| Section Name | Field Name | Field and/or Section Description |
| TITLE ACORD 90 OR (2009/07) | Oregon Personal Auto Application | The title of the form. ACORD 90 OR, Oregon Personal Auto Application, is used when insurance is desired for personal vehicles. Following are the unique characteristics specific to Oregon: * Personal Injury Protection coverages are revised to reflect Oregon’s unique coverages and options. Refer to your State Manual. * Underinsured Motorists coverage is included in Uninsured Motorists coverage. * Statement added to the back of the form, referring to the state supplement, ACORD 61OR, which must be given to the applicant to explain Uninsured Motorists coverage, and the options available. Although this form has been filed and approved by the Oregon Insurance Division, the Division requires that insurers using this form must notify the Division that they are doing so. |
| IDENTIFICATION SECTION | Date | Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
| IDENTIFICATION SECTION | Agency | Enter text: The full name of the producer/agency. |
| IDENTIFICATION SECTION | Enter text: The mailing address line one of the producer/agency. | |
| IDENTIFICATION SECTION | Enter text: The mailing address line two of the producer/agency. | |
| IDENTIFICATION SECTION | Enter text: The mailing address city name of the producer/agency. | |
| IDENTIFICATION SECTION | Enter code: The mailing address state or province code of the producer/agency. | |
| IDENTIFICATION SECTION | Enter code: The mailing address postal code of the producer/agency. | |
| IDENTIFICATION SECTION | Code | Enter code: The identification code assigned to the producer (e.g. agency or brokerage firm) by the insurer. |
| IDENTIFICATION SECTION | Sub Code | Enter code: The identification code assigned by the insurer to the sub-producer (e.g. person) within a producer’s office (e.g. agency or brokerage). |
| IDENTIFICATION SECTION | Agency Customer ID | Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage). |
| Section Name | Field Name | Field and/or Section Description |
| IDENTIFICATION SECTION | Applicant’s Name and Mailing Address | Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
| IDENTIFICATION SECTION | Enter text: The named insured’s mailing address line one. | |
| IDENTIFICATION SECTION | Enter text: The named insured’s mailing address line two. | |
| IDENTIFICATION SECTION | Enter text: The named insured’s mailing address city name. | |
| IDENTIFICATION SECTION | Enter text: The applicant’s physical address county name. | |
| IDENTIFICATION SECTION | Enter code: The named insured’s mailing address state or province code. | |
| IDENTIFICATION SECTION | Enter code: The named insured’s mailing address postal code. | |
| IDENTIFICATION SECTION | NAIC Code | Enter code: The identification code assigned to the insurer by the NAIC. |
| IDENTIFICATION SECTION | Telephone Number | Enter number: The named insured’s primary phone number. |
| IDENTIFICATION SECTION | CO/Plan | 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 | Enter code: The product code of the insurer for the policy. | |
| IDENTIFICATION SECTION | POL# | 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 | ACCT# | Enter identifier: The account number to be used for billing purposes. This is the billing number assigned by the billing entity. If agency bill, the agency assigns; if direct bill, the insurer assigns. If the account already exists, the agent should provide the previously assigned number. |
| IDENTIFICATION SECTION | Effective Date | Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
| IDENTIFICATION SECTION | Expiration Date | Enter date: The date on which the terms and conditions of the policy will expire. |
| Section Name | Field Name | Field and/or Section Description |
| IDENTIFICATION SECTION | Direct Bill | Check the box (if applicable): Indicates if the policy is to be direct billed. |
| IDENTIFICATION SECTION | Agency Bill | Check the box (if applicable): Indicates if the policy is to be producer/agency billed. |
| IDENTIFICATION SECTION | Mail Policy to Agent | Check the box (if applicable): Indicates if the policy paper should be sent to the producer. |
| IDENTIFICATION SECTION | Mail Policy to Applicant | Check the box (if applicable): Indicates if the policy paper should be mailed directly to the named insured. |
| IDENTIFICATION SECTION | Payment Plan | Enter code: The payment plan for the policy (i.e., AN – Annual, MO – Monthly, QT -Quarterly, etc.). |
| RESIDENCE | Owned | Check the box (if applicable): Indicates if the insured owns their current residence. |
| RESIDENCE | Rented | Check the box (if applicable): Indicates if the insured rents their current residence. |
| RESIDENCE | Number of Years at Current Address | Enter number: The number of years at the current address. |
| RESIDENCE | Number of Years at Previous Address | Enter number: The number of years at the previous address. |
| RESIDENCE | Previous Address | Enter text: The first address line of the previous residence address. |
| RESIDENCE | Enter text: The second address line of the previous residence. | |
| RESIDENCE | Enter text: The city of the previous residence. | |
| RESIDENCE | Enter code: The state or province code of the previous residence. | |
| RESIDENCE | Enter text: The postal code of the previous residence. | |
| GARAGING ADDRESS | Veh # | Enter number: The producer assigned vehicle number. |
| GARAGING ADDRESS | Location | Enter text: The vehicle’s physical address line one. |
| GARAGING ADDRESS | Enter text: The vehicle’s physical address line two. | |
| GARAGING ADDRESS | Enter text: The vehicle’s physical address city name. | |
| GARAGING ADDRESS | Enter text: The vehicle’s physical address county name. | |
| GARAGING ADDRESS | Enter code: The vehicle’s physical address state or province code. | |
| GARAGING ADDRESS | Enter code: The vehicle’s physical address postal code. | |
| VEHICLE DESCRIPTION/USE | Total # Vehicles InHousehold | Enter number: The total number of vehicles in the household. |
| VEHICLE DESCRIPTION/USE | Veh # One-A | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Year One | Enter year: The model year of the vehicle. |
