| Section Name | Field Name | Field and/or Section Description |
| TITLE ACORD 90 MT (2009/08) | Montana Personal Auto Application | The title of the form. ACORD 90 MT, Montana Personal Auto Application, is used when insurance is desired for personal vehicles. Following are the unique characteristics specific to Montana: * Personal Injury Protectioncoverage is not available; this is not a “no-fault” state. * Uninsured Motorists Property Damage and Underinsured Motorists Property Damage coverages are not available. * Provision is made to select “stacked” or “non-stacked” coverage under Uninsured and Underinsured Motorists BI coverages. Property Damage coverage is not available. * Provision is made to select “stacked” or “non-stacked” coverage under Uninsured and Underinsured Motorists BI coverages. * A statement has been added to the back of the form, referencing the offering of Uninsured Motorists coverage. * A state-specific privacy notice is added. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| 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 | 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 | Effective Date | Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
| IDENTIFICATION SECTION | Named Insured(s) | Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
| Section Name | Field Name | Field and/or Section Description |
| 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. As used here, this may contain the name of the residual market plan. |
| IDENTIFICATION SECTION | NAIC Code | Enter code: The identification code assigned to the insurer by the NAIC. |
| GARAGING ADDRESS (from ACORD 88) | Location # | Enter number: The producer assigned number of the location. |
| GARAGING ADDRESS (from ACORD 88) | Veh # | Enter number: The producer assigned vehicle number. |
| GARAGING ADDRESS (from ACORD 88) | Street | Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | City | Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | County | Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | State | Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Zip + 4 | Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Location # | Enter number: The producer assigned number of the location. |
| GARAGING ADDRESS (from ACORD 88) | Veh # | Enter number: The producer assigned vehicle number. |
| GARAGING ADDRESS (from ACORD 88) | Street | Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | City | Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | County | Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | State | Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Zip + 4 | Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Location # | Enter number: The producer assigned number of the location. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| GARAGING ADDRESS (from ACORD 88) | Veh # | Enter number: The producer assigned vehicle number. |
| GARAGING ADDRESS (from ACORD 88) | Street | Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | City | Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | County | Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | State | Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Zip + 4 | Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Location # | Enter number: The producer assigned number of the location. |
| GARAGING ADDRESS (from ACORD 88) | Veh # | Enter number: The producer assigned vehicle number. |
| GARAGING ADDRESS (from ACORD 88) | Street | Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | City | Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | County | Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | State | Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle. |
| GARAGING ADDRESS (from ACORD 88) | Zip + 4 | Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle. |
| VEHICLE DESCRIPTION / USE | Total Number of Vehicles inHousehold | Enter number: The total number of vehicles in the household. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION / USE | Body Type | Enter code: The body type of the vehicle. |
| VEHICLE DESCRIPTION / USE | VIN | Enter identifier: The vehicle identificationnumber (VIN) or serial number assigned by the manufacturer. |
| VEHICLE DESCRIPTION / USE | Registered State | Enter code: The state or province in which the vehicle is registered. |
| 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 | Miles 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). |
| Section Name | Field Name | Field and/or Section Description |
| 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 | Carpool | 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 Number | 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 Number | 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 Number | 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. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION / USE | Driver Number | 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 Number | 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 Number | 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 Drv/Both | 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 | 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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 | Registered State | Enter code: The state or province in which the vehicle is registered. |
| 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 | Miles 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). |
| Section Name | Field Name | Field and/or Section Description |
