| Section Name |
Field Name |
Field and/or Section Description |
| TITLE |
Business Auto Section |
The Business Auto Section of the ACORD Commercial Insurance Application series contains basic policy information as well as essential underwriting information forcommercial auto accounts. Through the effective use of the Business Auto Section, specific needs of an individual account can be addressed. Space is provided to enter driver information for up to ten drivers. For additional drivers, ACORD 163, Driver Information Schedule, can be attached. Space is also provided to enter descriptions of up to eight vehicles. If the fleet should exceed this number, the ACORD Vehicle Schedule (ACORD 129), which contains space for 7 additional vehicles, can be attached. |
| TITLE |
|
Insurance coverages, “no fault” and uninsured/underinsured motorists coverages in particular, vary widely from state to state. In addition, there are numerous state-specific requirements that apply to Business Auto applications. ACORD 127 cannot address these various unique specifications. Therefore, state-specific forms, ACORD 137, have been developed to respond to these requirements. Use the ACORD 137 for your state to provide coverages / limits information, as well as the required disclosure and other data unique to the state. |
| TITLE |
|
This form was also designed to be used in conjunction with the Commercial Insurance Application – Applicant Information Section (ACORD 125). Many states require supplements to all auto applications, to provide specific coverage explanation or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in all states. |
| TITLE |
|
Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account. |
| IDENTIFICATION SECTION |
Date |
Month/day/year on which the form is completed. |
| IDENTIFICATION SECTION |
Agency |
Agency’s name and address. |
| IDENTIFICATION SECTION |
Phone (A/C, No, Ext) |
Producer’s telephone numbers. Include area code and extension, if applicable. |
| IDENTIFICATION SECTION |
FAX No |
Producer’s fax number, include area code. |
| IDENTIFICATION SECTION |
Code |
Identification code assigned to the agency or brokerage firm by the insurance company receiving this form. |
| IDENTIFICATION SECTION |
Subcode |
If the agency uses a subcode identification system with the company, enter the appropriate code. |
| IDENTIFICATION SECTION |
Agency Customer ID |
Customer’s identification number assigned by the agency. |
| IDENTIFICATION SECTION |
Applicant (First Named Insured) |
First Named Insured as it appears on the ACORD 125. |
| IDENTIFICATION SECTION |
Effective Date |
Month/day/year on which the terms and conditions of the policy will commence. |
| IDENTIFICATION SECTION |
Expiration Date |
Month/day/year on which the terms and conditions of the policy will terminate unless renewed. |
| IDENTIFICATION SECTION |
Billing Plan |
Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy. |
| IDENTIFICATION SECTION |
Payment Plan |
Plan used to pay the company for the policy. Use the company’s specific designation for the plan where possible (e.g., Prepaid, Annual, Semi-annual, Bi-monthly, 40-30-30). |
| IDENTIFICATION SECTION |
Audit |
The audit term for policies that are subject to periodic audit. If the audit period is known, enter the code: A . . . . . . . . . . . . . . . . . . . . . . . . . . . . annual S . . . . . . . . . . . . . . . . . . . . . . . . . . . . semi-annual Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . quarterly M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . monthly O . . . . . . . . . . . . . . . . . . . . . . . . . . . . .other |
| IDENTIFICATION SECTION |
For Company Use Only |
|
| COVERAGES/LIMITS |
Covered Auto Symbols |
The Business Auto Policy uses numeric symbols on the policy declarations to indicate the type(s) of vehicles for which coverage is in effect. Be sure to place an “X” in the appropriate box for each type of coverage. Only those symbols specified for a coverage may be used. Symbols 1 through 6 provide fleet automatic coverage. Symbol 1 includes Hired and Non-Owned auto coverage. If symbol 1 is not used and Hired auto (symbol 8) or Non-Owned auto (symbol 9) coverage is desired, those symbols must be checked. The symbols indicate coverage for each applicable automobile. The symbols “trigger” coverage. Please refer to the company’s policy declarations page for exact policy definitions of the symbols. |
