ACORD 71 Instructions


ACORD 71 (2009/06) rev. 07-31-2009 1 of 48

Section Name Field Name Field and/or Section Description
TITLE ACORD 71 (2009/06) PersonalAuto PolicyChange Request The title of the form. ACORD 71, Personal Auto Policy Change Request, is used to request mid-term changes to any personal auto policy. The form should be used instead of individual turnaround endorsement requests. A copy of the request may be sent to the insured to confirm that the change is submitted to the company.
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name Enter text: The name of the individual at the producer’s establishment that is the primary contact.
IDENTIFICATION SECTION Phone No. Enter number: The producer’s contact person’s phone number. If applicable, include the area code and extension.
IDENTIFICATION SECTION Fax No. Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-mail Address Enter text: The producer’s contact person e-mail address.
IDENTIFICATION SECTION Code Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer.
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).
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
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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Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Insured Name and Address Enter text: The named insured(s) as it/they will appear on the policy declarations page. As used here, the Insured Name and Mailing Address should only be used if a portion of it has changed.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address line one.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address line two.
IDENTIFICATION SECTION Enter text: The named insured’s mailing address city name.
IDENTIFICATION SECTION Enter code: The named insured’s mailing address state or province code.
IDENTIFICATION SECTION Enter code: The named insured’s mailing address postal code.
IDENTIFICATION SECTION Tax Code Enter code: The city, county or state tax code. As used here, enter the tax code only if it has changed.
IDENTIFICATION SECTION Carrier Enter text: The insurer’s full legal company name(s) as found in thefile 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.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION Attention Enter text: The name of the individual at the insurance company that is the primary contact.
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.
IDENTIFICATION SECTION Account Number Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number.
IDENTIFICATION SECTION Effective Date of Change Enter date: The date on which the change should take effect.
IDENTIFICATION SECTION Effective Date of Policy Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Expiration Date Enter date: The date on which the terms and conditions of the policy will expire.
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Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Change Billing Plan to Direct Check the box (if applicable): Indicates if the policy is to be direct billed. As used here, only check if the billing plan is changing.
IDENTIFICATION SECTION Change Billing Plan to Direct Agency Check the box (if applicable): Indicates if the policy is to be producer/agency billed. As used here, only check if the billing plan is changing.
GARAGING ADDRESS Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
GARAGING ADDRESS Loc Enter number: The producer assigned number of the location.
GARAGING ADDRESS Veh Enter number: The producer assigned vehicle number.
GARAGING ADDRESS Street Enter text: The vehicle’s physical address line one.
GARAGING ADDRESS City Enter text: The vehicle’s physical address city name.
GARAGING ADDRESS County Enter text: The vehicle’s physical address county name.
GARAGING ADDRESS State Enter code: The vehicle’s physical address state or province code.
GARAGING ADDRESS Zip Enter code: The vehicle’s physical address postal code.
GARAGING ADDRESS Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
GARAGING ADDRESS Loc Enter number: The producer assigned number of the location.
GARAGING ADDRESS Veh Enter number: The producer assigned vehicle number.
GARAGING ADDRESS Street Enter text: The vehicle’s physical address line one.
GARAGING ADDRESS City Enter text: The vehicle’s physical address city name.
GARAGING ADDRESS County Enter text: The vehicle’s physical address county name.
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Section Name Field Name Field and/or Section Description
GARAGING ADDRESS State Enter code: The vehicle’s physical address state or province code.
GARAGING ADDRESS Zip Enter code: The vehicle’s physical address postal code.
VEHICLE DESCRIPTION / USE Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Reg St Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE Reg to Drv # Enter number: The producer assigned driver number of the driver registered to the vehicle.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Mile 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/Mo. Enter number: The 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.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Car Pool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.

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Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). 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
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver # 1 Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver # 2 Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver # 3 Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver # 4 Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver # 5 Enter number: The producer assigned driver number of the driver using the vehicle.
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Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver # 6 Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti – Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti – Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
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Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Reg St Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE Reg to Drv # Enter number: The producer assigned driver number of the driver registered to the vehicle.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Mile 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
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Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/Mo. Enter number: The 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.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Car Pool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). 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
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
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Section Name Field Name Field and/or Section Description
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti – Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti – Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
VEHICLE COVERAGES (excluding NO FAULT) Vehicle # Enter number: The producer assigned vehicle number.
VEHICLE COVERAGES (excluding NO FAULT) Single Limit Liability (CSL) Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
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Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Single Limit Liability (CSL) Ea Accident Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Ea Person Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Ea Accident Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Ea Accident Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Deductible Enter deductible: The property damage deductible amount.
Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Medical Payments Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Medical Payments Ea Person Enter limit: The medical payments per person limit.
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Ea Person Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Ea Accident Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL / BI Option Enter text: The description of the options applicable to uninsured motorists coverage.