| 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 | Carpool | 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. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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 Drv/Both | 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 | 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 | Registered State | Enter code: The state or province in which the vehicle is registered. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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 | Miles 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 | Carpool | Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
ACORD 90 MT (2009/08) rev. 08-31-2009 10 of 37
| 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 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 | 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. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION / USE | Air Bag Drv/Both | 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 | 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 | Registered State | Enter code: The state or province in which the vehicle is registered. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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 | Miles 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 | Carpool | 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 |
| Section Name | Field Name | Field and/or Section Description |
| 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. |
| 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 Drv/Both | 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. |
| COVERAGES / PREMIUMS | Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Single Limit Liability | 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). |
| COVERAGES / PREMIUMS | Single Limit Liability Amount Vehicle One | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES / PREMIUMS | Single Limit Liability Amount Vehicle Two | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES / PREMIUMS | Single Limit Liability Amount Vehicle Three | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES / PREMIUMS | Single Limit Liability Amount Vehicle Four | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES / PREMIUMS | Bodily Injury Each 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). |
| COVERAGES / PREMIUMS | Bodily Injury Each 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). |
| COVERAGES / PREMIUMS | Bodily Injury Amount Vehicle One | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES / PREMIUMS | Bodily Injury Amount Vehicle Two | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES / PREMIUMS | Bodily Injury Amount Vehicle Three | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES / PREMIUMS | Bodily Injury Amount Vehicle Four | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES / PREMIUMS | Property Damage Each 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). |
| COVERAGES / PREMIUMS | Property Damage Amount Vehicle One | Enter amount: The property damage premium amount. |
| COVERAGES / PREMIUMS | Property Damage Amount Vehicle Two | Enter amount: The property damage premium amount. |
| COVERAGES / PREMIUMS | Property Damage Amount Vehicle Three | Enter amount: The property damage premium amount. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Property Damage Amount Vehicle Four | Enter amount: The property damage premium amount. |
| COVERAGES / PREMIUMS | Medical Payments Each Person | Enter limit: The medical payments per person limit. |
| COVERAGES / PREMIUMS | Medical Payments Amount Vehicle One | Enter amount: The medical payments premium amount. |
| COVERAGES / PREMIUMS | Medical Payments Amount Vehicle Two | Enter amount: The medical payments premium amount. |
| COVERAGES / PREMIUMS | Medical Payments Amount Vehicle Three | Enter amount: The medical payments premium amount. |
| COVERAGES / PREMIUMS | Medical Payments Amount Vehicle Four | Enter amount: The medical payments premium amount. |
| COVERAGES / PREMIUMS | Uninsured Motorists Stacked (check box) | Check the box (if applicable): Indicates the uninsured motorists coverage is stacked. |
| COVERAGES / PREMIUMS | Uninsured Motorists Non-Stacked (check box) | Check the box (if applicable): Indicates the uninsured motorists coverage is not stacked. |
| COVERAGES / PREMIUMS | Uninsured Motorists CSL Each Accident | Enter limit: The uninsured motorists combined single limit per accident limit amount. |
| COVERAGES / PREMIUMS | Uninsured Motorists BI Each 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.) |
| COVERAGES / PREMIUMS | Uninsured Motorists BI Each 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. |
| COVERAGES / PREMIUMS | Uninsured Motorists Amount Vehicle One | Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Uninsured Motorists Amount Vehicle Two | Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Uninsured Motorists Amount Vehicle Three | Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Uninsured Motorists Amount Vehicle Four | Enter amount: The uninsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Underinsured Motorists Stacked (check box) | Check the box (if applicable): Indicates the underinsured motorists coverage is stacked. |
| COVERAGES / PREMIUMS | Underinsured Motorists Non-Stacked (check box) | Check the box (if applicable): Indicates the underinsured motorists coverage is not stacked. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Underinsured Motorists CSL Each Accident | Enter limit: The underinsured motorists combined single limit per accident limit amount. |
| COVERAGES / PREMIUMS | Underinsured Motorists BI Each 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 |
| COVERAGES / PREMIUMS | Underinsured Motorists BI Each 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. |
