Use this form to request mid-term changes to any personal auto policy. The form
should be used instead of individual turnaround endorsement requests. A copy
of the request may be sent to the insured to confirm that the change is submitted
to the company.
The generic fields on this form are explained in the Personal
Lines Generic Section at the beginning of the Personal Lines Section of the
Forms Instruction Guide. On the ACORD website (www.acord.org),, this information
appears under the title PERSONAL LINES GENERIC SECTIONS.
For changes to property, mobile home, inland marine, watercraft
and umbrella coverages, use ACORD 70, Personal Policy Change Request (Except
Auto). 229
IDENTIFICATION
This section provides essential producer, company and insured
information. It should be fully completed for all types of changes. A copy of
the policy's declaration page can be attached to provide additional identification
information.
All data fields in this section, except the insured's name
and mailing address and tax code (if changed), should contain existing policy
information, not changed data.
* Most sections begin with a change indicator. Enter either
an A-Add, C-Change, D-Delete, or check the appropriate box. Various combinations
of changes are permitted in one submission.
Use "A" to add an item that was not previously in
the policy (e.g., add a vehicle, add a coverage). Use "D" to delete
an item (e.g., delete a vehicle, delete a driver). Use "C" to change
an item in the policy (e.g., change a deductible, change coverage limits).
VEHICLE DESCRIPTION/USE
If the request pertains to change of vehicle information, complete
this section. The form permits three vehicle modifications. Obtain information
directly from the policy or vehicle registration when possible. Vehicles include
automobiles, motorcycles, vans, recreational vehicles, motor
homes, trailers and pickups. Indicate the type of change being requested.
When adding a vehicle, the entire description section should
be completed to assist the company in processing the request. Also complete
questions 1-5 of the General Information section and at least
the comprehensive and collision portion of the Coverage section. Use the Remarks
section for any additional information required by the company.
When requesting a change, enter only the information being
changed. All other items on the policy will remain the same. If deleting an
item, provide adequate information to process the request and indicate the reason
for the deletion in the Remarks section.
Veh #
The current vehicle number, before renumbering.
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
Full vehicle identification number appearing on the title certificate or registration.
Enter the state where the vehicle is registered. If the vehicle is registered
in a state other than where it is garaged, explain in the Remarks area.
Reg to Drv #
Indicate the driver number of the registered owner of the vehicle.
HP/CC
Amount of horsepower or the number of cubic centimeters of displacement.
Date Leased
Year the applicant leased the vehicle in the YYYY format.
Date Purch
Year the applicant acquired the vehicle in YYYY format.
New/Used
Mark "N" if the applicant bought the vehicle new or "U"
if the vehicle was used.
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.
Mile 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 including 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
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.
Car Pool
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 section. Examples of exposures are:
Off street (driveway)
Off street (at school)
Street (at school)
Street (at residence)
Odometer Reading
Current number of miles on the odometer.
Annual Mileage
Total estimated annual mileage for each vehicle.
Govern Driver
Driver assigned to each vehicle for rating purposes.
Driver Use %
Percentage that each driver uses each vehicle. Usage for each vehicle should
total 100 percent.
Class
Rate classification for each vehicle. Refer to manual. Some companies determine
class automatically from information provided in Vehicle Use and Driver Information
sections.
Seat Belt
Check box if the vehicle is equipped with automatic seat belts.
Air Bag
Indicate D for driver side air bag; B for vehicle equipped with air bags for
both driver and front 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 the type.
Credits and Surcharges
Any other credits and/or surcharges that will apply to any vehicles.
GARAGE LOCATION
Indicate the vehicle number and the complete address including
the ZIP code for any vehicle not kept at the mailing address. Provide this information
if the mailing address is a P.O. box or rural route address, or when a driver
is at school with one of the vehicles.
VEHICLE COVERAGE/PREMIUMS
For each automobile to be added or changed, enter the vehicle
number, year and make on the first row of the Vehicle Coverage/Premium section.
If the vehicle is added, enter all applicable coverage information. If coverages
on an existing vehicle are to be added, changed and/or deleted, enter only coverage
information that is different.
Single Limit Liability (CSL)
Desired limit of both bodily injury and property damage. If an entry is made
in this field, leave blank the separate Bodily Injury and Property Damage fields.
Show a property damage deductible, if applicable.
Bodily Injury Liability
Desired per person and per accident limits.
Property Damage Liability
Desired limit. Include a property damage deductible, if applicable.
No Fault Coverages
Refer to the applicable state manual for no fault/personal injury protection
coverages. Each state where these coverages are available has a unique mandatory
coverage and unique coverage options. Space is provided here to list both mandatory
and optional coverages.
Medical Payments
Desired per person limit.
Uninsured Motorist
Bodily injury (per person and per accident) and property damage (per accident)
limits. Circle CSL and enter the limit in the per accident area for combined
single limits. Many companies require supplemental uninsured motorists applications.
Include them when submitting this application.
Underinsured Motorist
Bodily injury (per person and per accident) and the property damage (per accident)
limits. Circle CSL and enter the limit in the per accident area for combined
single limits. Many companies require supplemental underinsured motorist applications.
Include them when submitting this application.
Comprehensive
Comprehensive coverage deductible for each vehicle. Enter stated amount, if
other than actual cash value (ACV), in the space to the right and indicate the
vehicle to which it applies.
Collision
Collision coverage deductible for each vehicle. If stated amount applies for
the type of vehicle being insured, enter the amount in the space to the right
and indicate the vehicle to which it applies.
Towing & Labor
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 Expense/Rental Reimbursement
Amount desired, per day limit and maximum amount.
