ACORD 90HI Instructions


ACORD 90 HI (2005/01) - Hawaii Personal Auto Application

Following are the differences from ACORD 90, the generic Personal Auto Application.

  • Unique Personal Injury Protection and Additional Personal Injury Protection items are provided.
  • The applicant can select ""stacked"" or ""non-stacked"" Uninsured and Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available.
  • A state-specific fraud warning is added to the back of the form.

IDENTIFICATION SECTION

Date

Month/day/year (MM/DD/YYYY) on which the form is completed.


Agency

Producer's name and address.

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.


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.


If the address does not have a street number and name, provide sufficient information and directions so that the property can be physically located. Provide legal description if required by the mortgage holder.

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 at Current Address

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.

GARAGING ADDRESS

Veh #

Indicate vehicle number.

Address

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.


Veh #

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

Month and Year the applicant leased the vehicle (MM/YYYY).

Date Purch

Month and Year the applicant acquired the vehicle (MM/YYYY).

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.

Gar Code

Indicate by type letter code where the vehicle is garaged. Select from the following options:


A - Garaged at School
B - Off street at school
C - On street at school
D - Driveway
G - Garaged
N - Not garaged (if other options do not apply)
O - Off street
P - Parking Lot
R - Carport
S - Street

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.


Single Limit Liability

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.

Personal Inj Protection

Refer to applicable state manual for options. Include any deductible selected by the applicant.

Additional Personal Inj Protection

Refer to applicable state manual for options.

Medical Payments

The desired per person limit.

Uninsured Motorists

The bodily injury (per person and per accident) and the property damage (per accident) limits. For COMBINED SINGLE LIMIT (CSL), enter the limit in the BI per accident area for combined single limits.

Underinsured 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

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:


* S Single
* M Married
* D Divorced
* SP Separated
* W Widowed

Relation to Applicant

Driver's relationship to the applicant. Examples:

* I Insured
* Sp Spouse
* C Child
* Sib Brother/Sister
* P Parent
* E Employee

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.


Veh #

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.


Address of Employment 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.

Prior Carrier and Producer

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 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.

6. Any other insurance with company?

Indicate the type and policy number of any other insurance the applicant has with the company.

7. 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.

8. Any license suspended/revoked?

Indicate the driver number, the period of suspension, the reason for suspension, and the date the license was reinstated.

9. 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.

10. Any financial responsibility filing?

Indicate the driver's name, the reason for the filing, and the date of original filing.

11. 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.

12. 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.

13. Is this brokered business to the agent?

Indicate if the application came through a broker not part of the agency.

14. 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.


If the coverage is bound, complete the Insurance Binder section. If coverage is not bound, check the box.


Effective Date

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.

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.

National Producer Number

The National Producer Number assigned by the NAIC should be shown.


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