| VEHICLE DESCRIPTION/USE | Make One | Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Model One | Enter text: The manufacturer’s model name for the vehicle. |
| VEHICLE DESCRIPTION/USE | Body Type One | Enter code: The body type of the vehicle. |
| VEHICLE DESCRIPTION/USE | VIN One | Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
| VEHICLE DESCRIPTION/USE | Registered State One | Enter code: The state or province in which the vehicle is registered. |
| VEHICLE DESCRIPTION/USE | HP/CC One | Enter number: The amount of horsepower or the number of cubic centimeters of displacement. |
| VEHICLE DESCRIPTION/USE | Date Leased One | Enter date: The date the insured leased the vehicle. |
| VEHICLE DESCRIPTION/USE | Date Purch One | Enter date: The date the vehicle was purchased. |
| VEHICLE DESCRIPTION/USE | New/Used One | Enter code: A code indicating if the vehicle was purchased new or used. |
| VEHICLE DESCRIPTION/USE | Veh # One-B | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Cost New One | Enter amount: The original cost of the vehicle. |
| VEHICLE DESCRIPTION/USE | Symbol Age Grp One | Enter code: The symbol required for physical damage coverage. |
| VEHICLE DESCRIPTION/USE | Terr One | Enter code: The rating territory code where the vehicle is principally garaged. |
| VEHICLE DESCRIPTION/USE | Miles 1 Way Wk/Schl One | Enter number: The number of miles from the garage location to school or work. |
| VEHICLE DESCRIPTION/USE | # Days Week One | 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. One | 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 One | Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm). |
| VEHICLE DESCRIPTION/USE | Perform One | Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car). |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Multi-Car One | Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount. |
| VEHICLE DESCRIPTION/USE | Carpool One | Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
| VEHICLE DESCRIPTION/USE | Gar Code One | 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 One | Enter number: The odometer reading at the time the insurance policy is applied for. |
| VEHICLE DESCRIPTION/USE | Annual Mileage One | Enter number: The total estimated annual mileage for the vehicle. |
| VEHICLE DESCRIPTION/USE | Govern Driver One | Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes. |
| VEHICLE DESCRIPTION/USE | Driver Number One-A | Enter number: The producer assigned driver number of the driver using the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % One-A | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Number One-B | Enter number: The producer assigned driver number of the driver using the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % One-B | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Number One-C | Enter number: The producer assigned driver number of the driver using the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % One-C | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Number One-D | Enter number: The producer assigned driver number of the driver using the vehicle. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Driver Use % One-D | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Number One-E | Enter number: The producer assigned driver number of the driver using the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % One-E | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Number One-F | Enter number: The producer assigned driver number of the driver using the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % One-F | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Class One | 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 | Veh # One-C | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Passive Seat Belt One | Enter code: The type of seat belts in the vehicle. |
| VEHICLE DESCRIPTION/USE | Air Bag Drv/Both One | 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 One | Enter code: The type of anti-lock brakes in the vehicle. |
| VEHICLE DESCRIPTION/USE | Anti-Theft Devices One | 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 One | Enter text: A credit or surcharge represented as text. |
| VEHICLE DESCRIPTION/USE | Veh # Two-A | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Year Two | Enter year: The model year of the vehicle. |
| VEHICLE DESCRIPTION/USE | Make Two | Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
| VEHICLE DESCRIPTION/USE | Model Two | Enter text: The manufacturer’s model name for the vehicle. |
| VEHICLE DESCRIPTION/USE | Body Type Two | Enter code: The body type of the vehicle. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | VIN Two | Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
| VEHICLE DESCRIPTION/USE | Registered State Two | Enter code: The state or province in which the vehicle is registered. |
| VEHICLE DESCRIPTION/USE | HP/CC Two | Enter number: The amount of horsepower or the number of cubic centimeters of displacement. |
| VEHICLE DESCRIPTION/USE | Date Leased Two | Enter date: The date the insured leased the vehicle. |
| VEHICLE DESCRIPTION/USE | Date Purch Two | Enter date: The date the vehicle was purchased. |
| VEHICLE DESCRIPTION/USE | New/Used Two | Enter code: A code indicating if the vehicle was purchased new or used. |
| VEHICLE DESCRIPTION/USE | Veh # Two-B | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Cost New Two | Enter amount: The original cost of the vehicle. |
| VEHICLE DESCRIPTION/USE | Symbol Age Grp Two | Enter code: The symbol required for physical damage coverage. |
| VEHICLE DESCRIPTION/USE | Terr Two | Enter code: The rating territory code where the vehicle is principally garaged. |
| VEHICLE DESCRIPTION/USE | Miles 1 Way Wk/Schl Two | Enter number: The number of miles from the garage location to school or work. |
| VEHICLE DESCRIPTION/USE | # Days Week Two | 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. Two | 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 Two | Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm). |
