ACORD 90AR Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 90 AR (2008/04) Arkansas Personal Auto Application Section ACORD 90 AR, Arkansas Personal Auto ApplicationSection, was designed to be used in conjunction with ACORD 88, Personal Insurance Application – Applicant Information Section. ACORD 90 AR must be attached to ACORD 88 for a completed application submission.Following are the unique state characteristics of ACORD 90 AR, Arkansas Personal Auto Application Section: *Personal Injury Protectioncoverages are revised to reflect unique Arkansas coverages and options. Refer to your state manual. * Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorists Property Damage is not available.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer’s name.
IDENTIFICATION SECTION Policy Number Provide the policy number if a policy has already been issued.
IDENTIFICATION SECTION Carrier Name of the applicable insurance company. Do not use group names; use the actual name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code Individual company code assigned by the NAIC.
IDENTIFICATION SECTION Named Insured(s) Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).
RESIDENCE Owned/Rented Check the box indicating whether your home is owned or rented.
RESIDENCE Current Address Current physical address of the first named insured.
GARAGING ADDRESS Veh # Indicate vehicle number.
GARAGING ADDRESS Location Indicate complete address including ZIP code for any vehicle not kept at the current address. Also, provide this information if the mailing address is a post office box or rural route address, or when a driver is at school with a vehicle.
VEHICLE DESCRIPTION / USE Total # Vehicles InHousehold All owned, leased, or regularly used vehicles in household, including non-registered and non-insured vehicles.
VEHICLE DESCRIPTION / USE Veh # Indicate vehicle number.
VEHICLE DESCRIPTION / USE Year Model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Manufacturer’s make of the vehicle (e.g., Ford).
VEHICLE DESCRIPTION / USE Model Manufacturer’s model of the vehicle (e.g., Taurus).
VEHICLE DESCRIPTION / USE Body Type Body type of the vehicle, including number of doors (e.g., 4 door sedan).
VEHICLE DESCRIPTION / USE VIN Vehicle identification number as it appears on the title certificate orregistration.
VEHICLE DESCRIPTION / USE Registered State Enter the state where the vehicle is registered. If the vehicle is registered in a state different from where it is garaged, provide an explanation in the Remarks section.
VEHICLE DESCRIPTION / USE HP/CC Horsepower, or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Month and Year the applicant leased the vehicle (MM/YYYY).
VEHICLE DESCRIPTION / USE Date Purch Year the applicant acquired the vehicle (YYYY).
VEHICLE DESCRIPTION / USE New/Used Enter “N” if the applicant bought the vehicle new, “U” if the vehicle was used.
VEHICLE DESCRIPTION / USE Veh # Indicate vehicle number.
VEHICLE DESCRIPTION / USE Cost New Original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual.
VEHICLE DESCRIPTION / USE Terr Rating territory code where the vehicle is principally garaged. Refer to rating manual.
VEHICLE DESCRIPTION / USE Miles 1 Way Wk/Schl Number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Number of days per week 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 # Weeks/ Mo. 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 pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation, profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of occupation, profession or business is considered pleasure.
VEHICLE DESCRIPTION / USE Perform Vehicle’s performance level. Indicate High (H), Intermediate (I) or Sport (S).
VEHICLE DESCRIPTION / USE Multi-Car Check box only if multi-car credit applies.
VEHICLE DESCRIPTION / USE Carpool Indicate if any vehicle is used in a car pool for travel to work (W) or school (S).
VEHICLE DESCRIPTION / USE Gar Code Indicate by type letter code where the vehicle is garaged. 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 Current number of miles on the odometer.
VEHICLE DESCRIPTION / USE Annual Mileage Total estimated annual mileage for each vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Driver to be assigned to each vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Use % Percentage that each driver uses each vehicle. Each vehicle should total 100 percent. If any driver has 0 percent use for all vehicles, indicate why in the Remarks section.
VEHICLE DESCRIPTION / USE Class Rate classification for each vehicle. Refer to manual; some companies determine class automatically from information provided in Vehicle Use and Driver Information sections.
VEHICLE DESCRIPTION / USE Veh # Indicate vehicle number.
VEHICLE DESCRIPTION / USE Passive Seat Belt Check the box if the vehicle is equipped with automatic seat belts.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Indicate “D” for driver side air bag, “B” for vehicle equipped with air bag for both front driver and passenger.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel anti-lock braking system.
VEHICLE DESCRIPTION / USE Anti-Theft Devices If vehicle is equipped with an anti-theft device, indicate type.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter any other credits and/or surcharges that are to apply to any or all vehicles.
VEHICLE DESCRIPTION / USE Veh # Indicate vehicle number.
VEHICLE DESCRIPTION / USE Passive Seat Belt Check the box if the vehicle is equipped with automatic seat belts.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Indicate “D” for driver side air bag, “B” for vehicle equipped with air bag for both front driver and passenger.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel anti-lock braking system.
VEHICLE DESCRIPTION / USE Anti-Theft Devices If vehicle is equipped with an anti-theft device, indicate type.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter any other credits and/or surcharges that are to apply to any or all vehicles.
