ACORD 90MA Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 90 MA (2008/03) Application For Massachusetts Motor Vehicle Insurance ACORD 90 MA, Application for Massachusetts Motor Vehicle Insurance, is entirely different than applications in other states. The state of Massachusetts requires personal automobile, new business and renewals, to be submitted on forms that are prescribed by the Massachusetts Commissioner of Insurance. ACORD 90 MA, Application for Massachusetts Motor Vehicle Insurance, meets the prescribed requirements. Questions or comments regarding this form should be directed to the Massachusetts Automobile Insurers Bureau (www.aib.org). This application is designed for up to two vehicles and four operators. If these limits are insufficient, attach an additional ACORD 90 MA.
IDENTIFICATION SECTION Producer Name of the producer submitting the application.
IDENTIFICATION SECTION Code Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.
IDENTIFICATION SECTION Binder/Policy Number assigned by the agent, if a binder is used, or the company, if the policy number is known.
IDENTIFICATION SECTION Effective Date Month, day and year on which the terms and conditions of the policy will commence.
IDENTIFICATION SECTION Expiration Date Month, day and year on which the terms and conditions will terminate unless renewed.
IDENTIFICATION SECTION For Company Use Only Leave this area blank.
IDENTIFICATION SECTION Applicant’s Name, Residential Address and Zip 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 the additional insured 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 correspondence.
IDENTIFICATION SECTION Phone Telephone number at which the applicant may be reached, including area code and extension, if applicable.
IDENTIFICATION SECTION Mail Address (if different) Address at which the applicant is to receive mail; this may be a P.O. Box.
IDENTIFICATION SECTION Direct Bill/Agency Bill Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.
IDENTIFICATION SECTION Payment Plan Indicate the plan to be used to pay the company for the policy. Use the company’s specific designation for the plan where possible.
IDENTIFICATION SECTION Deposit Premium Deposit submitted with the application.
COVERAGES Space is provided for two vehicles. Coverages 1-4 are compulsory and must be provided for each vehicle. Coverages 5-12 are optional. The applicant may choose all, none or any number of these optional coverages. Refer to the Massachusetts Personal Automobile Manual for descriptions of coverages.
COVERAGES Total Premium Aggregate dollar amount owed to the company for all vehicles on this policy
VEHICLE INFORMATION Place of Principal Garaging -Street Address, City or Town, Zip Code – Auto 1 Street address, city or town and zip code in which the vehicle (Auto 1) is primarily located.
VEHICLE INFORMATION Auto 2 Street address, city or town and zip code in which the vehicle (Auto 2) is primarily located.
VEHICLE INFORMATION # Enter the carrier specific vehicle number assigned to the primary vehicle (Auto 1).
VEHICLE INFORMATION Year Model year of the vehicle.
VEHICLE INFORMATION Make, Model and if Motorcycle cc Manufacturer’s trade name for the vehicle (e.g., Ford Taurus). Number of cubic centimeters of displacement for motorcycles.
VEHICLE INFORMATION Vehicle Identification Number Full vehicle identification number appearing on the title certificate orregistration.
VEHICLE INFORMATION Gross Vehicle Weight Rating for Van or Pick-Up Provide the gross vehicle weight rating for the vehicle.
VEHICLE INFORMATION Registration Plate Number Number on the license plate for the vehicle.
VEHICLE INFORMATION Date of Purchase Year the applicant acquired the vehicle.
VEHICLE INFORMATION Cost New Original cost of the vehicle.
VEHICLE INFORMATION Miles Auto was Driven in the past 12 months Number of actual miles, the vehicle was driven in the past 12 months.
VEHICLE INFORMATION Odometer Reading Current number of miles on the odometer.
VEHICLE INFORMATION Air Bag/Passive Seat Belt Answer “Yes” if the vehicle is equipped with an air bag or automatic shoulder harness seat belt. If not, enter “NO”.
VEHICLE INFORMATION Anti-Theft Device Answer “Yes” if the vehicle is equipped with an anti-theft device. If not, enter “NO”
VEHICLE INFORMATION Vehicle Recovery System Answer “Yes” if the vehicle is equipped with a vehicle recovery system. If not, enter “NO”.
VEHICLE INFORMATION Leased Auto Answer “Yes” if the vehicle is currently provided through a leasing program. If not, enter “NO”.
