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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 93 (2009/10) |
Young Driver Questionnaire |
The title of the form. The ACORD 93, the Young Driver Questionnaire, is generally completed by drivers under the age of twenty five. The Young Driver Questionnaire provides additional underwriting information that is usually common to youthful drivers. This form should be completed and signed exclusively by the young driver with no input from the parents and/or agent. The top section of the form must be completed by the young driver in his/her own handwriting. IMPORTANT: Question # 8 may not be asked in the District of Columbia, Missouri or Ohio. |
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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 |
Driver # |
Enter number: The number assigned to the driver by the producer. |
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IDENTIFICATION SECTION |
Date (MM/DD/YYYY) |
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 |
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 |
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 |
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 |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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QUESTIONAIRE QUESTIONS |
Do you have any driving limitations imposed by your parents? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you have any driving limitations imposed by your parents?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
QUESTIONAIRE QUESTIONS |
Do you allow others to use your car? (who and why) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Do you allow others to use your car?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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QUESTIONAIRE QUESTIONS |
Has your driver's license or permit ever been revoked or suspended? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Has your driver's license or permit ever been revoked or suspended?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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QUESTIONAIRE QUESTIONS |
Have you ever received a ticket, citation, or warning for any traffic violation other than parking? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever received a ticket, citation, or warning for any traffic violation other than parking?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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QUESTIONAIRE QUESTIONS |
Have you ever been in an accident as a driver? (give dates and details) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been in an accident as a driver?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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QUESTIONAIRE QUESTIONS |
Have you ever been arrested or detained for any reason, other than a traffic violation? (give dates and details) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever been arrested or detained for any reason, other than a traffic violation?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
|
QUESTIONAIRE QUESTIONS |
Is the auto you operated modified or equipped with any special equipment, have modified bodywork, or special paint? |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Is the auto you operate modified or equipped with any special equipment, have modified bodywork, or special paint?". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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QUESTIONAIRE QUESTIONS |
Have you ever had auto insurance declined or cancelled? (give dates and details) |
Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, "Have you ever had auto insurance declined or cancelled? (Not applicable in the District of Columbia, Missouri, or Ohio)". |
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QUESTIONAIRE QUESTIONS |
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Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation. |
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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). |
|
IDENTIFICATION SECTION |
Driver # |
Enter number: The number assigned to the driver by the producer. |
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REMARKS |
Remarks |
Enter text: The producer's comments. |
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SIGNATURE |
Young Driver's Signature |
Sign here: Accommodates the signature of the driver. |
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SIGNATURE |
Date |
Enter date: The date the driver signed the form. |
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SIGNATURE |
Producer's Signature |
Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) by all companies to issue Certificates. This is required in most states. |
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SIGNATURE |
National Producer Number |
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number. |
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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). |