| VEHICLE DESCRIPTION/USE | Perform Two | 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 Two | Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount. |
| VEHICLE DESCRIPTION/USE | Carpool Two | Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Gar Code Two | 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 Two | Enter number: The odometer reading at the time the insurance policy is applied for. |
| VEHICLE DESCRIPTION/USE | Annual Mileage Two | Enter number: The total estimated annual mileage for the vehicle. |
| VEHICLE DESCRIPTION/USE | Govern Driver Two | Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-A | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-B | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-C | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-D | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-E | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Two-F | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Class Two | 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 | Veh # Two-C | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Passive Seat Belt Two | 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 Two | 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 Two | Enter code: The type of anti-lock brakes in the vehicle. |
| VEHICLE DESCRIPTION/USE | Anti-Theft Devices Two | 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 Two | Enter text: A credit or surcharge represented as text. |
| VEHICLE DESCRIPTION/USE | Veh # Three-A | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Year Three | Enter year: The model year of the vehicle. |
| VEHICLE DESCRIPTION/USE | Make Three | Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
| VEHICLE DESCRIPTION/USE | Model Three | Enter text: The manufacturer’s model name for the vehicle. |
| VEHICLE DESCRIPTION/USE | Body Type Three | Enter code: The body type of the vehicle. |
| VEHICLE DESCRIPTION/USE | VIN Three | Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
| VEHICLE DESCRIPTION/USE | Registered State Three | Enter code: The state or province in which the vehicle is registered. |
| VEHICLE DESCRIPTION/USE | HP/CC Three | Enter number: The amount of horsepower or the number of cubic centimeters of displacement. |
| VEHICLE DESCRIPTION/USE | Date Leased Three | Enter date: The date the insured leased the vehicle. |
| VEHICLE DESCRIPTION/USE | Date Purch Three | Enter date: The date the vehicle was purchased. |
| VEHICLE DESCRIPTION/USE | New/Used Three | Enter code: A code indicating if the vehicle was purchased new or used. |
| VEHICLE DESCRIPTION/USE | Veh # Three-B | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Cost New Three | Enter amount: The original cost of the vehicle. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Symbol Age Grp Three | Enter code: The symbol required for physical damage coverage. |
| VEHICLE DESCRIPTION/USE | Terr Three | Enter code: The rating territory code where the vehicle is principally garaged. |
| VEHICLE DESCRIPTION/USE | Miles 1 Way Wk/Schl Three | Enter number: The number of miles from the garage location to school or work. |
| VEHICLE DESCRIPTION/USE | # Days Week Three | 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. Three | 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 Three | Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm). |
| VEHICLE DESCRIPTION/USE | Perform Three | 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 Three | Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount. |
| VEHICLE DESCRIPTION/USE | Carpool Three | Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
| VEHICLE DESCRIPTION/USE | Gar Code Three | 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 Three | Enter number: The odometer reading at the time the insurance policy is applied for. |
| VEHICLE DESCRIPTION/USE | Annual Mileage Three | Enter number: The total estimated annual mileage for the vehicle. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Govern Driver Three | Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-A | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-B | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-C | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-D | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-E | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Three-F | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Class Three | 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 | Veh # Three-C | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Passive Seat Belt Three | Enter code: The type of seat belts in the vehicle. |
| VEHICLE DESCRIPTION/USE | Air Bag Drv/Both Three | 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 Three | Enter code: The type of anti-lock brakes in the vehicle. |
| VEHICLE DESCRIPTION/USE | Anti-Theft Devices Three | 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 Three | Enter text: A credit or surcharge represented as text. |
| VEHICLE DESCRIPTION/USE | Veh # Four-A | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Year Four | Enter year: The model year of the vehicle. |
| VEHICLE DESCRIPTION/USE | Make Four | Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Model Four | Enter text: The manufacturer’s model name for the vehicle. |
| VEHICLE DESCRIPTION/USE | Body Type Four | Enter code: The body type of the vehicle. |
| VEHICLE DESCRIPTION/USE | VIN Four | Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
| VEHICLE DESCRIPTION/USE | Registered State Four | Enter code: The state or province in which the vehicle is registered. |
| VEHICLE DESCRIPTION/USE | HP/CC Four | Enter number: The amount of horsepower or the number of cubic centimeters of displacement. |
| VEHICLE DESCRIPTION/USE | Date Leased Four | Enter date: The date the insured leased the vehicle. |
| VEHICLE DESCRIPTION/USE | Date Purch Four | Enter date: The date the vehicle was purchased. |
| VEHICLE DESCRIPTION/USE | New/Used Four | Enter code: A code indicating if the vehicle was purchased new or used. |
| VEHICLE DESCRIPTION/USE | Veh # Four-B | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Cost New Four | Enter amount: The original cost of the vehicle. |