Additional miscellaneous coverages can be included in the blank
spaces, or in the Remarks Section.
GENERAL INFORMATION
Complete this section if a vehicle or driver is being added
to the policy. Questions 1-5 pertain to addition of a vehicle. Questions 6-10
refer to addition of a driver to the policy. Answer only questions pertinent
to the change being requested. If there are any "Yes" responses, explain
completely in the Remarks section. Use an additional sheet of paper if space
in the Remarks section is inadequate.
1. Excluding any encumbrances, are any vehicles not solely
owned by and registered to the applicant?
Show the vehicle number and name of the vehicle registrant as they appear on
the registration, if not 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 and describe modifications and the cost of the special equipment.
3. Any existing damage to vehicle, including damaged glass?
Indicate if any vehicle has been damaged and unrepaired as of the application
date. Indicate the vehicle number and completely describe the damage.
4. Any car kept at school?
Identify the household member and name and location of the school. Include the
distance between the school and the residence garage location.
5. Any car parked on street?
Determine if any vehicle is parked on the street or otherwise kept outside an
enclosed garage when not in use. (Indicate vehicle number from the vehicle description
area indicating where the vehicle is parked.)
6. Any household member in military service?
Detail branch of service, rank and location of base for any household member
in active military service. Determine if any vehicle is located at the military
location.
7. Any driver's license been suspended/revoked?
Indicate the driver number, period of suspension, reason for suspension, and
date the license was reinstated.
8. Any driver have physical/mental impairment?
List any operator with a physical or mental impairment which could hinder the
safe operation of a vehicle (e.g., amputation, epilepsy). If impaired, enter
the name of the driver, describe any special equipment installed and treatment
or medication being administered. NOTE: This question cannot be asked in Wisconsin.
9. Any financial responsibility filing?
Indicate the driver's name, reason for the filing and date of original filing.
10. Any coverage declined, cancelled, or non-renewed during
the last three years?
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. NOTE: This question cannot be asked in Missouri.
DRIVER INFORMATION
When adding a driver, complete this entire section, questions
6-10 of the General Information section and the entire Accidents/Convictions
section. Refer to the driver's license for the licensed operator being added
to the policy. If more space is required, use the Remarks section. If a change
is made, enter only the information being changed.
If a driver is being deleted, provide sufficient information
to identify and process the request. Indicate reason for the deletion in the
Remarks section.
Driver #
Indicate the current driver number, before renumbering.
b
Name of the licensed operator appearing on the driver's license. Enter the surname
only if it differs from the insured's.
Sex
F for female, M for male.
Mar Stat
Marital status of the driver. Examples:
S . . . . . . . . . . . . . . . . . . . . . . . . . Single
M. . . . . . . . . . . . . . . . . . . . . . . . . Married
D . . . . . . . . . . . . . . . . . . . . . . . .. Divorced
SP . . . . . . . . . . . . . . . . . . . . . . .Separated
W. . . . . . . . . . . . . . . . . . . . . . . . Widowed.
Relation to Applicant
Driver's relationship to the insured. Examples:
I . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Insured
S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Spouse
C . . . . . . . . . . . . . . . . . . . . . . . . . . . . Child
SIB. . . . . . . . . . . . . . . . . . . . . . . . . . . Brother/Sister
P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Parent
E . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employee.
Date of Birth
Birth date of the driver (e.g., March 7, 1944 should be 03/07/1944).
Occupation
Occupation of the driver.
Date Lic
Date (MM/YYYY) the driver was permanently licensed.
Stdt >> 100
Indicate if the driver resides at a school over 100 road miles from the principal
place of garaging. In the Remarks section, show name of institution and address.
Good Stdt
Indicate if the 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 (ACORD 91) if the operator
is under age 21 and has successfully completed this training and qualifies for
the credit.
ACC Prev Cse Date
Date on which the driver successfully completed an approved accident prevention
or defensive driver course. Attach a Course Completion Certificate if the driver
qualifies.
Drivers License #/Licensed State
Complete driver's license number and licensed state for the licensed operator.
Copy directly from license if possible.
Social Security #
Driver's social security number.
ACCIDENTS/CONVICTIONS
Complete this section only if any driver being added to the
policy has had an accident, been convicted of a violation or had a comprehensive
loss. The number of years this information should cover must be in accordance
with the company's and state's requirements. If there have not been
any accidents, convictions or comprehensive losses during the indicated time
period, enter "None".
This section must 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.
Date of Accident/Conviction
Date the accident or conviction occurred.
Description of Accident or Conviction
Complete description of the accident or conviction including the number of vehicles
involved and the type of vehicles (private passenger or commercial). Convictions
constitute a judgement of guilty, plea of nolo contendere or forfeiture of bail.
Use 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. Fully describe the accident.
Amount of Property Damage
Total amount of property damage (applicant's and all claimants' combined damages).
Refer to company manual.
ADDITIONAL INTEREST
Indicate if Additional Interest (additional insured-lessor,
certificate holder) or Loss Payee. Show complete name and mailing address. This
section is often used to delete a lienholder from a policy after the loan is
repaid.
PRODUCER'S SIGNATURE / INSURED'S SIGNATURE
Space is provided for signatures of the producer and/or the
insured. Some companies require one or both signatures when limits of insurance
are increased or reduced, or other changes are made that are considered significant
to the company. Refer to your company rules.
Many companies, or state laws require the insured's signature
when auto, liability, no fault, or uninsured motorists coverage is changed or
deleted. Refer to your company or state rules.
Space is also provided for the National Producer Number.