| COVERAGES / PREMIUMS | Underinsured Motorists Amount Vehicle One | Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Underinsured Motorists Amount Vehicle Two | Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Underinsured Motorists Amount Vehicle Three | Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Underinsured Motorists Amount Vehicle Four | Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount One | Enter deductible: The comprehensive or other than collision deductible amount. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Two | Enter deductible: The comprehensive or other than collision deductible amount. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Three | Enter deductible: The comprehensive or other than collision deductible amount. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Four | Enter deductible: The comprehensive or other than collision deductible amount. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Vehicle One | Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Vehicle Two | Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Vehicle Three | Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
| COVERAGES / PREMIUMS | Comprehensive / OTC Amount Vehicle Four | Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
| COVERAGES / PREMIUMS | Collision Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Collision Amount One | Enter deductible: The collision deductible amount. |
| COVERAGES / PREMIUMS | Collision Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Collision Amount Two | Enter deductible: The collision deductible amount. |
| COVERAGES / PREMIUMS | Collision Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Collision Amount Three | Enter deductible: The collision deductible amount. |
| COVERAGES / PREMIUMS | Collision Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Collision Amount Four | Enter deductible: The collision deductible amount. |
| COVERAGES / PREMIUMS | Collision Amount Vehicle One | Enter amount: The collision premium amount. |
| COVERAGES / PREMIUMS | Collision Amount Vehicle Two | Enter amount: The collision premium amount. |
| COVERAGES / PREMIUMS | Collision Amount Vehicle Three | Enter amount: The collision premium amount. |
| COVERAGES / PREMIUMS | Collision Amount Vehicle Four | Enter amount: The collision premium amount. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Amount One | Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Amount Two | Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Amount Three | Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | ACV unless Amount Stated Amount Four | Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here. |
| COVERAGES / PREMIUMS | Towing & Labor Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Towing & Labor Amount One | Enter limit: The towing and labor limit amount. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Towing & Labor Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Two | Enter limit: The towing and labor limit amount. |
| COVERAGES / PREMIUMS | Towing & Labor Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Three | Enter limit: The towing and labor limit amount. |
| COVERAGES / PREMIUMS | Towing & Labor Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Four | Enter limit: The towing and labor limit amount. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Vehicle One | Enter amount: The towing and labor premium amount. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Vehicle Two | Enter amount: The towing and labor premium amount. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Vehicle Three | Enter amount: The towing and labor premium amount. |
| COVERAGES / PREMIUMS | Towing & Labor Amount Vehicle Four | Enter amount: The towing and labor premium amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Vehicle Number One | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Transportation Expense Per Day Limit One | Enter limit: The transportation expense or rental reimbursement per day limit amount. |
| COVERAGES / PREMIUMS | Transportation Expense Maximum Limit One | Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Vehicle Number Two | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Transportation Expense Per Day Limit Two | Enter limit: The transportation expense or rental reimbursement per day limit amount. |
| COVERAGES / PREMIUMS | Transportation Expense Maximum Limit Two | Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Vehicle Number Three | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Transportation Expense Per Day Limit Three | Enter limit: The transportation expense or rental reimbursement per day limit amount. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Transportation Expense Maximum Limit Three | Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES / PREMIUMS | Transportation Expense Per Day Limit Four | Enter limit: The transportation expense or rental reimbursement per day limit amount. |
| COVERAGES / PREMIUMS | Transportation Expense Maximum Limit Four | Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Amount Vehicle One | Enter amount: The transportation expense or rental reimbursement premium amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Amount Vehicle Two | Enter amount: The transportation expense or rental reimbursement premium amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Amount Vehicle Three | Enter amount: The transportation expense or rental reimbursement premium amount. |
| COVERAGES / PREMIUMS | Transportation Expenses And Rental Reimbursement Amount Vehicle Four | Enter amount: The transportation expense or rental reimbursement premium amount. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Coverage Code | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES / PREMIUMS | Description | Enter text: The description of the coverage. |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Limit | Enter limit: The limit amount of the other coverage. |
| COVERAGES / PREMIUMS | Limit Applies To | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). |
| COVERAGES / PREMIUMS | Deductible $ | Enter deductible: The deductible amount of the coverage. |