| VEHICLE DESCRIPTION/USE | Symbol Age Grp Four | Enter code: The symbol required for physical damage coverage. |
| VEHICLE DESCRIPTION/USE | Terr Four | Enter code: The rating territory code where the vehicle is principally garaged. |
| VEHICLE DESCRIPTION/USE | Miles 1 Way Wk/Schl Four | Enter number: The number of miles from the garage location to school or work. |
| VEHICLE DESCRIPTION/USE | # Days Week Four | 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. Four | 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 Four | Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm). |
| VEHICLE DESCRIPTION/USE | Perform Four | Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car). |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Multi-Car Four | Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount. |
| VEHICLE DESCRIPTION/USE | Carpool Four | Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
| VEHICLE DESCRIPTION/USE | Gar Code Four | 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 Four | Enter number: The odometer reading at the time the insurance policy is applied for. |
| VEHICLE DESCRIPTION/USE | Annual Mileage Four | Enter number: The total estimated annual mileage for the vehicle. |
| VEHICLE DESCRIPTION/USE | Govern Driver Four | Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-A | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-B | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-C | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-D | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-E | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Driver Use % Four-F | Enter percentage: The percentage of time a particular driver uses the vehicle. |
| VEHICLE DESCRIPTION/USE | Class Four | Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code. |
| Section Name | Field Name | Field and/or Section Description |
| VEHICLE DESCRIPTION/USE | Veh # Four-C | Enter number: The producer assigned vehicle number. |
| VEHICLE DESCRIPTION/USE | Passive Seat Belt Four | Enter code: The type of seat belts in the vehicle. |
| VEHICLE DESCRIPTION/USE | Air Bag Drv/Both Four | 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 Four | Enter code: The type of anti-lock brakes in the vehicle. |
| VEHICLE DESCRIPTION/USE | Anti-Theft Devices Four | 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 Four | 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. |
| COVERAGES/PREMIUMS | Vehicle Number Four | Enter number: The producer assigned vehicle number. |
| COVERAGES/PREMIUMS | Single Limit Liability Each Accident | Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). |
| COVERAGES/PREMIUMS | Single Limit Liability Amount One | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES/PREMIUMS | Single Limit Liability Amount Two | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES/PREMIUMS | Single Limit Liability Amount Three | Enter amount: The vehicle combined single limit liability premium amount. |
| COVERAGES/PREMIUMS | Single Limit Liability Amount 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 One | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES/PREMIUMS | Bodily Injury Amount Two | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES/PREMIUMS | Bodily Injury Amount Three | Enter amount: The vehicle policy, bodily injury per accident premium amount. |
| COVERAGES/PREMIUMS | Bodily Injury Amount 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. |
| COVERAGES/PREMIUMS | Property Damage Amount Vehicle Four | Enter amount: The property damage premium amount. |
| COVERAGES/PREMIUMS | Personal Inj Protection Amount | Enter limit: The personal injury protection (PIP) limit amount. As used here, refer to applicable state manual for options. Include any deductible selected by the applicant. |
| COVERAGES/PREMIUMS | Personal Inj Protection Medical Expense Deductible None | Check the box (if applicable): Indicates the personal injury protection (PIP) has no deductible. |
| COVERAGES/PREMIUMS | Personal Inj Protection Medical Expense Deductible $100 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $100. |
| COVERAGES/PREMIUMS | Personal Inj Protection Medical Expense Deductible $250 | Check the box (if applicable): Indicates the personal injury protection (PIP) deductible is $250. |
| COVERAGES/PREMIUMS | Personal Inj Protection Medical Expense Deductible Named Insured | Check the box (if applicable): Indicates the personal injury protection (PIP) coverage applies to the named insured. |
| COVERAGES/PREMIUMS | Personal Inj Protection Medical Expense Deductible Named Insured & Family Members | Check the box (if applicable): Indicates the personal injury protection (PIP) coverage applies to the named insured and family members. |
| COVERAGES/PREMIUMS | Personal Inj Protection Amount Vehicle One | Enter amount: The premium associated with personal injury protection (PIP) coverage. |
| COVERAGES/PREMIUMS | Personal Inj Protection Amount Vehicle Two | Enter amount: The premium associated with personal injury protection (PIP) coverage. |
| COVERAGES/PREMIUMS | Personal Inj Protection Amount Vehicle Three | Enter amount: The premium associated with personal injury protection (PIP) coverage. |
| COVERAGES/PREMIUMS | Personal Inj Protection Amount Vehicle Four | Enter amount: The premium associated with personal injury protection (PIP) coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES/PREMIUMS | Additional Personal Inj Protection Amount | Enter limit: The additional personal injury protection (APIP) limit amount. As used here, refer to applicable state manual for options. In this state. Additional PIP is an option that can be provided by insurers if they choose to. The individual state manuals are the only way the user can determine if such coverages are available. |
| COVERAGES/PREMIUMS | Additional Personal Inj Protection Amount Vehicle One | Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
| COVERAGES/PREMIUMS | Additional Personal Inj Protection Amount Vehicle Two | Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
