ACORD 90OR Instructions


ACORD 90 OR (2009/07) rev. 08-31-2009 1 of 30

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).
ACORD 90 OR (2009/07) rev. 08-31-2009 2 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 3 of 30

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).
ACORD 90 OR (2009/07) rev. 08-31-2009 4 of 30

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).
ACORD 90 OR (2009/07) rev. 08-31-2009 5 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 6 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 7 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 8 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 9 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 10 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 11 of 30

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).
ACORD 90 OR (2009/07) rev. 08-31-2009 12 of 30

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).
ACORD 90 OR (2009/07) rev. 08-31-2009 13 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 14 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 15 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 16 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 17 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 18 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 19 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 20 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 21 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 22 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 23 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 24 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 25 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 26 of 30

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.
ACORD 90 OR (2009/07) rev. 08-31-2009 27 of 30

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?”.
ACORD 90 OR (2009/07) rev. 08-31-2009 28 of 30

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?”.
ACORD 90 OR (2009/07) rev. 08-31-2009 29 of 30

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).