| COVERAGES / PREMIUMS | Deductible % | Enter percentage: The deductible percentage for the coverage. |
| COVERAGES / PREMIUMS | Option 1 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 2 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 3 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Option 4 | Enter code: The option applicable to this coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Amount | Enter amount: The premium amount associated with the coverage. |
| COVERAGES / PREMIUMS | Estimated Total | Enter amount: The estimated total cost amount of the policy. |
| COVERAGES / PREMIUMS | Policy Fee | Enter amount: The amount of fee associated with the policy. |
| COVERAGES / PREMIUMS | Total Per Vehicle | Enter amount: The total amount for the vehicle. |
| COVERAGES / PREMIUMS | Total Per Vehicle | Enter amount: The total amount for the vehicle. |
| COVERAGES / PREMIUMS | Total Per Vehicle | Enter amount: The total amount for the vehicle. |
| COVERAGES / PREMIUMS | Total Per Vehicle | Enter amount: The total amount for the vehicle. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| RESIDENT & 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. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| RESIDENT & DRIVER INFORMATION | First Name | Enter text: The driver’s first name (given name). |
| RESIDENT & DRIVER INFORMATION | Middle Name | Enter text: The driver’s middle name or initial (other given name). |
| RESIDENT & DRIVER INFORMATION | Last Name | Enter text: The driver’s last name (surname). |
| RESIDENT & DRIVER INFORMATION | Sex | Enter code: The gender of the driver. |
| RESIDENT & 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 |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Date of Birth | Enter date: The birth date of the driver. |
| RESIDENT & DRIVER INFORMATION | Number (#) | Enter number: The number assigned to the driver by the producer. |
| Section Name | Field Name | Field and/or Section Description |
| RESIDENT & DRIVER INFORMATION | Occupation | Enter text: The occupation of the driver. |
| RESIDENT & DRIVER INFORMATION | Date Lic | Enter date: The original date on which a driver’s license was issued to this driver. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & 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. |
| RESIDENT & DRIVER INFORMATION | Drivers License # | Enter identifier: The driver’s license number. |
| RESIDENT & DRIVER INFORMATION | Licensed State | Enter code: The state the driver is licensed in. |
| RESIDENT & DRIVER INFORMATION | Social Security # | Enter identifier: The tax identifier (social security number) of the driver. |
| ACCIDENTS / CONVICTIONS | Within Last_Years? | Enter number: The number of years associated with “… an accident… or convicted of a moving violation” question. |
| ACCIDENTS / CONVICTIONS | 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. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| ACCIDENTS / CONVICTIONS | Place of Accident / Conviction | Enter text: The place of the accident or conviction. |
| ACCIDENTS / CONVICTIONS | BI 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 | BI 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 | BI 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. |
| Section Name | Field Name | Field and/or Section Description |
| ACCIDENTS / CONVICTIONS | Place of Accident / Conviction | Enter text: The place of the accident or conviction. |
| ACCIDENTS / CONVICTIONS | BI 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 | BI 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. Vehicle not registered to 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. As used here, this is the name of the other owner of the vehicle. |
| GENERAL INFORMATION | Veh # | Enter number: The producer assigned vehicle number. |
| GENERAL INFORMATION | Name of Other Owner | Enter text: The additional interest’s full name. As used here, this is the name of the other owner of the vehicle. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| GENERAL INFORMATION | 3. Any existing damage? | 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 other losses incurred? | Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any other losses incurred (not shown in Accident/Convictions area)?”. |
| GENERAL INFORMATION | Drv # | Enter number: The number assigned to the driver by the producer. |
| GENERAL INFORMATION | Description | Enter text: The description of any other losses incurred. |
| GENERAL INFORMATION | Cost | Enter amount: The cost of any other losses incurred. |
| GENERAL INFORMATION | Drv # | Enter number: The number assigned to the driver by the producer. |
| GENERAL INFORMATION | Description | Enter text: The description of any other losses incurred. |
| GENERAL INFORMATION | Cost | Enter amount: The cost of any other losses incurred. |
| GENERAL INFORMATION | 5. Any other automobile insurance? | Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any other auto insurance in household? (Include any provided by employer)”. |
| GENERAL INFORMATION | Name Insured | Enter text: The named insured on other insurance. |
| GENERAL INFORMATION | Year | Enter year: The model year of the vehicle. As used here, this is a vehicle covered by other insurance. |
| GENERAL INFORMATION | Make | Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). As used here, this is a vehicle covered by other insurance. |
| GENERAL INFORMATION | Model | Enter text: The manufacturer’s model name for the vehicle. As used here, this is a vehicle covered by other insurance. |
| GENERAL INFORMATION | Carrier | Enter text: The insurer name on any other applicable insurance. |
| GENERAL INFORMATION | NAIC # | Enter code: The NAIC code of the insurance company that issued the policy. |
| GENERAL INFORMATION | Policy # | Enter identifier: The policy number on any other applicable insurance. |