| COVERAGES/LIMITS |
Symbol 1 – Any Auto |
Symbol 1 can only be used for liability insurance. This includes coverage for owned, non-owned, and hired autos. Provides automatic coverage for autos the insured newly acquires. Not to be used for No-Fault, Medical Payments, Uninsured or Underinsured Motorists, or Physical Damage coverages. |
| COVERAGES/LIMITS |
Symbol 2 – All Owned Autos |
Applies only to autos owned by the insured, and for liability coverage on any non-owned trailers while attached to power units the insured owns. This provides automatic coverage for autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, or Physical Damage coverages, except Towing and Labor. |
| COVERAGES/LIMITS |
Symbol 3 – Owned Private Passenger Autos |
Provides automatic coverage for private passenger autos the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, Physical Damage, or Towing. |
| COVERAGES/LIMITS |
Symbol 4 – Owned Autos Other Than Private Passenger |
Provides automatic coverage for autos other than private passenger the insured newly acquires. Used for Liability, Medical Payments, Uninsured and Underinsured Motorists, and Physical Damage except Towing. |
| COVERAGES/LIMITS |
Symbol 5 – All Owned Autos Which Require No-Fault Coverage |
Provides automatic coverage for autos the insured newly acquires where no-fault is required by law. Used only for P.I.P. and Additional P.I.P. |
| COVERAGES/LIMITS |
Symbol 6 – Owned Autos Subject To Compulsory U.M. Law |
Provides automatic coverage for autos the insured newly acquires where rejection of U.M. is not permitted by law. |
| COVERAGES/LIMITS |
Symbol 7 – Autos Specified OnSchedule |
Applies only to those autos described on the schedule for which a premium charge is shown, and for liability coverage on any non-owned trailers while attached to power units the insured owns. Provides no automatic coverage for autos the insured newly acquires. The company must be notified of newly acquired autos within 30 days. Used for all coverages. |
| COVERAGES/LIMITS |
Symbol 8 – Hired Autos |
Applies only to those autos leased, hired, rented or borrowed by the insured. This does not include any auto leased, hired, rented or borrowed from any of the insured’s employees or members of their households. Can be used for all coverages except no-fault, towing, and labor. For medical payments, this symbol applies only to funeral directors. |
| COVERAGES/LIMITS |
Symbol 9 – Non-Owned Autos |
Applies only to those autos not owned, leased, or hired by the insured which are used in connection with the insured’s business. Used only for liability coverage. Coverages / Limits – Use ACORD 137 for your state. |
| DRIVER INFORMATION |
|
This section is used to collect information on all the drivers that will be covered under this account. The driver list should include any family member that will be driving company vehicles and employees who regularly drive their own vehicles for company business. |
| DRIVER INFORMATION |
Driver # |
Indicate the driver number assigned by the agency/agency-vendor system used for tracking purposes. |
| DRIVER INFORMATION |
Name |
Enter driver’s full name. If the company requires the address, enter it as well. |
| DRIVER INFORMATION |
Sex |
Enter F for female, M for male. |
| DRIVER INFORMATION |
Marital Stat |
Enter the marital status for each driver. Examples: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . ..Divorced SP . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed |
| DRIVER INFORMATION |
Date of Birth |
Enter the driver’s birth date. |
| DRIVER INFORMATION |
Yrs Exp |
Enter the number of years of driving experience for each driver. |
| DRIVER INFORMATION |
Year Licensed |
Enter the year in which the driver was first licensed. |
| DRIVER INFORMATION |
Driver’s License Number/Soc. Sec. # |
Enter the complete driver’s license number. If a license number is unavailable, enter the driver’s social security number. |