| COVERAGES/PREMIUMS | Additional Personal Inj Protection Amount Vehicle Three | Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
| COVERAGES/PREMIUMS | Additional Personal Inj Protection Amount Vehicle Four | Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
| COVERAGES/PREMIUMS | Medical Payments Each Person | Enter limit: The medical payments per person limit. |
| COVERAGES/PREMIUMS | Medical Payments Amount One | Enter amount: The medical payments premium amount. |
| COVERAGES/PREMIUMS | Medical Payments Amount Two | Enter amount: The medical payments premium amount. |
| COVERAGES/PREMIUMS | Medical Payments Amount Three | Enter amount: The medical payments premium amount. |
| COVERAGES/PREMIUMS | Medical Payments Amount Four | Enter amount: The medical payments premium amount. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
|---|---|---|
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount | Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Applies to Vehicle One | Check the box (if applicable): Indicates uninsured motorists coverage applies to vehicle one. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Applies to Vehicle Two | Check the box (if applicable): Indicates uninsured motorists coverage applies to vehicle two. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Applies to Vehicle Three | Check the box (if applicable): Indicates uninsured motorists coverage applies to vehicle three. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Applies to Vehicle Four | Check the box (if applicable): Indicates uninsured motorists coverage applies to vehicle four. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Vehicle One | Enter amount: The uninsured motorists property damage premium amount. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Vehicle Two | Enter amount: The uninsured motorists property damage premium amount. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Vehicle Three | Enter amount: The uninsured motorists property damage premium amount. |
| COVERAGES/PREMIUMS | Uninsured Motorists PD Amount Vehicle Four | Enter amount: The uninsured motorists property damage 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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. |
| 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 | ACV unless Amount Stated Amount Vehicle One | Enter amount: The stated amount premium amount. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES/PREMIUMS | ACV unless Amount Stated Amount Vehicle Two | Enter amount: The stated amount premium amount. |
| COVERAGES/PREMIUMS | ACV unless Amount Stated Amount Vehicle Three | Enter amount: The stated amount premium amount. |
| COVERAGES/PREMIUMS | ACV unless Amount Stated Amount Vehicle Four | Enter amount: The stated amount premium amount. |
| 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. |
| 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. |
| Section Name | Field Name | Field and/or Section Description |
| 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. |
| 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 Blank Field One | Enter code: The coverage code of the other coverage or adjustment. |
| COVERAGES/PREMIUMS | Limits Blank Field One | Enter limit: The limit amount of the other coverage. |
| COVERAGES/PREMIUMS | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). | |
| COVERAGES/PREMIUMS | Enter limit: The limit amount of the other coverage. |
| Section Name | Field Name | Field and/or Section Description |
| COVERAGES/PREMIUMS | Enter code: The code indicating what the limit applies to (e.g. per accident, per person). | |
| COVERAGES/PREMIUMS | Enter deductible: The deductible amount of the coverage. | |
| COVERAGES/PREMIUMS | Amount Vehicle One | Enter amount: The premium amount associated with the coverage. |
| COVERAGES/PREMIUMS | Amount Vehicle Two | Enter amount: The premium amount associated with the coverage. |
| COVERAGES/PREMIUMS | Amount Vehicle Three | Enter amount: The premium amount associated with the coverage. |
| COVERAGES/PREMIUMS | Amount Vehicle Four | Enter amount: The premium amount associated with the coverage. |
| COVERAGES/PREMIUMS | Additional Coverages/Endorsements | Enter text: The description of additional coverages and endorsements including limits, deductible and premium. |
| COVERAGES/PREMIUMS | Policy Fee | Enter amount: The amount of fee associated with the policy. |
| COVERAGES/PREMIUMS | Total Per Vehicle One | Enter amount: The total amount for the vehicle. |
| COVERAGES/PREMIUMS | Total Per Vehicle Two | Enter amount: The total amount for the vehicle. |
| COVERAGES/PREMIUMS | Total Per Vehicle Three | Enter amount: The total amount for the vehicle. |
| COVERAGES/PREMIUMS | Total Per Vehicle Four | Enter amount: The total amount for the vehicle. |
| COVERAGES/PREMIUMS | Estimated Total | Enter amount: The estimated total cost amount of the policy. |
| COVERAGES/PREMIUMS | Deposit | Enter amount: The amount of the premium received as a deposit. |
| COVERAGES/PREMIUMS | Balance Due | Enter amount: The amount still owed on the policy. |
| DRIVER INFORMATION | Number (#) One | Enter number: The number assigned to the driver by the producer. |
| DRIVER INFORMATION | Name One | Enter text: The driver’s first name (given name). |
| DRIVER INFORMATION | Enter text: The driver’s middle name or initial (other given name). | |
| DRIVER INFORMATION | Enter text: The driver’s last name (surname). | |
| DRIVER INFORMATION | Sex One | Enter code: The gender of the driver. |
| DRIVER INFORMATION | Mar Stat One | Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other |
| DRIVER INFORMATION | Relation to Applicant One | Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee. |
| DRIVER INFORMATION | Date of Birth One | Enter date: The birth date of the driver. |
| DRIVER INFORMATION | Occupation One | Enter text: The occupation of the driver. |
| DRIVER INFORMATION | Date Lic One | Enter date: The original date on which a driver’s license was issued to this driver. |
| DRIVER INFORMATION | Stdt > 100 One | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address. |