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Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist PD Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist PD Ea Accident Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Ea Person Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Ea Accident Enter limit: The underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL / BI Option Enter text: The description of the options applicable to underinsured motorists coverage.
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Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist PD Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist PD Ea Accident Enter limit: The underinsured motorists property damage per accident amount. The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive/ OTC Deductible Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive/ OTC Deductible Amount Enter deductible: The comprehensive or other than collision deductible amount.
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive / OTC Option Enter text: The description of the options applicable to comprehensive / other than collision coverage.
VEHICLE COVERAGES (excluding NO FAULT) Collision Deductible Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Collision Deductible Amount Enter deductible: The collision deductible amount.
VEHICLE COVERAGES (excluding NO FAULT) Collision Option Enter text: The description of the options applicable to collision coverage.
VEHICLE COVERAGES (excluding NO FAULT) ACV Unless Amt Stated Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) ACV Unless Amt Stated Limit Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
VEHICLE COVERAGES (excluding NO FAULT) Towing & Labor Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Towing & Labor Limit Enter limit: The towing and labor limit amount.

ACORD 71 (2009/06) rev. 07-31-2009 15 of 48 ACORD 71 (2009/06) rev. 07-31-2009 16 of 48

Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense / Rental Reimbursement Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense Ea Day Enter limit: The transportation expense or rental reimbursement per day limit amount.
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense Maximum Limit Enter limit: The transportation expense or rental reimbursement maximum limit amount.
VEHICLE COVERAGES (excluding NO FAULT) Vehicle # Enter number: The producer assigned vehicle number.
VEHICLE COVERAGES (excluding NO FAULT) Single Limit Liability (CSL) Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Single Limit Liability (CSL) Ea Accident Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
ACORD 71 (2009/06) rev. 07-31-2009 17 of 48

Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Ea Person Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Bodily Injury Liability Ea Accident Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Ea Accident Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
VEHICLE COVERAGES (excluding NO FAULT) Property Damage Liability Deductible Enter deductible: The property damage deductible amount.
Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Medical Payments Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Medical Payments Ea Person Enter limit: The medical payments per person limit.
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Ea Person Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL/BI Ea Accident Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist CSL / BI Option Enter text: The description of the options applicable to uninsured motorists coverage.

ACORD 71 (2009/06) rev. 07-31-2009 18 of 48 ACORD 71 (2009/06) rev. 07-31-2009 19 of 48

Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist PD Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Uninsured Motorist PD Ea Accident Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Ea Person Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL/BI Ea Accident Enter limit: The underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist CSL / BI Option Enter text: The description of the options applicable to underinsured motorists coverage.
ACORD 71 (2009/06) rev. 07-31-2009 20 of 48

Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist PD Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Underinsured Motorist PD Ea Accident Enter limit: The underinsured motorists property damage per accident amount. The use of this limit varies by state.
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive / OTC Deductible Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive/ OTC Deductible Amount Enter deductible: The comprehensive or other than collision deductible amount.
VEHICLE COVERAGES (excluding NO FAULT) Comprehensive / OTC Option Enter text: The description of the options applicable to comprehensive / other than collision coverage.
VEHICLE COVERAGES (excluding NO FAULT) Collision Deductible Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Collision Deductible Amount Enter deductible: The collision deductible amount.
VEHICLE COVERAGES (excluding NO FAULT) Collision Option Enter text: The description of the options applicable to collision coverage.
VEHICLE COVERAGES (excluding NO FAULT) ACV Unless Amt Stated Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) ACV Unless Amt Stated Limit Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
VEHICLE COVERAGES (excluding NO FAULT) Towing & Labor Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Towing & Labor Limit Enter limit: The towing and labor limit amount.

ACORD 71 (2009/06) rev. 07-31-2009 21 of 48

ACORD 71 (2009/06) rev. 07-31-2009 22 of 48

Section Name Field Name Field and/or Section Description
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense/Rental Reimbursement Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense Ea Day Enter limit: The transportation expense or rental reimbursement per day limit amount.
VEHICLE COVERAGES (excluding NO FAULT) Transportation Expense Maximum Limit Enter limit: The transportation expense or rental reimbursement maximum limit amount.
REMARKS Remarks Enter text: The remarks associated with a policy change. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
IDENTIFICATION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ACORD 71 (2009/06) rev. 07-31-2009 23 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ACORD 71 (2009/06) rev. 07-31-2009 24 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 25 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.

ACORD 71 (2009/06) rev. 07-31-2009 26 of 48

ACORD 71 (2009/06) rev. 07-31-2009 27 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 28 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.