| DRIVER INFORMATION |
State Lic. |
Enter the state in which the license was issued. |
| DRIVER INFORMATION |
Date Hire |
Enter the date of hire for each driver. |
| DRIVER INFORMATION |
Broadened No Fault |
Certain states “no fault” liability laws permit broadened no fault coverage to be written for specific drivers. If such specific coverage is to apply, indicate “yes” here for each driver that is to be covered. |
| DRIVER INFORMATION |
DOC |
Enter Y in this column for any driver specifically covered by Drive Other Car coverage. |
| DRIVER INFORMATION |
Use Vehicle # |
Enter the vehicle number that this driver primarily uses. |
| DRIVER INFORMATION |
% Use |
Indicate the percentage of driving done by this driver in the primary vehicle that this driver uses. |
| GENERAL INFORMATION |
|
Use the Remarks section to provide additional information for any questions answered with a “Yes” response. The overview below lists the expected information that should be added to the remarks section for “Yes” responses. |
| GENERAL INFORMATION |
1. With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant? |
Indicate if any of the vehicles described in the application are not owned by or registered to the applicant. |
| GENERAL INFORMATION |
2. Do over 50% of the employees use their autos in the business? |
Indicate if more than 50% of applicant’s employees use their vehicles in the applicant’s business. |
| GENERAL INFORMATION |
3. Is there a vehicle maintenance program in operation? |
Explain the type of program and if there are maintenance records kept on file. |
| GENERAL INFORMATION |
4. Are any vehicles leased to others? |
Indicate if autos are leased on a short term or long term basis. Are certificates of insurance required from lessees? List who the vehicles are leased to. |
| GENERAL INFORMATION |
5. Are any vehicles customized, altered or have special equipment? |
Provide the details on such alterations/customizations. List customized item and estimated value of customization. |
| GENERAL INFORMATION |
6. Are ICC, PUC or other filings required? |
If Interstate Commerce Commission or Public Utilities Commission filings are required, describe the insured operations and trip frequency. |
| GENERAL INFORMATION |
7. Do operations involve transporting hazardous material? |
List the materials hauled, safety measures taken and if the applicant is subject to the Federal Motor Carrier Act Requirements. |
| GENERAL INFORMATION |
8. Any Hold Harmless Agreements? |
If any hold harmless agreements are in force, describe any in which the applicant indemnifies others. Attach a copy of the agreement. |
| GENERAL INFORMATION |
9. Any vehicles used by family members? |
Provide details regarding which vehicles are used and how often. Make sure the driver is included in the Driver Information section. |
| GENERAL INFORMATION |
10. Does the applicant obtain MVR verifications? |
Indicate if applicant reviews MVRs on all assigned drivers. How often? Upon hiring only? If No, provide explanation of why MVRs are not reviewed. |
|
11. Does the applicant have a |
|
| GENERAL INFORMATION |
specific driver recruiting method? |
Describe the recruiting method. Are written and/or road tests conducted? |
|
12. Are any drivers not covered by |
|
| GENERAL INFORMATION |
Workers Compensation? |
Provide the names of all drivers not covered. |
|
13. Any vehicles owned but not |
List vehicles not to be covered and explain why. Indicate where coverage is placed for |
| GENERAL INFORMATION |
scheduled on this application? |
these vehicles. |
|
14. Any drivers with convictions |
Give driver name and number, date, type and place for each conviction. Enter the number |
| GENERAL INFORMATION |
for moving traffic violations? |
of years reviewed, in accordance with the company’s and state’s requirements. |
| GENERAL INFORMATION |
15. Has agent inspected vehicles? |
Describe any damage to vehicles, including any missing safety devices. |
|
Maximum Dollar Value Subject to |
List the highest value that the insurer would be subject to if a major automobile loss |
| GENERAL INFORMATION |