| GENERAL INFORMATION | 6. 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. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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 | 7. Any license 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 | 8. Any driver have physical / mental impairments? | 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. |
| GENERAL INFORMATION | 9. 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 | Drv # | Enter number: The number assigned to the driver by the producer. |
| GENERAL INFORMATION | Reason for Filing | Enter text: The description of why a financial responsibility filing is required. |
| GENERAL INFORMATION | Filing Date | Enter date: The date on which the financial responsibility filing was originally required. |
| GENERAL INFORMATION | 10. 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?”. |
| GENERAL INFORMATION | Drv # | Enter number: The number assigned to the driver by the producer. |
| GENERAL INFORMATION | 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. |
| GENERAL INFORMATION | 11. Is this brokered business to the agent? | Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Is this brokered business to the agent?”. |
| GENERAL INFORMATION | Remarks | Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| Section Name | Field Name | Field and/or Section Description |
| GENERAL INFORMATION | 12. Has agent inspected vehicle? | Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Has agent inspected vehicles?”. |
| GENERAL INFORMATION | Remarks | Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation. |
| GENERAL INFORMATION | 13. Has any named insured driven without liability insurance during any part of the last six (6) months? | Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has any named insured driven without liability insurance during any part of the last specified period of time?”. |
| GENERAL INFORMATION | Drv # | Enter number: The number assigned to the driver by the producer. |
| GENERAL INFORMATION | Explanation | Enter text: The explanation of why the driver has driven with no liability insurance within the last mandated time. |
| REMARKS / ATTACHMENTS | Young Driver Questionnaire | Check the box (if applicable): Indicates if an attachment will follow containing a young driver questionnaire. |
| REMARKS / ATTACHMENTS | Driver Training Certificate | Check the box (if applicable): Indicates if an attachment will follow containing a driver training certificate. |
| REMARKS / ATTACHMENTS | Good Student Certificate | Check the box (if applicable): Indicates if an attachment will follow containing a good student certificate. |
| REMARKS / ATTACHMENTS | Anti-Theft Device Certificate | Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft device certificate. |
| REMARKS / ATTACHMENTS | Medical Statement | Check the box (if applicable): Indicates if an attachment will follow containing a medical statement. |
| REMARKS / ATTACHMENTS | Motor Vehicle Report | Check the box (if applicable): Indicates if an attachment will follow containing a motor vehicle report. |
| REMARKS / ATTACHMENTS | Photograph | Check the box (if applicable): Indicates if an attachment will follow containing a photograph. |
| REMARKS / ATTACHMENTS | Bill of Sale | Check the box (if applicable): Indicates if an attachment will follow containing a bill of sale. |
| REMARKS / ATTACHMENTS | Other | Check the box (if applicable): Indicates there are attachments other than those listed. |
| REMARKS / ATTACHMENTS | Other Description | Enter text: The description of the attachment. |
| REMARKS / ATTACHMENTS | Other | Check the box (if applicable): Indicates there are attachments other than those listed. |
| REMARKS / ATTACHMENTS | Other Description | Enter text: The description of the attachment. |
| Section Name | Field Name | Field and/or Section Description |
| REMARKS / ATTACHMENTS | Other | Check the box (if applicable): Indicates there are attachments other than those listed. |
| REMARKS / ATTACHMENTS | Other Description | Enter text: The description of the attachment. |
| REMARKS / ATTACHMENTS | Other | Check the box (if applicable): Indicates there are attachments other than those listed. |
| REMARKS / ATTACHMENTS | Other Description | Enter text: The description of the attachment. |
| REMARKS / ATTACHMENTS | Remarks | Enter text: The personal vehicle line of business remarks. |
| SIGNATURE | Producer’s Statement | Enter text: The length of time the named insured has been known by the producer. |
| SIGNATURE | UM Stacked Coverage (initials) | Initial here: The named insured’s initials. As used here, indicates the named insured has rejected uninsured and underinsured motorists coverage. |
| SIGNATURE | UM Stacked Coverage (initials) | Initial here: The named insured’s initials. As used here, indicates the named insured has been offered uninsured motorists stacked coverage. |
| SIGNATURE | UM Non-Stacked Coverage (initials) | Initial here: The named insured’s initials. As used here, indicates the named insured has been offered uninsured motorists non-stacked coverage. |
| SIGNATURE | UIM Stacked Coverage (initials) | Initial here: The named insured’s initials. As used here, indicates the named insured has been offered underinsured motorists stacked coverage. |
| SIGNATURE | UIM Non-Stacked Coverage (initials) | Initial here: The named insured’s initials. As used here, indicates the named insured has been offered underinsured motorists stacked coverage. |
| SIGNATURE | Applicant’s Signature | Sign here: Accommodates the signature of the applicant or named insured. |
| SIGNATURE | Date | Enter date: The date the form was signed by the named insured. |
| 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 | 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). |