COVERAGES / PREMIUMS For information relating to each state’s unique coverages, refer to the State forms section in this guide, and your company’s rating manual.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS Single Limit Liability The desired limit of both bodily injury and property damage. If an entry is made in this field, leave the separate Bodily Injury and Property Damage fields blank, except be sure to show a property damage deductible if applicable.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Bodily Injury The desired per person and per accident limits.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Property Damage The desired per accident limit.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Personal Inj Protection Refer to applicable state manual for options. Include any deductible selected by the applicant.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Uninsured Motorists The bodily injury (per person and per accident) and the property damage (per accident) limits. For COMBINED SINGLE LIMIT (CSL), enter the limit in the BI per accident area for combined single limits.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Underinsured Motorists The bodily injury (per person and per accident) limits. For COMBINED SINGLE LIMIT (CSL), enter the limit in the BI per accident area for combined single limits.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS Comprehensive / OTC The comprehensive (other than collision) coverage deductible for each vehicle.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS Collision The collision coverage deductible for each vehicle if applicable. Some companies provide a verbal limit. Consult company manuals for cases in which a verbal limits applies.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS ACV unless Amount Stated If stated amount applies for the type of vehicle being insured, enter the amount and indicate the vehicle to which it applies.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS Towing & Labor The amount per disablement for each vehicle if applicable. Some companies provide a verbal limit. Consult company manuals for cases in which a verbal limit applies.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Vehicle # Enter the applicable vehicle # as identified in the VEHICLE DESCRIPTION / USE section.
COVERAGES / PREMIUMS Transportation Expenses/Rental Reimbursements The desired per day limit and maximum amount. Additional miscellaneous coverages can be included in the blank line or the additional line or the Additional Coverages/Endorsements Section.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Blank Row Additional miscellaneous coverages can be included in the blank row.
COVERAGES / PREMIUMS $ Enter the premium per vehicle.
COVERAGES / PREMIUMS Additional Coverages/Endorsements Indicate any additional coverages and endorsements. Include limits, deductible and premium.
COVERAGES / PREMIUMS Policy Fee Enter any applicable policy fee permitted by law.
COVERAGES / PREMIUMS Total Per Vehicle The estimated total premium for each vehicle.
COVERAGES / PREMIUMS Estimated Total The estimate total premium for all vehicles on policy. Include all coverages, credits and surcharges.
COVERAGES / PREMIUMS Deposit The amount of premium submitted with the application.
COVERAGES / PREMIUMS Balance Due Estimated total premium minus deposit.
FORMS AND ENDORSEMENTS Veh # Enter the vehicle number.
FORMS AND ENDORSEMENTS Form Number Enter the Form number to be endorsed to the policy.
FORMS AND ENDORSEMENTS Form Name Enter the name of the form to be endorsed to the policy.
FORMS AND ENDORSEMENTS Edition Date Enter the edition date of the form to be endorsed to the policy.
FORMS AND ENDORSEMENTS Copyright Owner Code Enter the copyright code of the owner of the form to be added to the policy.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
RESIDENT & DRIVER INFORMATION Number (#) Number all licensed operators. Show the applicant as driver #1, even if not an operator.
RESIDENT & DRIVER INFORMATION Name Name of each licensed operator (resident or not) as it appears on their drivers licenses, and every resident of the household regardless of age. Enter the surname only if different from the applicant’s. Show the applicant as driver #1, even if not an operator. Use the REMARKS section or additional sheets if the number of individuals exceeds the space provided.
RESIDENT & DRIVER INFORMATION Sex Enter F for female, M for male.
RESIDENT & DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. The applicable codes are: * S Single * M Married * D Divorced * P Separated * W Widowed * C Domestic Partner (unmarried) * V Civil Union * U Unknown * O Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Driver’s relationship to the applicant. Examples: * I Insured * Sp Spouse * C Child * Sib Brother/Sister * P Parent * E Employee
RESIDENT & DRIVER INFORMATION Date of Birth Date of birth of each driver and household resident (MM/DD/YYYY) (e.g., March 7, 1944 should be 03/07/1944).
RESIDENT & DRIVER INFORMATION Occupation Occupation of each operator.
RESIDENT & DRIVER INFORMATION Date Lic Date (MM/YYYY) each driver was permanently licensed.
RESIDENT & DRIVER INFORMATION Stdt > 100 Indicate (Y) or (N) if any youthful driver is residing at a school over 100 road miles from the principal place of garaging. Show name of institution and address in the Remarks section.
RESIDENT & DRIVER INFORMATION Good Stdt Indicate (Y) or (N) if any driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Indicate (Y) or (N) if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate for any operator under age 21 who has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date on which the driver successfully completed an approved motor vehicle accident prevention course (or a similarly recognized defensive driving course). Attach a completion certificate for each driver who qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Complete drivers license number for each licensed operator. Copy directly from license if possible.
RESIDENT & DRIVER INFORMATION Licensed State Licensed state for each licensed operator.
RESIDENT & DRIVER INFORMATION Social Security # Social security number for each named driver and household resident.