Loss |
occurred on the insured premises. |
|
Description of Garage/Storage |
Provide a brief description of all garage or storage locations for the vehicles (e.g., Fenced |
| GENERAL INFORMATION |
Locations |
in secured lot or Closed secured garage). |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
|
Use this section for information on any additional interests, employees who should be listed as additional insureds, and others who require Certificates of Insurance on the automobile portion of this policy. For additional names attach an ACORD 45. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
|
| RECIPIENTS |
Interest |
Indicate all appropriate options for the individual named. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
|
| RECIPIENTS |
Rank |
Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
|
| RECIPIENTS |
Name and Address |
List the additional interest’s name and address. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
Indicate the additional interest’s reference number for this applicant such as the loan or |
| RECIPIENTS |
Reference # |
mortgage number. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
|
| RECIPIENTS |
Certificate Required |
If a Certificate of Insurance is required, check this box. |
| ADDITIONAL |
|
|
| INTERESTS/CERTIFICATE |
|
List the item number corresponding with the application for the item of interest for this |
| RECIPIENTS |
Interest in Item Number |
additional insured. |
| ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS |
Item Description |
If needed, further clarify the item of interest in this field. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting. |
| REMARKS |
|
Use this section to provide any additional information required for underwriting or rating. |
| VEHICLE DESCRIPTION |
|
This section is used to collect pertinent information on the vehicles that are to be insured, what they are, how they are used and what coverage applies to them. If there are more than eight vehicles associated with this risk, place additional vehicles on the ACORD 129 Vehicle Schedule. |
| VEHICLE DESCRIPTION |
Veh # |
Number assigned by the agent to this vehicle for purposes of tracking in the application process. |
| VEHICLE DESCRIPTION |
Year |
Vehicle’s model year. |
| VEHICLE DESCRIPTION |
Make |
Vehicle’s manufacturer (e.g., Buick). |
| VEHICLE DESCRIPTION |
Model |
Manufacturer’s model name (e.g., Regal). |
| VEHICLE DESCRIPTION |
Body Type |
Vehicle’s body type (e.g., 4 door sedan). |
| VEHICLE DESCRIPTION |
V.I.N. |
Full vehicle identification number assigned by the manufacturer. |
| VEHICLE DESCRIPTION |
Vehicle Type |
Indicate whether the vehicle type is private passeger, special or commercial. |
| VEHICLE DESCRIPTION |
City, State, Zip where garaged |
List the location where this vehicle is normally garaged. |
| VEHICLE DESCRIPTION |
Lic State |
Enter the state where the vehicle is licensed. |
| VEHICLE DESCRIPTION |
Terr |
Enter the rating territory in which the vehicle is principally garaged. |
| VEHICLE DESCRIPTION |
GVW/GCW |
These terms identify the size class of commercial vehicles. The weights must be indicated to classify the vehicle correctly. |
| VEHICLE DESCRIPTION |
GVW |
Gross Vehicle Weight. The maximum loaded weight for which a single vehicle is designed by the manufacturer. |
| VEHICLE DESCRIPTION |
GCW |
Gross Combined Weight. The maximum loaded weight for a combination truck-tractor and semi-trailer or trailer for which the truck-tractor is designed as specified by the manufacturer. |
| VEHICLE DESCRIPTION |
Class |
This is the primary industry classification code found in rating manuals for commercial vehicles as determined by: *If this is a fleet or non-fleet policy *Commercial autos by size, business use, radius of operation and whether truck or trailer type *Public autos by type of vehicle, radius or seating capacity |
| VEHICLE DESCRIPTION |
S.I.C. |
This is the secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. |
| VEHICLE DESCRIPTION |
Factor |
This is the sum of the rating factors from the primary and secondary classification tables. This field may be left blank if you are not rating this application. |