ACORD 71 (2009/06) rev. 07-31-2009 29 of 48

ACORD 71 (2009/06) rev. 07-31-2009 30 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 31 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.

ACORD 71 (2009/06) rev. 07-31-2009 32 of 48

ACORD 71 (2009/06) rev. 07-31-2009 33 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 34 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.

ACORD 71 (2009/06) rev. 07-31-2009 35 of 48

ACORD 71 (2009/06) rev. 07-31-2009 36 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 37 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.

ACORD 71 (2009/06) rev. 07-31-2009 38 of 48

ACORD 71 (2009/06) rev. 07-31-2009 39 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Type of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Veh Enter number: The producer assigned vehicle number.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Code Enter code: The coverage code of the other coverage or adjustment.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Description Enter text: The description of the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Enter limit: The limit amount of the other coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Limit Applies to Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Amount Enter deductible: The deductible amount of the coverage.
ACORD 71 (2009/06) rev. 07-31-2009 40 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Deductible Percentage Enter percentage: The deductible percentage for the coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
ADDITIONAL VEHICLE COVERAGES (including NO FAULT) Option Enter code: The option applicable to this coverage.
DRIVER INFORMATION Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
DRIVER INFORMATION Driver # Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
DRIVER INFORMATION Sex Enter code: The gender of the driver.
DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
ACORD 71 (2009/06) rev. 07-31-2009 41 of 48

Section Name Field Name Field and/or Section Description
DRIVER INFORMATION Driver # Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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 Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
DRIVER INFORMATION Type Of Change Enter code: The type of change being requested. Enter either an A-Add, C-Change, D-Delete or I – Informational Only No Change. Various combinations of changes are permitted in one submission. Use “A” to add an item that was not previously in the policy (e.g., add a vehicle, add a coverage). Use “D” to delete an item (e.g., delete a vehicle, delete a driver). Use “C” to change an item in the policy (e.g., change a deductible, change coverage limits). Use “I” to identify a risk or other item that is not being changed but is related to another change on the form. Example: When adding collision coverage to a vehicle, enter “A” in the type of change for Collision. Enter “I” in the type of change for the Vehicle. Enter enough information to identify the vehicle that is having coverage changed (e.g. year, make, model, body, VIN).
DRIVER INFORMATION Driver # Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
DRIVER INFORMATION Sex Enter code: The gender of the driver.
ACORD 71 (2009/06) rev. 07-31-2009 42 of 48

Section Name Field Name Field and/or Section Description
DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver # Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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 Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
ACCIDENTS / CONVICTIONS Has Any Driver Shown Above Had An Accident, Regardless Of Fault, Or Been Convicted Of A Moving Violation Within The Last _____ Years? Enter number: The number of years associated with “… an accident… or convicted of a moving violation” question.
ACCIDENTS / CONVICTIONS Accident Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if any driver has had an accident or been convicted of a moving violation in the mandated number of years.
ACCIDENTS / CONVICTIONS DRV # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACORD 71 (2009/06) rev. 07-31-2009 43 of 48

Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS Bodily Injury Or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS DRV # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS Bodily Injury Or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS DRV # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS Bodily Injury Or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS DRV # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACORD 71 (2009/06) rev. 07-31-2009 44 of 48

Section Name Field Name Field and/or Section Description
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS Bodily Injury Or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
GENERAL INFORMATION 1. With the exception of any encumbrances, are any vehicles not solely owned by and registered to the applicant? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Name of Other Owner Enter text: The additional interest’s full name.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Name of Other Owner Enter text: The additional interest’s full name.
GENERAL INFORMATION 2. Any car modified / special equipment? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any vehicles customized, altered or with special equipment?”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION Cost Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION Cost Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION 3. Any existing damage to vehicle? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any existing damage to vehicle? (Include damaged glass)”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION 4. Any household member in military service? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any household member in military service?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Branch Enter text: The branch of military service.
ACORD 71 (2009/06) rev. 07-31-2009 45 of 48

