ACORD 90VA Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 90 VA (2010/01) Virginia Personal Auto Application Section The title of the form. The ACORD 90 VA, Delaware Personal Auto Application Section, was designed to be used in conjunction with ACORD 88, Personal Insurance Application -Applicant Information Section. ACORD 90 DE must be attached to ACORD 88 for a completed application submission. Following are the unique state characteristics of ACORD 90 DE, Delaware Personal Auto Application Section: * Personal Injury Protection coverages are revised to reflect Delaware’s unique coverages and options. Refer to your state manual. * Underinsured Motorists Bodily Injury coverage is included in Uninsured Motorists coverage; Property Damage coverage is not available. * Notice of Information Practices contains language specific to this state * Statement added to the back of the form, referencing the auto supplement, ACORD 61 DE, which must be used whenever the applicant selects Uninsured Motorists (UM) Bodily Injury coverage. In addition, if the applicant selects UM Bodily Injury coverage less than the limits of the policy’s basic Bodily Injury Liability limits, or rejects coverage entirely, they must read and sign ACORD 61 DE.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
IDENTIFICATION SECTION Date Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION Effective Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence.
IDENTIFICATION SECTION Named Insured(s) Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Carrier Enter text: The insurer’s full legal company name(s) as found in thefile copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer’s group name or trade name. As used here, this may contain the name of the residual market plan.
IDENTIFICATION SECTION NAIC Code Enter code: The identification code assigned to the insurer by the NAIC.
GARAGING ADDRESS (from ACORD 88) Location # Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88) Veh # Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88) Street Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) City Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) County Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) State Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Zip + 4 Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Location # Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88) Veh # Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88) Street Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) City Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) County Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) State Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Zip + 4 Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Location # Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88) Veh # Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88) Street Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) City Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) County Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) State Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Zip + 4 Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Location # Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88) Veh # Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88) Street Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) City Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) County Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) State Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88) Zip + 4 Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
VEHICLE DESCRIPTION / USE Total Number of Vehicles inHousehold Enter number: The total number of vehicles in the household.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: Thevehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Registered State Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number ofcubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Miles 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/ Mo. Enter number: The number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Carpool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options: A – Garaged at School B – Off street at school C – On street at school D – Driveway G – Garaged N – Not garaged (if other options do not apply) O – Off street P – Parking Lot R – Carport S – Street
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Number Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti-Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Registered State Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Miles 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/ Mo. Enter number: The number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Carpool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options: A – Garaged at School B – Off street at school C – On street at school D – Driveway G – Garaged N – Not garaged (if other options do not apply) O – Off street P – Parking Lot R – Carport S – Street
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti-Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Registered State Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Miles 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/ Mo. Enter number: The number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Carpool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options: A – Garaged at School B – Off street at school C – On street at school D – Driveway G – Garaged N – Not garaged (if other options do not apply) O – Off street P – Parking Lot R – Carport S – Street
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti-Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Year Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE Model Enter text: The manufacturer’s model name for the vehicle.
VEHICLE DESCRIPTION / USE Body Type Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE VIN Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE Registered State Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE HP/CC Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE Date Leased Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE Date Purch Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE New/Used Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Cost New Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE Symbol Age Grp Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE Comp / OTC Sym Enter code: The symbol required for comprehensive / other than collision coverage.
VEHICLE DESCRIPTION / USE Coll Sym Enter code: The symbol required for collision coverage.
VEHICLE DESCRIPTION / USE Terr Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE Miles 1 Way Wk/Schl Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE # Days Week Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE # Weeks/ Mo. Enter number: The number of weeks per month the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE Usage Enter code: The predominant use of the vehicle (e.g. P – Pleasure, B – Business, F -Farm).
VEHICLE DESCRIPTION / USE Perform Enter code: The performance level of the vehicle (i.e. B – Basic, H – High, I – Intermediate, P – Sport Premium, S – Sports car).
VEHICLE DESCRIPTION / USE Multi-Car Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE Carpool Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE Gar Code Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options: A – Garaged at School B – Off street at school C – On street at school D – Driveway G – Garaged N – Not garaged (if other options do not apply) O – Off street P – Parking Lot R – Carport S – Street
VEHICLE DESCRIPTION / USE Odometer Reading Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE Annual Mileage Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE Govern Driver Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Driver Use % Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE Veh # Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE Class Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE Passive Seat Belt Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE Air Bag Drv/Both Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE Anti-Lock Brakes 2/4 Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE Anti-Theft Devices Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE Credits and Surcharges Enter text: A credit or surcharge represented as text.