ACCIDENTS / CONVICTIONS It is important that this section be completed fully and accurately. Many companies verify driving records with state motor vehicle departments. Discrepancies between the application and the report may result in processing delays and unnecessary correspondence with the company. If there have not been any accidents, convictions or comprehensive losses during the indicated time period, enter “None”. Be sure to enter the number of years reviewed, in accordance with the company’s and state’s requirements, as the experience period. Use the REMARKS section or additional sheets if necessary to provide the necessary information.
ACCIDENTS / CONVICTIONS Drv # Driver number as found in the driver information section.
ACCIDENTS / CONVICTIONS Date of Accident/Conviction Date the accident or conviction occurred. (MM/DD/YYYY)
ACCIDENTS / CONVICTIONS Description of Accident or Conviction A complete description of the accident or conviction. This would include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail. Use the Remarks section or an additional piece of paper if necessary.
ACCIDENTS / CONVICTIONS Place of Accident/Conviction City and state of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Indicate by whether bodily injury or death occurred. Include details in the description of accident.
ACCIDENTS / CONVICTIONS Amount of Property Damage Total amount of property damage, both the applicant’s and all claimant’s combined damages. Refer to company manual.
GENERAL INFORMATION If there are any “YES” responses, provide a complete explanation in the space provided below each question. Use REMARKS section if more space is required.
GENERAL INFORMATION 1. Any vehicle not solely owned by and registered to applicant? Provide the vehicle number and the name of any vehicle not owned by or registered to the applicant.
GENERAL INFORMATION 2. Any car modified/special equipment? Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any customized painting such as murals or pin striping, any equipment installed to overcome a physical handicap. Indicate vehicle number, a description of the modifications and the cost of the special equipment.
GENERAL INFORMATION 3. Any existing damage? Indicate if any vehicle has been damaged and not repaired as of the date of application. Indicate the vehicle number and a complete description of the damage.
GENERAL INFORMATION 4. Any other losses incurred? Any other losses, such as glass damage, vandalism, fire or theft, not shown in the Accident/Conviction section, incurred within the last three years. Provide description and amount of loss.
GENERAL INFORMATION 5. Any other auto insurance? Provide the insured’s name, vehicle description, insurance company, type of coverage and policy number for any other household resident’s automobile insurance.
GENERAL INFORMATION 6. Any household member in military service? Provide details on branch of service, rank, and location of base for any household member in active military service. Determine if any vehicle is at the military location.
GENERAL INFORMATION 7. Any license suspended/revoked? Indicate the driver number, the period of suspension, the reason for suspension, and the date the license was reinstated.
GENERAL INFORMATION 8. Any driver have physical/mental impairments? List any operator with a physical or medical impairment which could hinder the safe operation of a vehicle ( amputation, epilepsy). If impaired, enter the name of the driver, a description of any special equipment installed, and treatment or medication being administered. This question cannot be asked in some states. In those states, the question does not appear on the application.
GENERAL INFORMATION 9. Any financial responsibility filing? Indicate the driver’s name, the reason for the filing, and the date of original filing.
GENERAL INFORMATION 10. Any coverage declined, cancelled or non-renewed during the last three (3) years? Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within the last three years. List the person’s name and why the action was taken. This question cannot be asked in some states. In those states, the question does not appear on the application.
GENERAL INFORMATION 11. Is this brokered business to the agent? Indicate if the application came through a broker not part of the agency.
GENERAL INFORMATION 12. Has agent inspected vehicle? Indicate if the agent has inspected the vehicle.
GENERAL INFORMATION 13. Has any applicant or driver had a foreclosure, repossession, bankruptcy, judgement or lien during the last five (5) years? If yes, provide specific details surrounding the circumstances involved in the foreclosure, repossession, bankruptcy, judgement or lien.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
REMARKS / ATTACHMENTS Check the applicable box(es) if attachments have been included. Blank check boxes are provided for attachments not previously identified (describe). Use this space for any additional remarks or comments. Attach additional sheets if more space is required.
BINDER / SIGNATURE This section is to be used by producers with the permission of the company underwriter or when the producer has binding authority for this line of business. If the coverage is bound, complete the Insurance Binder section. If coverage is not bound, check the box.
BINDER / SIGNATURE Effective Date Month/day/year (MM/DD/YYYY) on which the insurance applied for is bound. This insurance is subject to the terms, conditions, and limitations of the company.
BINDER / SIGNATURE Time Time the provisions of the binder become effective.
BINDER / SIGNATURE Expiration Date Month/day/year (MM/DD/YYYY) on which the binder terminates.
BINDER / SIGNATURE 12:01/ Noon Indicate the time on which the binder terminates.
BINDER / SIGNATURE Producer’s Statement Indicate how long the applicant is known to the agent.
BINDER / SIGNATURE Applicant’s Signature The applicant should read and understand the Fair Credit Reporting Act, the Privacy Act (where applicable), the Applicant’s Statement, and any other disclosure information on the form before personally signing the application.
BINDER / SIGNATURE Date Date the form was signed (MM/DD/YYYY).
BINDER / SIGNATURE Producer’s Signature The producer should sign the application. This is required in most states.
BINDER / SIGNATURE National Producer Number The National Producer Number assigned by the NAIC should be shown.