ACORD 90KS Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 90 KS (2007/12) Kansas Personal Auto Application Following are the unique state characteristics of ACORD 90 KS, Kansas Personal Auto Application: *Personal Injury Protectioncoverages have been revised to recognize statutory limits and options. Refer to your state manual. * Uninsured Motorists coverage includes Underinsured Motorists coverage; however, there is no Property Damage coverage available. * Information relating to accidents or convictions on Page 2 of the form is limited to the last 3 years, as is information regarding license suspension/revocation contained in Question 8 of the General Information section.
TITLE Kansas Personal Auto Application * A required statement has been added to the back of the form, advising the applicant that autoliability insurance may be available through the KansasAutomobile InsurancePlan. * In addition, a statement has been added to the back of the form requiring the applicant to acknowledge available Uninsured Motorists coverage options, including the option of rejecting UM limits higher than the mandatory minimum limits. * Notice of Information Practices contains reference to the use of “credit scoring” to determine eligibility for insurance and the premium charged. A third party may be used in the development of the score.
IDENTIFICATION SECTION Date Month/day/year (MM/DD/YYYY) on which the form is completed.
IDENTIFICATION SECTION Agency Producer’s name and address.
IDENTIFICATION SECTION Contact Name Indicate the name of the contact within the agency.
IDENTIFICATION SECTION Phone No. Producer’s telephone number. (Include area code and extension if applicable)
IDENTIFICATION SECTION Fax No. Producer’s fax number. (Include area code)
IDENTIFICATION SECTION E-Mail Address Producer’s e-mail address.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
IDENTIFICATION SECTION Sub Code If the agency or brokerage uses a sub-code identification system with the company, enter the appropriate code.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Applicant’s Name and Mailing Address 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). Provide the physical address, not a P.O. Box, at which the first named insured is to receive all mail. Address should include: Street number, if any; Pre-direction, if any (example: 150 N Central Ave); Street name, if any; Street type (e.g.: st, rd, ave) ; Post-direction, if any (e.g.: 150 Central Ave N); City; County; State; ZIP code If the address does not have a street number and name, provide sufficient information and directionsso that the property can be physically located. Provide legal description if required by the mortgage holder.
IDENTIFICATION SECTION Telephone Number Telephone number at which the applicant may be reached. Include area code and extension, if applicable.
IDENTIFICATION SECTION Carrier Name of the insurance company (or residual market plan) that will receive the application. Do not use group names, use the actual name of the company within the group in which you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Plan Indicate the type of plan or policy program (example: Preferred) that you wish to use when issuing the policy. Use the specific plan name that is unique to that company.
IDENTIFICATION SECTION POL# The number assigned by the insurance company for the policy. In general, policy numbers will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION ACCT# Indicate account number, if applicable.
IDENTIFICATION SECTION Effective Date Date (MM/DD/YYYY) on which the terms and conditions of the policy will commence.
Date (MM/DD/YYYY) on which the terms and conditions of the policy will terminate unless
IDENTIFICATION SECTION Expiration Date renewed.
Indicate whether the agency or the company (direct) will bill the insured or other payee for
IDENTIFICATION SECTION Billing Plan the policy. Indicate to whom the policy should be mailed.
IDENTIFICATION SECTION Payment Plan If direct bill, also indicate who is to be billed, and the plan to be used for payment.
RESIDENCE Owned/Rented Check the box indicating whether your home is owned or rented.
Number of Years at Current
RESIDENCE Address Number of years present at the applicant’s current address.
Number of Years at Previous
RESIDENCE Address Number of years present at previous address.
Physical address of the first named insured if the applicant has been at the current
RESIDENCE Previous Address address for less than three years.
GARAGING ADDRESS Veh # Indicate vehicle number.
Indicate complete address including ZIP code for any vehicle not kept at the mailing
address. Also, provide this information if the mailing address is a post office box or rural
GARAGING ADDRESS Location route address, or when a driver is at school with a vehicle.
VEHICLE All owned, leased, or regularly used vehicles in household, including non-registered and
DESCRIPTION/USE Total # Vehicles In Household non-insured vehicles.
VEHICLE
DESCRIPTION/USE Veh # Indicate vehicle number.
