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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 91 (2009/10) |
Good Student/ Driver Training |
The title of the form. The ACORD 91, Good Student / Driver Training, can be used for two purposes: to qualify for a credit/discount for achieving a good student status in school, or for completing driver training instruction. An operator can qualify for both credits. Please check with the company on whether one or both credits are available. This form is generally used for operators age 21 or younger. |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line one of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address line two of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter text: The mailing address city name of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address state or province code of the producer/agency. |
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IDENTIFICATION SECTION |
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Enter code: The mailing address postal code of the producer/agency. |
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IDENTIFICATION SECTION |
Contact Name |
Enter text: The name of the individual at the producer's establishment that is the primary contact. |
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IDENTIFICATION SECTION |
Phone |
Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. |
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IDENTIFICATION SECTION |
Fax |
Enter number: The fax number of the producer/agency. |
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IDENTIFICATION SECTION |
E-Mail |
Enter text: The producer's contact person e-mail address. |
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IDENTIFICATION SECTION |
Code |
Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
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IDENTIFICATION SECTION |
Subcode |
Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer's office (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Carrier |
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
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IDENTIFICATION SECTION |
Insured's Name and Mailing Address (include zip code) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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IDENTIFICATION SECTION |
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Enter text: The named insured's mailing address line one. |
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IDENTIFICATION SECTION |
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Enter text: The named insured's mailing address line two. |
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IDENTIFICATION SECTION |
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Enter text: The named insured's mailing address city name. |
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IDENTIFICATION SECTION |
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Enter code: The named insured's mailing address state or province code. |
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IDENTIFICATION SECTION |
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Enter code: The named insured's mailing address postal code. |
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IDENTIFICATION SECTION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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IDENTIFICATION SECTION |
Plan |
Enter code: The product code of the insurer for the policy. |
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IDENTIFICATION SECTION |
New |
Check the box (if applicable): Indicates the response expected from the company is a new issued policy. |
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IDENTIFICATION SECTION |
Renew |
Check the box (if applicable): Indicates the response expected from the company is a renewed policy. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Expiration Date |
Enter date: The date on which the terms and conditions of the policy will expire. |
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STUDENT INFORMATION |
Name of Student |
Enter text: The driver's full name. |
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STUDENT INFORMATION |
Full Time Student |
Check the box (if applicable): Indicates the student attends school full time. |
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STUDENT INFORMATION |
Part Time Student |
Check the box (if applicable): Indicates the student attends school part time. |
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STUDENT INFORMATION |
Freshmen |
Check the box (if applicable): Indicates the student is in their freshman year. |
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STUDENT INFORMATION |
Sophomore |
Check the box (if applicable): Indicates the student is in their sophomore year. |
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STUDENT INFORMATION |
Junior |
Check the box (if applicable): Indicates the student is in their junior year. |
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STUDENT INFORMATION |
Senior |
Check the box (if applicable): Indicates the student is in their senior year. |
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STUDENT INFORMATION |
Name and Address of School |
Enter text: The name of the school or educational institution. |
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STUDENT INFORMATION |
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Enter text: The first address line of the school or educational institution. |
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STUDENT INFORMATION |
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Enter text: The second address line of the school or educational institution. |
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STUDENT INFORMATION |
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Enter text: The city of the school or educational institution. |
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STUDENT INFORMATION |
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Enter code: The state or province of the school or educational institution. |
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STUDENT INFORMATION |
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Enter code: The postal code of the school or educational institution. |
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GOOD STUDENT CERTIFICATE |
Ranked Among the Upper 20% of their class scholastically |
Check the box (if applicable): Indicates the student is ranked amount the upper 20% of their class scholastically. |
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GOOD STUDENT CERTIFICATE |
In a school using letter grades, had a grade average of "B" |
Check the box (if applicable): Indicates the student had a grade average of "B" in a school using letter grades. If the system of letter grading cannot be averaged, no grade shall be below "B". |
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GOOD STUDENT CERTIFICATE |
Had a grade average of at least 3 points on a 4 point scale |
Check the box (if applicable): Indicates the student had a grade average of 3 points on a 4 point scale (or its equivalent). |
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GOOD STUDENT CERTIFICATE |
Was included in "Dean's List" or "Honor Roll" |
Check the box (if applicable): Indicates the student was included in the "Dean's List" or "Honor Roll" (or other comparable list for scholastic achievement). |
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DRIVER TRAINING CERTIFICATE |
Clock Hours of Classroom Instruction |
Enter number: The number of clock hours of classroom instruction. |
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DRIVER TRAINING CERTIFICATE |
Clock Hours on the average per driving student |
Enter number: The number of clock hours on the average per student for actual driving experience in the practice driving phase (exclusive of observation time in the car). |
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DRIVER TRAINING CERTIFICATE |
Clock Hours on the average per driving student in an approved device |
Enter number: The number of clock hours on the average per student in an approved device which simulates practice driving. |
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SIGNATURE |
Name of School Official / Representative |
Enter text: The name of the school official. |
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SIGNATURE |
Title |
Enter text: The title of the school official. |
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SIGNATURE |
Authorized Signature |
Sign here: The signature of the school's authorized official. |
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SIGNATURE |
Date |
Enter date: The date of the signature. |
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Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