| DRIVER INFORMATION | Good Stdt One | 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. |
| Section Name | Field Name | Field and/or Section Description |
| DRIVER INFORMATION | Drv Train One | Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit. |
| DRIVER INFORMATION | Acc Prev Cse One | Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies. |
| DRIVER INFORMATION | Drivers License # One | Enter identifier: The driver’s license number. |
| DRIVER INFORMATION | Licensed State One | Enter code: The state the driver is licensed in. |
| DRIVER INFORMATION | Social Security # One | Enter identifier: The tax identifier (social security number) of the driver. |
| DRIVER INFORMATION | Number (#) Two | Enter number: The number assigned to the driver by the producer. |
| DRIVER INFORMATION | Name Two | Enter text: The driver’s first name (given name). |
| DRIVER INFORMATION | Enter text: The driver’s middle name or initial (other given name). | |
| DRIVER INFORMATION | Enter text: The driver’s last name (surname). | |
| DRIVER INFORMATION | Sex Two | Enter code: The gender of the driver. |
| DRIVER INFORMATION | Mar Stat Two | Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other |
| DRIVER INFORMATION | Relation to Applicant Two | Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee. |
| DRIVER INFORMATION | Date of Birth Two | Enter date: The birth date of the driver. |
| DRIVER INFORMATION | Occupation Two | Enter text: The occupation of the driver. |
| DRIVER INFORMATION | Date Lic Two | Enter date: The original date on which a driver’s license was issued to this driver. |
| DRIVER INFORMATION | Stdt > 100 Two | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address. |
| DRIVER INFORMATION | Good Stdt Two | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies. |
| DRIVER INFORMATION | Drv Train Two | 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 |
| DRIVER INFORMATION | Acc Prev Cse Two | Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies. |
| DRIVER INFORMATION | Drivers License # Two | Enter identifier: The driver’s license number. |
| DRIVER INFORMATION | Licensed State Two | Enter code: The state the driver is licensed in. |
| DRIVER INFORMATION | Social Security # Two | Enter identifier: The tax identifier (social security number) of the driver. |
| DRIVER INFORMATION | Number (#) Three | Enter number: The number assigned to the driver by the producer. |
| DRIVER INFORMATION | Name Three | Enter text: The driver’s first name (given name). |
| DRIVER INFORMATION | Enter text: The driver’s middle name or initial (other given name). | |
| DRIVER INFORMATION | Enter text: The driver’s last name (surname). | |
| DRIVER INFORMATION | Sex Three | Enter code: The gender of the driver. |
| DRIVER INFORMATION | Mar Stat Three | Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other |
| DRIVER INFORMATION | Relation to Applicant Three | Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee. |
| DRIVER INFORMATION | Date of Birth Three | Enter date: The birth date of the driver. |
| DRIVER INFORMATION | Occupation Three | Enter text: The occupation of the driver. |
| DRIVER INFORMATION | Date Lic Three | Enter date: The original date on which a driver’s license was issued to this driver. |
| DRIVER INFORMATION | Stdt > 100 Three | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address. |
| DRIVER INFORMATION | Good Stdt Three | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies. |
| DRIVER INFORMATION | Drv Train Three | Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit. |
| DRIVER INFORMATION | Acc Prev Cse Three | Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies. |
| DRIVER INFORMATION | Drivers License # Three | Enter identifier: The driver’s license number. |
| DRIVER INFORMATION | Licensed State Three | Enter code: The state the driver is licensed in. |
| DRIVER INFORMATION | Social Security # Three | Enter identifier: The tax identifier (social security number) of the driver. |
| Section Name | Field Name | Field and/or Section Description |
| DRIVER INFORMATION | Number (#) Four | Enter number: The number assigned to the driver by the producer. |
| DRIVER INFORMATION | Name Four | Enter text: The driver’s first name (given name). |
| DRIVER INFORMATION | Enter text: The driver’s middle name or initial (other given name). | |
| DRIVER INFORMATION | Enter text: The driver’s last name (surname). | |
| DRIVER INFORMATION | Sex Four | Enter code: The gender of the driver. |
| DRIVER INFORMATION | Mar Stat Four | Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other |
| DRIVER INFORMATION | Relation to Applicant Four | Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee. |
| DRIVER INFORMATION | Date of Birth Four | Enter date: The birth date of the driver. |
| DRIVER INFORMATION | Occupation Four | Enter text: The occupation of the driver. |
| DRIVER INFORMATION | Date Lic Four | Enter date: The original date on which a driver’s license was issued to this driver. |
| DRIVER INFORMATION | Stdt > 100 Four | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address. |
| DRIVER INFORMATION | Good Stdt Four | Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies. |
| DRIVER INFORMATION | Drv Train Four | Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit. |
| DRIVER INFORMATION | Acc Prev Cse Four | Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies. |
| DRIVER INFORMATION | Drivers License # Four | Enter identifier: The driver’s license number. |
| DRIVER INFORMATION | Licensed State Four | Enter code: The state the driver is licensed in. |
| DRIVER INFORMATION | Social Security # Four | 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 | Yes | Check the box (if applicable): Indicates a driver has had an accident or been convicted of a moving violation in the mandated number of years. |
| ACCIDENTS/CONVICTIONS | No | Check the box (if applicable): Indicates that no driver has had an accident or been convicted of a moving violation in the mandated number of years. |
| Section Name | Field Name | Field and/or Section Description |