COVERAGES / PREMIUMS Vehicle Number One Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Vehicle Number Two Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Vehicle Number Three Enter number: The producer assigned vehicle number.
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.
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 Deductible Enter deductible: The property damage deductible amount.
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 Income Loss Each Person Enter limit: The work loss benefits per person limit amount.
COVERAGES / PREMIUMS Income Loss Amount Vehicle One Enter amount: The work loss benefits premium amount.
COVERAGES / PREMIUMS Income Loss Amount Vehicle Two Enter amount: The work loss benefits premium amount.
COVERAGES / PREMIUMS Income Loss Amount Vehicle Three Enter amount: The work loss benefits premium amount.
COVERAGES / PREMIUMS Income Loss Amount Vehicle Four Enter amount: The work loss benefits premium amount.
COVERAGES / PREMIUMS Medical Expenses Each Person Enter limit: The medical expense per person limit amount.
COVERAGES / PREMIUMS Medical Expenses Amount One Enter amount: The medical expense premium amount.
COVERAGES / PREMIUMS Medical Expenses Amount Two Enter amount: The medical expense premium amount.
COVERAGES / PREMIUMS Medical Expenses Amount Three Enter amount: The medical expense premium amount.
COVERAGES / PREMIUMS Medical Expenses Amount Four Enter amount: The medical expense premium amount.
COVERAGES / PREMIUMS Uninsured Motorists CSL/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 CSL/BI Each Accident Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
COVERAGES / PREMIUMS Uninsured Motorists Amount Vehicle One Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS Uninsured Motorists Amount Vehicle Two Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS Uninsured Motorists Amount Vehicle Three Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS Uninsured Motorists Amount Vehicle Four Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS Uninsured Motorists PD Each Accident Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
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.
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 Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Limit 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 Vehicle # Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Limit 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 Vehicle # Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Limit 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 Vehicle # Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Limit Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS Towing & Labor Vehicle Number One Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Towing & Labor Amount One Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS Towing & Labor Vehicle Number Two Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Towing & Labor Amount Two Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS Towing & Labor Vehicle Number Three Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Towing & Labor Amount Three Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS Towing & Labor Vehicle Number Four Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Towing & Labor Amount Four Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS Towing & Labor Amount Vehicle One Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS Towing & Labor Amount Vehicle Two Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS Towing & Labor Amount Vehicle Three Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS Towing & Labor Amount Vehicle Four Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Vehicle Number One Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Transportation Expense Per Day Limit One Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS Transportation Expense Maximum Limit One Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Vehicle Number Two Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Transportation Expense Per Day Limit Two Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS Transportation Expense Maximum Limit Two Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Vehicle Number Three Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Transportation Expense Per Day Limit Three Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS Transportation Expense Maximum Limit Three Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Vehicle Number Four Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS Transportation Expense Per Day Limit Four Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS Transportation Expense Maximum Limit Four Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Amount Vehicle One Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Amount Vehicle Two Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Amount Vehicle Three Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS Transportation Expenses And Rental Reimbursement Amount Vehicle Four Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Coverage Code Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS Description Enter text: The description of the coverage.
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Limit Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS Limit Applies To Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS Deductible $ Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS Deductible % Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS Option 1 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 2 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 3 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Option 4 Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Amount Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS Estimated Total Enter amount: The estimated total cost amount of the policy.
COVERAGES / PREMIUMS Policy Fee Enter amount: The amount of fee associated with the policy.
COVERAGES / PREMIUMS Total Per Vehicle Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS Total Per Vehicle Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS Total Per Vehicle Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS Total Per Vehicle Enter amount: The total amount for the vehicle.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION First Name Enter text: The driver’s first name (given name).
RESIDENT & DRIVER INFORMATION Middle Name Enter text: The driver’s middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION Last Name Enter text: The driver’s last name (surname).
