for each driver who qualifies. Drivers License #/ Licensed State Complete drivers
license number and licensed state for each licensed operator. Copy directly
from license if possible. Social Security # Social security
number for each named driver and household resident. ACCIDENTS/CONVICTIONS It is important that this section be completed fully and accurately. Many companies verify driving records with state motor vehicle departments. Discrepancies between the application and the report may result in processing delays and unnecessary correspondence with the company. If there have not been any accidents, convictions or comprehensive losses during the indicated time period, enter "None". Be sure to enter the number of years reviewed, in accordance with the company's and state's requirements, as the experience period. Use the REMARKS section or additional sheets if necessary to provide the necessary information. Drv # Driver number
as found in the driver information section. Date of Accident/Conviction Date the accident
or conviction occurred. (MM/DD/YYYY) Description of Accident or Conviction A complete description
of the accident or conviction. This would include the number of vehicles involved
and the type of vehicles (private passenger or commercial). Convictions constitute
a judgment of guilty, plea of nolo contendere or forfeiture of bail. Use the
Remarks section or an additional piece of paper if necessary. Place of Accident/Conviction City and state
of the accident or conviction. BI or Death Indicate whether
bodily injury or death occurred. Include details in the description of accident. Amount of Property Damage Total amount of
property damage, both the applicant's and all claimant's combined damages. Refer
to company manual. ADDITIONAL INTEREST Indicate if additional interest is an additional insured-lessor, certificate holder or a loss payee. Show complete name and mailing address. Provide the following information for each entity having an interest in the personal automobile(s) to be insured. The interest number or rank (1st, 2nd), whether additional interest or loss payee, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
Enter the vehicle
number referenced in the VEHICLE DESCRIPTION/USE section in which there is an
additional interest. Check boxes Identify whether
the additional interest is the loss payee or other additional interest. Name and Address Enter the name
and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown,
NY 10010) Loan Number Provide the loan
number. EMPLOYMENT INFORMATION Applicant's/Co-Applicant's Employer Name of the organization that employs the applicant(s) named in the identification section.
Applicant's employment
location. This may differ from where the main office/plant is situated. Work Phone Number Work phone number
at which the applicant/co-applicant may be reached. Yrs Empl The number of
years the applicant(s) have been with the employer indicated above. If less
than 3 years, provide the number of years in the same or other career field
or industry in the Remarks section. PRIOR COVERAGE Provide the prior insurance company's name, producer, number of years with the company, policy number and the date the prior policy expired.
Provide the prior
insurance company's name and producer. # of Years W/ Company Indicate the
number of years with the company. Prior Policy Number/Expiration Date Provide the prior
policy number and the date the prior policy expired. GENERAL INFORMATION If there are any
Yes responses, provide a complete explanation in the Remarks section. Use an
additional sheet of paper if the room in the Remarks section is not adequate. 1. Vehicle not registered to applicant? Provide the vehicle
number and the name of any vehicle not owned by or registered to the applicant. 2. Any car modified/special equipment? Indicate which
vehicles have been altered, customized or equipped with special equipment or
racing items. Include any customized painting such as murals or pin striping,
any equipment installed to overcome a physical handicap. Indicate vehicle number,
a description of the modifications and the cost of the special equipment. 3. Any existing damage? Indicate if any
vehicle has been damaged and not repaired as of the date of application. Indicate
the vehicle number and a complete description of the damage. 4. Any other losses incurred? Any other losses,
such as glass damage, vandalism, fire or theft, not shown in the Accident/Conviction
section, incurred within the last three years. Provide description and amount
of loss. 5. Any car kept at school? Identify the household
member and the name and location of the school. Provide the distance between
the school and the residence garage location. 6. Any car parked on street? Determine if any
vehicle is parked on the street or kept in other than an enclosed garage when
not in use. Indicate vehicle number from vehicle description area and where
the vehicle is parked. 7. Any other automobile insurance? Provide the insured's
name, vehicle description, insurance company, type of coverage and policy number
for any other household resident's automobile insurance. 8. Any other insurance with company? Indicate the
type and policy number of any other insurance the applicant has with the company. 9. Any household member in military service? Provide details
on branch of service, rank, and location of base for any household member in
active military service. Determine if any vehicle is at the military location. 10. Any license suspended/revoked? Indicate the driver
number, the period of suspension, the reason for suspension, and the date the
license was reinstated. 11. Any physical/mental impairments? List any operator
with a physical or medical impairment which could hinder the safe operation
of a vehicle ( amputation, epilepsy). If impaired, enter the name of the driver,
a description of any special equipment installed, and treatment or medication
being administered. This question cannot be asked in some states. In those states,
the question does not appear on the application. 12. Any financial responsibility filing? Indicate the
driver's name, the reason for the filing, and the date of original filing. 13. Has insurance been transferred within agency? Indicate if prior
carrier and previous policy number information shown on the front of the application
represents a policy being transferred within the agency. If Yes, give reason
for transfer. 14. Any insurance declined/cancelled? Indicate if any
resident in the household has been declined, cancelled or non-renewed through
a previous carrier within the last three years. List the person's name and why
the action was taken. This question cannot be asked in some states. In those
states, the question does not appear on the application. 15. Is this brokered business to the agent? Indicate if the
application came through a broker not part of the agency. 16. Has Agent Inspected Vehicle? Indicate if the
agent has inspected the vehicle. REMARKS If there are
any Yes responses, provide a complete explanation in the Remarks section. Use
an additional sheet of paper if the room in the Remarks section is not adequate. ATTACHMENTS Check the applicable
box(es). BINDER/SIGNATURE This section is to be used by producers with the permission of the company underwriter or when the producer has binding authority for this line of business.
Month/day/year
(MM/DD/YYYY) on which the insurance applied for is bound. This insurance is
subject to the terms, conditions, and limitations of the company. Expiration Date Month/day/year
(MM/DD/YYYY) on which the binder terminates. Time Time the provisions
of the binder become effective. 12:01/ Noon Indicate the
time on which the binder terminates. Producer's Statement Indicate how
long the applicant is known to the agent. Selection/Rejection of UM BI Coverage The applicant
must initial his selection of UMBI coverage. If the applicant rejects UMBI coverage,
his signature is required. Applicant's Signature The applicant
should read and understand the Fair Credit Reporting Act, the Privacy Act (where
applicable), the Applicant's Statement, and any other disclosure information
on the form before personally signing the application. Date Date the form
was signed. Producer's Signature The producer should
sign the application. This is required in most states. The National Producer Number assigned
by the NAIC should be shown. Sign up for Free Access to all ACORD forms. Get the extra benefits of Fill In On Screen ACORD forms for only $99.95 a year. Return to Simply Easier ACORD Forms home page from ACORD 90 Instructions page. UpGrade to Cap-Dat ACORD for Even More Benefits You can upgrade to the Full Features of Save, Email, Combine, Print and Re-use ACORD Forms and over 250 Proposals for only $250.00 a year or 12 monthly payments of $24.95.
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