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION Rank Enter text: The driver’s rank in the military.
GENERAL INFORMATION Base Location – Street Enter text: The military base’s first address line.
GENERAL INFORMATION Base Location – City Enter text: The city of the military base.
GENERAL INFORMATION Base Location – State Enter code: The state or province code of the military base.
GENERAL INFORMATION Base Location – Zip Enter code: The postal code of the military base.
GENERAL INFORMATION Base Location – Country Enter code: The country code of the military base.
GENERAL INFORMATION Veh at Base Y/N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the driver has a vehicle at a military base.
GENERAL INFORMATION 5. Any drivers license been suspended / revoked? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any drivers license been suspended/revoked?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Suspension Period Start Date Enter date: The date the driver’s license suspension became effective.
GENERAL INFORMATION Suspension Period End Date Enter date: The date the driver’s license suspension is scheduled to end.
GENERAL INFORMATION Explanation Enter text: The reason the driver’s license was suspended or revoked.
GENERAL INFORMATION Reinstatement Date Enter date: The date a suspended or revoked driver’s license was reinstated.
GENERAL INFORMATION 6. Any driver have physical / mental impairment? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any driver have physical/mental impairment?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Description of Special Equipment Enter text: The description of any special equipment for a driver with physical or mental impairments.
GENERAL INFORMATION Medication / Treatment Enter text: The description of any medication or treatments for a driver with physical or mental impairments.
IDENTIFICATION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION (Continued) 7. Any financial responsibility filing? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any financial responsibility filing?”.
GENERAL INFORMATION (Continued) Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION (Continued) Reason for Filing Enter text: The description of why a financial responsibility filing is required.
GENERAL INFORMATION (Continued) Filing Date Enter date: The date on which the financial responsibility filing was originally required.
GENERAL INFORMATION (Continued) 8. Any coverage declined, cancelled or non-renewed during the last three (3) years? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”.
ACORD 71 (2009/06) rev. 07-31-2009 46 of 48

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION (Continued) Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION (Continued) Reason declined, cancelled, or non-renewed Enter text: The description of the reason for coverage being declined, cancelled or non-renewed within the last mandated number of years.
ADDITIONAL INTEREST Add Check the box (if applicable): Indicates if the type of change being requested is an add.
ADDITIONAL INTEREST Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
ADDITIONAL INTEREST Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST Lienholder Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST Loss Payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST Owner Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST Registrant Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST Other Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTEREST Other Description Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTEREST Name and Address Enter text: The additional interest’s full name.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTEREST Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTEREST Enter code: The additional interest’s mailing address postal code.
ADDITIONAL INTEREST Enter code: The additional interest’s country code.
ADDITIONAL INTEREST Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST Vehicle Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST Location Enter number: The producer assigned number of the location which has an additional interest.
ADDITIONAL INTEREST Add Check the box (if applicable): Indicates if the type of change being requested is an add.
ACORD 71 (2009/06) rev. 07-31-2009 47 of 48

Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST Change Check the box (if applicable): Indicates if the type of change being requested is a change to an existing piece of data.
ADDITIONAL INTEREST Delete Check the box (if applicable): Indicates if the type of change being request is a delete.
ADDITIONAL INTEREST Additional Insured Check the box (if applicable): Indicates the additional interest type is an additional insured.
ADDITIONAL INTEREST Lienholder Check the box (if applicable): Indicates the additional interest type is a lien holder.
ADDITIONAL INTEREST Loss Payee Check the box (if applicable): Indicates the additional interest type is a loss payee.
ADDITIONAL INTEREST Owner Check the box (if applicable): Indicates the additional interest type is an owner.
ADDITIONAL INTEREST Registrant Check the box (if applicable): Indicates the additional interest type is a registrant.
ADDITIONAL INTEREST Other Check the box (if applicable): Indicates the additional interest is not any of the types listed on the form.
ADDITIONAL INTEREST Other Description Enter text: The description of the type of interest in the item.
ADDITIONAL INTEREST Rank Enter number: The ranking of ‘this’ additional interest when multiple additional interests are associated with the same item.
ADDITIONAL INTEREST Name And Address Enter text: The additional interest’s full name.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address line one.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address line two.
ADDITIONAL INTEREST Enter text: The additional interest’s mailing address city name.
ADDITIONAL INTEREST Enter code: The additional interest’s mailing address state or province code.
ADDITIONAL INTEREST Enter code: The additional interest’s mailing address postal code.
ADDITIONAL INTEREST Enter code: The additional interest’s country code.
ADDITIONAL INTEREST Reference / Loan # Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured.
ADDITIONAL INTEREST Vehicle Enter number: The producer assigned number of the vehicle which has an additional interest.
ADDITIONAL INTEREST Location Enter number: The producer assigned number of the location which has an additional interest.
REMARKS Remarks Enter text: The personal vehicle line of business remarks.
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.
SIGNATURE Producer’s Name (Please Print) Enter text: The name of the authorized representative of the producer, agency and/or broker that signed the form.
SIGNATURE State Producer License No Enter identifier: The State License Number of the producer.
SIGNATURE Insured’s Signature Sign here: Accommodates the signature of the applicant or named insured.
Section Name Field Name Field and/or Section Description
SIGNATURE Date Enter date: The date the form was signed by the named insured.
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.
EDITION Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).