RESIDENT & DRIVER INFORMATION Sex Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION Mar Stat Enter code: The marital status of the driver. Examples are: S – Single; M – Married; D -Divorced; P – Separated; W – Widowed, C – Domestic Partner (unmarried), V – Civil Union, U – Unknown, O – Other
RESIDENT & DRIVER INFORMATION Relation to Applicant Enter code: The relationship of the driver to the named insured. Examples are: I -Insured; S – Spouse; C – Child; SIB – Brother or Sister; P – Parent; E – Employee.
RESIDENT & DRIVER INFORMATION Date of Birth Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION Number (#) Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION Occupation Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION Date Lic Enter date: The original date on which a driver’s license was issued to this driver.
RESIDENT & DRIVER INFORMATION Stdt > 100 Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION Good Stdt Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.
RESIDENT & DRIVER INFORMATION Drv Train Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit applies to the driver, if required by the company. Refer to the company’s manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION Acc Prev Cse Date Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION Drivers License # Enter identifier: The driver’s license number.
RESIDENT & DRIVER INFORMATION Licensed State Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION Social Security # Enter identifier: The tax identifier (social security number) of the driver.
ACCIDENTS / CONVICTIONS Within Last_Years? Enter number: The number of years associated with “… an accident… or convicted of a moving violation” question.
ACCIDENTS / CONVICTIONS Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if any driver has had an accident or been convicted of a moving violation in the mandated number of years.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS / CONVICTIONS Drv # Enter number: The producer’s driver number for the driver involved in the accident or conviction.
ACCIDENTS / CONVICTIONS Date of Accident / Conviction Enter date: The date of the accident or conviction.
ACCIDENTS / CONVICTIONS Description of Accident or Conviction Enter text: The description of the accident or conviction. Attach ACORD 101, Additional Remarks Schedule, if more space is needed.
ACCIDENTS / CONVICTIONS Place of Accident / Conviction Enter text: The place of the accident or conviction.
ACCIDENTS / CONVICTIONS BI or Death Y / N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or conviction resulted in bodily injury or death.
ACCIDENTS / CONVICTIONS Amount of Property Damage Enter amount: The amount of property damage resulting from the accident or conviction.
GENERAL INFORMATION 1. With the exception of any encumbrances, are any vehicles for which insurance is requested not solely owned by and registered to the applicant? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “With the exception of encumbrances, are any vehicles not solely owned by and registered to the applicant?”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Name of Other Owner Enter text: The additional interest’s full name. As used here, this is the name of the other owner of the vehicle.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Name of Other Owner Enter text: The additional interest’s full name. As used here, this is the name of the other owner of the vehicle.
GENERAL INFORMATION 2. Any car modified / special equipment? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any vehicles customized, altered or with special equipment?”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION Cost Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION Cost Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION 3. Any existing damage? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any existing damage to vehicle? (Include damaged glass)”.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION Veh # Enter number: The producer assigned vehicle number.
GENERAL INFORMATION Description Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION 4. Any other losses not shown in the Accidents / Convictions section that were incurred during the time period specified in that section? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any other losses incurred (not shown in Accident/Convictions area)?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Description Enter text: The description of any other losses incurred.
GENERAL INFORMATION Cost Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Description Enter text: The description of any other losses incurred.
GENERAL INFORMATION Cost Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION 5. Any other automobile insurance? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any other auto insurance in household? (Include any provided by employer)”.
GENERAL INFORMATION Name Insured Enter text: The named insured on other insurance.
GENERAL INFORMATION Year Enter year: The model year of the vehicle. As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION Make Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION Model Enter text: The manufacturer’s model name for the vehicle. As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION Carrier Enter text: The insurer name on any other applicable insurance.
GENERAL INFORMATION NAIC # Enter code: The NAIC code of the insurance company that issued the policy.
GENERAL INFORMATION Policy # Enter identifier: The policy number on any other applicable insurance.
GENERAL INFORMATION 6. Any household member in military service? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any household member in military service?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Branch Enter text: The branch of military service.
GENERAL INFORMATION Rank Enter text: The driver’s rank in the military.
GENERAL INFORMATION Base Location – Street Enter text: The military base’s first address line.
GENERAL INFORMATION Base Location – City Enter text: The city of the military base.
GENERAL INFORMATION Base Location – State Enter code: The state or province code of the military base.
GENERAL INFORMATION Base Location – Zip Enter code: The postal code of the military base.