VEHICLE
DESCRIPTION/USE Year Model year of the vehicle.
VEHICLE Manufacturer’s trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4
DESCRIPTION/USE Make, Model and Body Type door sedan).
Vehicle identification number as it appears on the title certificate orregistration. Also enter
VEHICLE the state where the vehicle is registered. If the vehicle is registered in a state different from
DESCRIPTION/USE VIN/Registered State 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 Indicate the 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 4wheel 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 4wheel 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 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 Bodily Injury The desired per person and per accident limits.
COVERAGES/PREMIUMS Property Damage The limit desired include applicable property damage deductible.
COVERAGES/PREMIUMS Personal Inj Protection Refer to applicable state manual for options. Include any deductible selected by the applicant.
COVERAGES/PREMIUMS Additional Personal Inj Protection Refer to applicable state manual for options.
COVERAGES/PREMIUMS Medical Payments The desired per person limit.
COVERAGES/PREMIUMS Uninsured 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 Comprehensive / OTC The comprehensive (other than collision) coverage deductible for each vehicle.
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 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 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 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 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.
DRIVER INFORMATION Number (#) Number all licensed operators. Show the applicant as driver #1, even if not an operator.
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.
DRIVER INFORMATION Sex Enter F for female, M for male.
DRIVER INFORMATION Mar Stat Enter the marital status of each listed driver. Examples: * S Single * M Married * D Divorced * SP Separated * W Widowed
DRIVER INFORMATION Relation to Applicant Driver’s relationship to the applicant. Examples: * I Insured * Sp Spouse * C Child * Sib Brother/Sister * P Parent * E Employee
DRIVER INFORMATION Date of Birth Date of birth of each driver and household resident (MM/DD/YYYY) (e.g., March 7, 1944 should be 03/07/1944).
DRIVER INFORMATION Occupation Occupation of each operator.
DRIVER INFORMATION Date Lic Date (MM/YYYY) each driver was permanently licensed.
DRIVER INFORMATION Stdt > 100 Indicate (Y) or (N) if any youthful driver is residing at a school over 100 road miles from the principal place of garaging. Show name of institution and address in the Remarks section.
DRIVER INFORMATION Good Stdt Indicate (Y) or (N) if any driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
DRIVER INFORMATION Drv Train Indicate (Y) or (N) if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate for any operator under age 21 who has successfully completed this training and qualifies for the credit.
DRIVER INFORMATION 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.
DRIVER INFORMATION Drivers License #/ Licensed State Complete drivers license number and licensed state for each licensed operator. Copy directly from license if possible.
DRIVER INFORMATION Social Security # Social security number for each named driver and household resident.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
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 within the last three (3) years, enter “None”. 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 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.
ADDITIONAL INTEREST Indicate if additional interest is an additional interest, loss payee or other entity. Show complete name and mailing address. Provide the following information for each entity having an interest in the personal automobile(s) to be insured. The Vehicle #, as referenced in the VEHICLE DESCRIPTION/USE section, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.
ADDITIONAL INTEREST Check boxes Identify whether the additional interest is the loss payee, additional interest or Other. Define “Other” in the space provided.
ADDITIONAL INTEREST Name and Address Enter the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010)
ADDITIONAL INTEREST Veh # Enter the vehicle number referenced in the VEHICLE DESCRIPTION/USE section in which there is an additional interest.
ADDITIONAL INTEREST Loan Number Provide the loan number.
EMPLOYMENT INFORMATION Applicant’s Employer Name of the organization that employs the applicant named in the identification section.
EMPLOYMENT INFORMATION Address of Employment Applicant’s employment location. This may differ from where the main office/plant is situated.
EMPLOYMENT INFORMATION Work Phone Number Work phone number at which the applicant may be reached.
EMPLOYMENT INFORMATION Yrs/W Curr Empl The number of years the applicant has been with the employer indicated.
EMPLOYMENT INFORMATION Yrs/W Prev Empl The number of years the applicant had been with the previous employer. If less than 3 years, provide the number of years in the same or other career field or industry in the Remarks section.
EMPLOYMENT INFORMATION Co-Applicant’s Employer Name of the organization that employs the co-applicant named in the identification section.
EMPLOYMENT INFORMATION Address of Employment Co-applicant’s employment location. This may differ from where the main office/plant is situated.