| 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 Yes | Check the box (if applicable): Indicates the accident or conviction resulted in bodily injury or death. |
| ACCIDENTS/CONVICTIONS | BI or Death No | Check the box (if applicable): Indicates the accident or conviction did not result in bodily injury or death. |
| ACCIDENTS/CONVICTIONS | Amount of Property Damage | Enter amount: The amount of property damage resulting from the accident or conviction. |
| ADDITIONAL INTEREST | Veh # One | Enter number: The producer assigned number of the vehicle which has an additional interest. |
| ADDITIONAL INTEREST | Additional Interest One | Check the box (if applicable): Indicates the additional interest type is an additional interest. |
| ADDITIONAL INTEREST | Loss Pay One | Check the box (if applicable): Indicates the additional interest type is a loss payee. |
| ADDITIONAL INTEREST | Name and Address One | Enter text: The additional interest’s full name. |
| ADDITIONAL INTEREST | Enter text: The additional interest’s mailing address line one. | |
| ADDITIONAL INTEREST | Enter text: The additional interest’s mailing address city name. | |
| ADDITIONAL INTEREST | Enter code: The additional interest’s mailing address state or province code. | |
| ADDITIONAL INTEREST | Enter code: The additional interest’s mailing address postal code. | |
| ADDITIONAL INTEREST | Loan Number One | Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
| ADDITIONAL INTEREST | Veh # Two | Enter number: The producer assigned number of the vehicle which has an additional interest. |
| ADDITIONAL INTEREST | Additional Interest Two | Check the box (if applicable): Indicates the additional interest type is an additional interest. |
| ADDITIONAL INTEREST | Loss Pay Two | Check the box (if applicable): Indicates the additional interest type is a loss payee. |
| ADDITIONAL INTEREST | Name and Address Two | Enter text: The additional interest’s full name. |
| ADDITIONAL INTEREST | Enter text: The additional interest’s mailing address line one. | |
| ADDITIONAL INTEREST | Enter text: The additional interest’s mailing address city name. | |
| ADDITIONAL INTEREST | Enter code: The additional interest’s mailing address state or province code. | |
| ADDITIONAL INTEREST | Enter code: The additional interest’s mailing address postal code. |
| Section Name | Field Name | Field and/or Section Description |
| ADDITIONAL INTEREST | Loan Number Two | Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. |
| EMPLOYMENT INFORMATION | Applicant’s Employer | Enter text: The employer name (business name if self-employed). |
| EMPLOYMENT INFORMATION | Address of Employment | Enter text: The first address line of the employer’s physical address. |
| EMPLOYMENT INFORMATION | Enter text: The city of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Enter code: The state code of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Enter code: The postal code of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Work Phone Number | Enter number: The phone number of the employer. |
| EMPLOYMENT INFORMATION | Years With Current Employer | Enter number: The number of years the named insured has been with their current employer. |
| PRIOR COVERAGE | Years With Previous Employer | Enter number: The number of years the named insured has been with their previous employer. |
| EMPLOYMENT INFORMATION | Co-Applicant’s Employer | Enter text: The employer name (business name if self-employed). |
| EMPLOYMENT INFORMATION | Address of Employment | Enter text: The first address line of the employer’s physical address. |
| EMPLOYMENT INFORMATION | Enter text: The city of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Enter code: The state code of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Enter code: The postal code of the employer’s physical address. | |
| EMPLOYMENT INFORMATION | Work Phone Number | Enter number: The phone number of the employer. |
| EMPLOYMENT INFORMATION | Years With Current Employer | Enter number: The number of years the named insured has been with their current employer. |
| PRIOR COVERAGE | Years With Previous Employer | Enter number: The number of years the named insured has been with their previous employer. |
| PRIOR COVERAGE | Prior Carrier | Enter text: The name of the previous insurer. |
| PRIOR COVERAGE | Prior Producer | Enter text: The name of the previous producer. |
| Section Name | Field Name | Field and/or Section Description |
| PRIOR COVERAGE | # of Years W/ Company | Enter number: The number of years with the previous insurer. |
| PRIOR COVERAGE | Prior Policy Number | Enter identifier: The policy number of the previous coverage. |
| GENERAL INFORMATION | Prior Policy Expiration Date | Enter date: The expiration date of the previous coverage. |
| GENERAL INFORMATION | 1. Vehicle not registered to applicant? | Check the box (if applicable): Indicates a “Yes” response to the question “With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?”. | |
| GENERAL INFORMATION | 2. Any car modified/special equipment? | Check the box (if applicable): Indicates a “Yes” response to the question “Any vehicles customized, altered or with special equipment?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any vehicles customized, altered or with special equipment?”. | |
| GENERAL INFORMATION | 3. Any existing damage? | Check the box (if applicable): Indicates a “Yes” response to the question “Any existing damage to vehicle? (Include damaged glass)”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any existing damage to vehicle? (Include damaged glass)”. | |
| GENERAL INFORMATION | 4. Any other losses incurred? | Check the box (if applicable): Indicates a “Yes” response to the question “Any other losses incurred (not shown in Accident/Convictions area)?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any other losses incurred (not shown in Accident/Convictions area)?”. | |
| GENERAL INFORMATION | 5. Any car kept at school? | Check the box (if applicable): Indicates a “Yes” response to the question “Car kept at school?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Car kept at school?”. | |