GENERAL INFORMATION Base Location – Country Enter code: The country code of the military base.
GENERAL INFORMATION Veh at Base Y/N Enter Y for a “Yes” response. Input N for “No” response. Indicates if the driver has a vehicle at a military base.
GENERAL INFORMATION 7. Any license suspended / revoked? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any drivers license been suspended/revoked?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Suspension Period Start Date Enter date: The date the driver’s license suspension became effective.
GENERAL INFORMATION Suspension Period End Date Enter date: The date the driver’s license suspension is scheduled to end.
GENERAL INFORMATION Explanation Enter text: The reason the driver’s license was suspended or revoked.
GENERAL INFORMATION Reinstatement Date Enter date: The date a suspended or revoked driver’s license was reinstated.
GENERAL INFORMATION 8. Any driver have a physical impairment? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any driver have physical/mental impairment?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Description of Special Equipment in Vehicle Enter text: The description of any special equipment for a driver with physical or mental impairments.
GENERAL INFORMATION 9. Any driver undergoing a course of medical treatment for a physical or mental impairment? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Any driver undergoing a course of medical treatment for a physical or mental impairment??”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Explanation Enter text: The description of any medication or treatments for a driver with physical or mental impairments.
GENERAL INFORMATION 10. Any financial responsibility filing? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any financial responsibility filing?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Reason for Filing Enter text: The description of why a financial responsibility filing is required.
GENERAL INFORMATION Filing Date Enter date: The date on which the financial responsibility filing was originally required.
IDENTIFICATION SECTION Agency Customer ID Enter identifier: The customer’s identification number assigned by the producer (e.g. agency or brokerage).
GENERAL INFORMATION 11. Any coverage declined, cancelled or non-renewed during the last three (3) years? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Reason declined, cancelled, or non-renewed Enter text: The description of the reason for coverage being declined, cancelled or non-renewed within the last mandated number of years.
GENERAL INFORMATION 12. Is this brokered business to the agent? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Is this brokered business to the agent?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 13. Has agent inspected vehicle? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question “Has agent inspected vehicles?”.
GENERAL INFORMATION Remarks Enter text: An explanation of a response to a general information or underwriting question. Normally, “Yes” responses require an explanation.
GENERAL INFORMATION 14. Has any named insured driven without liability insurance during any part of the last six (6) months? Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question, “Has any named insured driven without liability insurance during any part of the last specified period of time?”.
GENERAL INFORMATION Drv # Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION Explanation Enter text: The explanation of why the driver has driven with no liability insurance within the last mandated time.
REMARKS / ATTACHMENTS Young Driver Questionnaire Check the box (if applicable): Indicates if an attachment will follow containing a young driver questionnaire.
REMARKS / ATTACHMENTS Driver Training Certificate Check the box (if applicable): Indicates if an attachment will follow containing a driver training certificate.
REMARKS / ATTACHMENTS Good Student Certificate Check the box (if applicable): Indicates if an attachment will follow containing a good student certificate.
REMARKS / ATTACHMENTS Anti-Theft Device Certificate Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft device certificate.
REMARKS / ATTACHMENTS Medical Statement Check the box (if applicable): Indicates if an attachment will follow containing a medical statement.
REMARKS / ATTACHMENTS Motor Vehicle Report Check the box (if applicable): Indicates if an attachment will follow containing a motor vehicle report.
REMARKS / ATTACHMENTS Photograph Check the box (if applicable): Indicates if an attachment will follow containing a photograph.
REMARKS / ATTACHMENTS Bill of Sale Check the box (if applicable): Indicates if an attachment will follow containing a bill of sale.
REMARKS / ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Other Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS / ATTACHMENTS Other Description Enter text: The description of the attachment.
REMARKS / ATTACHMENTS Remarks Enter text: The personal vehicle line of business remarks.
SIGNATURE Producer’s Statement Enter text: The length of time the named insured has been known by the producer.
SIGNATURE Applicant’s Initials Initial here: The named insured’s initials.
SIGNATURE Applicant’s Signature Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
SIGNATURE Producer’s Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.) by all companies to issue Certificates. This is required in most states.
SIGNATURE National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer state license number.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).