VEHICLE INFORMATION Secured Lender/Lessor Provide complete name and mailing address of the lending institution holding the loan on the vehicle.
VEHICLE INFORMATION # Enter the carrier specific vehicle number assigned to the secondary vehicle (Auto 2).
VEHICLE INFORMATION Year Model year of the vehicle.
VEHICLE INFORMATION Make, Model and if Motorcycle cc Manufacturer’s trade name for the vehicle (e.g., Ford Taurus). Number of cubic centimeters of displacement for motorcycles.
VEHICLE INFORMATION Vehicle Identification Number Full vehicle identification number appearing on the title certificate or registration.
VEHICLE INFORMATION Gross Vehicle Weight Rating for Van or Pick-Up Provide the gross vehicle weight rating for the vehicle.
VEHICLE INFORMATION Registration Plate Number Number on the license plate for the vehicle.
VEHICLE INFORMATION Date of Purchase Year the applicant acquired the vehicle.
VEHICLE INFORMATION Cost New Original cost of the vehicle.
VEHICLE INFORMATION Miles Auto was Driven in the past 12 months Number of actual miles, the vehicle was driven in the past 12 months.
VEHICLE INFORMATION Odometer Reading Current number of miles on the odometer.
VEHICLE INFORMATION Air Bag/Passive Seat Belt Answer “Yes” if the vehicle is equipped with an air bag or automatic shoulder harness seat belt.
VEHICLE INFORMATION Anti-Theft Device Answer “Yes” if the vehicle is equipped with an anti-theft device.
VEHICLE INFORMATION Vehicle Recovery System Answer “Yes” if the vehicle is equipped with a vehicle recovery system.
VEHICLE INFORMATION Leased Auto Answer “Yes” if the vehicle is currently provided through a leasing program
VEHICLE INFORMATION Secured Lender/Lessor Provide complete name and mailing address of the lending institution holding the loan on the vehicle.
DRIVER INFORMATION # Enter the carrier specific driver number of this operator. Show the applicant as driver #1, even if not an operator.
DRIVER INFORMATION Operator Name Name of each licensed operator (resident or not). Show the applicant as driver #1, even if not an operator.
DRIVER INFORMATION Date of Birth Birth date of each driver andhousehold resident (MM/DD/YYYY). (e.g., March 7, 1944 should be 03/07/1944).
DRIVER INFORMATION Current Driver’s License #/Licensed State The complete current driver’s license number for each licensed operator. Copy directly from license if possible. List the licensed state for each operator.
DRIVER INFORMATION Merit Rating Points Indicate the assigned Merit Rating points.
DRIVER INFORMATION Date First Licensed Month and year in which each operator became licensed. Enter as many dates as applicable.
DRIVER INFORMATION Approved Driver Training Answer “YES” if the operator has completed an approved driver training course. If not, enter “NO”.
DRIVER INFORMATION % of Use Indicate how much the primary (Auto 1) and secondary vehicle (Auto 2) are driven by each operator. Usage for each operator should total to 100%.
DRIVER INFORMATION Driver Information Questions Answer questions A through F with respect to all listed operators. Explain “Yes” responses in Remarks.
DRIVER INFORMATION Question A – Been involved in anymotor vehicle accident or been found guilty of any moving violation? Fully describe accidents or convictions, including 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. Include city and state of the accident or conviction and date of the incident. Use Remarks section or an additional piece of paper if necessary.
GENERAL INFORMATION Provide a complete explanation in the Remarks section for any “Yes” responses for questions 1-8. Use additional paper if space in the Remarks section is inadequate. Respond to questions 9-11 in the spaces provided.
ATTACHMENTS Check the applicable box(es).
REMARKS Provide a complete explanation in the Remarks section for any “Yes” responses for questions 1-8. Use additional paper if space in the Remarks section is inadequate.
DECLARATIONS AND SIGNATURES Signature of Applicant Applicant must sign this form.
DECLARATIONS AND SIGNATURES Date and Time Date and time applicant signed the application.
DECLARATIONS AND SIGNATURES Signature of Agent Agent must sign this form.
DECLARATIONS AND SIGNATURES Date and Time Date and time agent signed the application.
DECLARATIONS AND SIGNATURES Applicant’s Name If the application is electronically submitted, the applicant’s name must be indicated in the space provided.