| GENERAL INFORMATION | 6. Any car parked on street? | Check the box (if applicable): Indicates a “Yes” response to the question “Car kept on street?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Car kept on street?”. | |
| GENERAL INFORMATION | 7. Any other automobile insurance? | Check the box (if applicable): Indicates a “Yes” response to the question “Any other auto insurance in household? (Include any provided by employer)”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any other auto insurance in household? (Include any provided by employer)”. | |
| GENERAL INFORMATION | 8. Any other insurance with company? | Check the box (if applicable): Indicates a “Yes” response to the question “Any other insurance with this company?”. |
| Section Name | Field Name | Field and/or Section Description |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any other insurance with this company?”. | |
| GENERAL INFORMATION | 9. Any household member in military service? | Check the box (if applicable): Indicates a “Yes” response to the question “Any household member in military service?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any household member in military service?”. | |
| GENERAL INFORMATION | 10. Any license suspended/revoked? | Check the box (if applicable): Indicates a “Yes” response to the question “Any drivers license been suspended/revoked?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any drivers license been suspended/revoked?”. | |
| GENERAL INFORMATION | 11. Any physical/mental impairments? | Check the box (if applicable): Indicates a “Yes” response to the question “Any driver have physical/mental impairment?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any driver have physical/mental impairment?”. | |
| GENERAL INFORMATION | 12. Any financial responsibility filing? | Check the box (if applicable): Indicates a “Yes” response to the question “Any financial responsibility filing?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any financial responsibility filing?”. | |
| GENERAL INFORMATION | 13. Has insurance been transferred within agency? | Check the box (if applicable): Indicates a “Yes” response to the question “Has insurance been transferred within agency?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Has insurance been transferred within agency?”. | |
| GENERAL INFORMATION | 14. Any insurance declined/cancelled? | Check the box (if applicable): Indicates a “Yes” response to the question “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”. | |
| GENERAL INFORMATION | 15. Is this brokered business to the agent? | Check the box (if applicable): Indicates a “Yes” response to the question “Is this brokered business to the agent?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Is this brokered business to the agent?”. | |
| GENERAL INFORMATION | 16. Has Agent Inspected Vehicle? | Check the box (if applicable): Indicates a “Yes” response to the question “Has agent inspected vehicles?”. |
| GENERAL INFORMATION | Check the box (if applicable): Indicates a “No” response to the question “Has agent inspected vehicles?”. |
| Section Name | Field Name | Field and/or Section Description |
| REMARKS | Remarks | Enter text: The personal vehicle line of business remarks. |
| ATTACHMENTS | Young Driver Questionnaire | Check the box (if applicable): Indicates if an attachment will follow containing a young driver questionnaire. |
| ATTACHMENTS | Driver Training Certificate | Check the box (if applicable): Indicates if an attachment will follow containing a driver training certificate. |
| ATTACHMENTS | Good Student Certificate | Check the box (if applicable): Indicates if an attachment will follow containing a good student certificate. |
| ATTACHMENTS | Anti-Theft Device Certificate | Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft device certificate. |
| ATTACHMENTS | Medical Statement | Check the box (if applicable): Indicates if an attachment will follow containing a medical statement. |
| ATTACHMENTS | Motor Vehicle Report | Check the box (if applicable): Indicates if an attachment will follow containing a motor vehicle report. |
| ATTACHMENTS | Photograph | Check the box (if applicable): Indicates if an attachment will follow containing a photograph. |
| ATTACHMENTS | Bill of Sale | Check the box (if applicable): Indicates if an attachment will follow containing a bill of sale. |
| ATTACHMENTS | Other | Check the box (if applicable): Indicates there are attachments other than those listed. |
| ATTACHMENTS | Other Description | Enter text: The description of the attachment. |
| BINDER/SIGNATURE | For Company Use Only | Enter text: This area is to be completed by the insurer. |
| BINDER/SIGNATURE | Effective Date | Enter date: The date on which the terms and conditions of the binder commenced. This date normally coincides with the effective date of the policy or of an endorsement to the policy. |
| BINDER/SIGNATURE | Time | Enter time: The time of the binder effective date that the binder becomes effective. |
| BINDER/SIGNATURE | Expiration Date | Enter date: The date on which the terms and conditions of the policy will or have expired. Certain state laws limit the terms of a binder, so this date may not coincide with the policy expiration date. |
| BINDER/SIGNATURE | 12:01 | Check the box (if applicable): Indicates the binder expires at 12:01 AM on the expiration date. |
| BINDER/SIGNATURE | Noon | Check the box (if applicable): Indicates the binder expires at 12:00 noon on the expiration date. |
| BINDER/SIGNATURE | Coverage Not Bound | Check the box (if applicable): Indicates the coverage has not been bound. |
| BINDER/SIGNATURE | Producer’s Statement | Enter text: The length of time the named insured has been known by the producer. |
| BINDER/SIGNATURE | Applicant’s Signature | Sign here: Accommodates the signature of the applicant or named insured. |
| BINDER/SIGNATURE | Date | Enter date: The date the form was signed by the named insured. |
| Section Name | Field Name | Field and/or Section Description |
| BINDER/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. |
| BINDER/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). |