ACORD 103 Instructions


Section Name Field Name Field and/or Section Description
Personal Auto Application Use ACORD 103, Personal Auto Application Schedule – Additional Resident and Driver
TITLE Schedule – Additional Resident Information Section as an attachment to the ACORD Personal Auto Application (90s),
ACORD 103 (2008/01) and Driver Information Section when more space is required for ADDITIONAL RESIDENT AND DRIVER INFOMRATION.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Page _ Enter the page number of this schedule.
Enter the total number of pages if multiple pages of this schedule are attached (e.g., Page
IDENTIFICATION SECTION Of _ 1 of 4). If only one page, indicate Page 1 of 1.
IDENTIFICATION SECTION Agency Producer’s name.
The number assigned by the insurance company for the policy. In general, policy numbers
IDENTIFICATION SECTION Policy Number will not appear on new business applications since they are not known at that point in time.
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
IDENTIFICATION SECTION Carrier you wish to have the policy issued
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Named Insured 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).
IDENTIFICATION SECTION Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
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
DRIVER INFORMATION Name provided.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. Examples: * S Single * M Married * D Divorced * SP Separated * W Widowed
DRIVER INFORMATION Relation to Applicant Driver’s relationship to the applicant. Examples: * I Insured * Sp Spouse * C Child * Sib Brother/Sister * P Parent * E Employee
DRIVER INFORMATION 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).
DRIVER INFORMATION Occupation Occupation of each operator.
DRIVER INFORMATION Date Lic Date (MM/YYYY) each driver was permanently licensed.
DRIVER INFORMATION Stdt > 100 Indicate (Y) or (N) 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.
DRIVER INFORMATION Good Stdt Indicate (Y) or (N) 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.
DRIVER INFORMATION Drv Train Indicate (Y) or (N) 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.
DRIVER INFORMATION Good Drv Indicate (Y) or (N) if any driver qualifies for a good driver credit (verify that company offers this credit). Attach a completion certificate for each driver who qualifies.
DRIVER INFORMATION Mat Drv Indicate (Y) or (N) if any driver qualifies for a mature driver credit (verify that company offers this credit). Attach a completion certificate for each driver who qualifies.
DRIVER INFORMATION Acc Prev Cse Date on which the driver successfully completed an approved motor vehicle accidentprevention course (or a similarly recognized defensive driving course). Attach a completion certificate for each driver who qualifies.
Complete drivers license number and licensed state for each licensed operator. Copy
DRIVER INFORMATION Drivers License #/ Licensed State directly from license if possible.
DRIVER INFORMATION Social Security # Social security number for each named driver and household resident.