EMPLOYMENT INFORMATION Work Phone Number Work phone number at which the co-applicant may be reached.
EMPLOYMENT
INFORMATION Yrs/W Curr Empl The number of years the co-applicant has been with the employer indicated.
The number of years the co-applicant had been with the previous employer. If less than 3
EMPLOYMENT years, provide the number of years in the same or other career field or industry in the
INFORMATION Yrs/W Prev Empl Remarks section.
Provide the prior insurance company’s name, producer, number of years with the
PRIOR COVERAGE company, policy number and the date the prior policy expired.
PRIOR COVERAGE Prior Carrier Provide the prior insurance company’s name.
PRIOR COVERAGE # of Years W/ Company Indicate the number of years with the company.
PRIOR COVERAGE Producer Provide the prior producer’s name.
PRIOR COVERAGE Prior Policy Number Provide the prior policy number.
PRIOR COVERAGE Expiration Date Provide the date the prior policy expired.
If there are any “YES” responses, provide a complete explanation in the space provided
GENERAL INFORMATION below each question. If more space is required, use the REMARKS section.
1. Vehicle not registered to Provide the vehicle number and the name of any vehicle not owned by or registered to the
GENERAL INFORMATION applicant? applicant.
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
2. Any car modified/special equipment installed to overcome a physical handicap. Indicate vehicle number, a
GENERAL INFORMATION equipment? description of the modifications and the cost of the special equipment.
Indicate if any vehicle has been damaged and not repaired as of the date of application.
GENERAL INFORMATION 3. Any existing damage? Indicate the vehicle number and a complete description of the damage.
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
GENERAL INFORMATION 4. Any other losses incurred? amount of loss.
5. Any other automobile Provide the insured’s name, vehicle description, insurance company, type of coverage and
GENERAL INFORMATION insurance? policy number for any other household resident’s automobile insurance.
6. Any other insurance with Indicate the type and policy number of any other insurance the applicant has with the
GENERAL INFORMATION company? company.
7. Any household member in Provide details on branch of service, rank, and location of base for any household
GENERAL INFORMATION military service? member in active military service. Determine if any vehicle is at the military location.
8. Any license suspended/revoked Indicate the driver number, the period of suspension, the reason for suspension, and the
GENERAL INFORMATION in the last three (3) years? date the license was reinstated.
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
9. Any physical/mental administered. This question cannot be asked in some states. In those states, the
GENERAL INFORMATION impairments? question does not appear on the application.
10. Any financial responsibility
GENERAL INFORMATION filing? Indicate the driver’s name, the reason for the filing, and the date of original filing.
Indicate if prior carrier and previous policy number information shown on the front of the
11. Has insurance been transferred application represents a policy being transferred within the agency. If Yes, give reason for
GENERAL INFORMATION within agency? transfer.
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
12. Any coverage declined, 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
GENERAL INFORMATION cancelled, or non-renewed during action was taken. This question cannot be asked in some states. In those states, the
(continued) the last three (3) years? question does not appear on the application.
GENERAL INFORMATION 13. Is this brokered business to
(continued) the agent? Indicate if the application came through a broker not part of the agency.
GENERAL INFORMATION
(continued) 14. Has Agent Inspected Vehicle? Indicate if the agent has inspected the vehicle.
15. Has any applicant or driver had
a foreclosure, repossession,
GENERAL INFORMATION bankruptcy, judgement or lien If yes, provide specific details surrounding the circumstances involved in the foreclosure,
(continued) during the last five (5) years? repossession, bankruptcy, judgement or lien.
Use this space for any additional remarks. Use an additional sheet of paper if more space
REMARKS is required.
ATTACHMENTS Check the applicable box(es).
IDENTIFICATION SECTION Agency Customer ID Customer’s identification number assigned by the agency or brokerage.
Use this space for any additional remarks. Use an additional sheet of paper if more space
REMARKS 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 Expiration Date Month/day/year (MM/DD/YYYY) on which the binder terminates.
BINDER/SIGNATURE Time Time the provisions of the binder become effective.
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 BI Limits Selection Applicant must sign his/her initials if he/she has selected UM Coverage less than their Bodily Injury (BI) limits.
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.
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.