| VEHICLE DESCRIPTION |
Seating Capacity |
Used for public vehicles and livery vehicles. Enter the number of passenger seats available. |
| VEHICLE DESCRIPTION |
Sym/Age |
Enter the age of the vehicle in years, as follows: *1-Current model year *2-First preceding model year *3-Second preceding model year *4-Third preceding model year *5-Fourth preceding model year *6-All other autos |
| VEHICLE DESCRIPTION |
Cost New |
If actual cash value coverage is desired, indicate the original retail cost the original purchaser paid for the vehicle and equipment. |
| VEHICLE DESCRIPTION |
Radius |
Enter the appropriate radius code as follows: |
| VEHICLE DESCRIPTION |
L – Local |
Up to 50 miles. Not frequently operated beyond a 50-mile radius from the point of principal garaging. |
| VEHICLE DESCRIPTION |
I -Intermediate |
Operation beyond 50 miles, but not regularly operated beyond a 200-mile radius from the point of principal garaging. |
| VEHICLE DESCRIPTION |
LD – Long Distance |
Regularly and frequently operated beyond a radius of 200 miles. |
| VEHICLE DESCRIPTION |
Farthest Term |
For zone-rated vehicles, enter the town name and state of the terminal farthest away from the normal garaging location of this vehicle, that this vehicle travels to. |
| VEHICLE DESCRIPTION |
Drive to Work/School |
If this vehicle is used for commuting purposes to work or school, check the box that applies. Options are: *Drive to Work or School under 15 miles one way *Drive to Work or School 15 miles or over one way |
|
|
Check the appropriate box for the primary use of this vehicle. Options are: |
|
|
*Pleasure – Private passenger vehicles or pickups/vans not used for business purposes *Farm -Private passenger vehicles or pickups/vans principally garaged and used on a farm or ranch |
| VEHICLE DESCRIPTION |
Use |
*Retail -Pick up or delivery of property to individual households *Service -Transportation of personnel, tools, equipment or supplies to or from a job site *Commercial -The transportation of property in vehicles other than those defined as retail or service |
|
|
Use this section to indicate the coverages applicable to this individual vehicle. These coverages should correspond to the symbols indicated in the coverage section of ACORD 137. |
|
|
Abbreviations are: |
|
|
Liab . . . . . . . . . Liability No-Fault . . . . . . “No-Fault” coverage, if applicable Add’l No-Fault . . Additional “No-Fault” Protection, if applicable Med Pay . . . . . .Medical Payments Unins. Mot . . . . Uninsured Motorist |
|
|
Underins Mot . . Underinsured Motorist |
| VEHICLE DESCRIPTION |
Check Coverages |
Towing & Labor . Towing and Labor Spec C of L . . . .Specified Cause of Loss F. . . . . . . . . . . .Specified Cause of Loss by Fire F & T. . . . . . . . .Specified Causes of Loss by Fire and Theft F, T, & W . . . . . Specified Causes of Loss by Fire, Theft and Windstorm LSP . . . . . . . . . Limited Specified Perils Comp. . . . . . . . .Comprehensive Coverage Coll. . . . . . . . . ..Collision Coverage Rent. Reimb. . . . Rental Reimbursement Coverage FG. . . . . . . . . . . Full Glass Coverage Blank space . . . .Specify Other Coverage |
| VEHICLE DESCRIPTION |
Deductibles |
Indicate if the deductible is based on an ACV – Actual Cash Value, AA – Agreed Amount, or ST Amt – Stated Amount basis by checking the appropriate box. For Agreed Amount or Stated Amount basis enter the applicable limit. Indicate if the other than collision deductible is for comprehensive or some sort of specified cause of loss. Enter the collision deductible in the space provided. |
| VEHICLE DESCRIPTION |
Net Veh Dr/Cr |
Enter the net rating factor that applies to this vehicle. Do not include debits or credits that apply on a policy level. Provide under Remarks a description of each debit or credit used in the calculation of the net rating factor. |
| VEHICLE DESCRIPTION |
Tot Prem |
Enter the total premium for the vehicle. |
| REMARKS |
|
Use this section to provide any additional information required for underwriting or rating. Also indicate if any attachments such as hold harmless agreements, or pictures of vehicles are being sent. |