ACORD 95MA Instructions


Section Name Field Name Field and/or Section Description
TITLE ACORD 95 MA (2009/12) Massachusetts Renewal Form The title of the form. ACORD 95 MA, Massachusetts Renewal Form. The state of Massachusetts requires personal automobile, new business and renewals to be submitted on forms prescribed by the Massachusetts Commissioner of Insurance. The ACORD Massachusetts Renewal Form meets the prescribed requirements. Questions or comments regarding this form should be directed to the MassachusettsAutomobile Insurance Bureau. The form is no longer a renewal application. It is a “statement of facts” sent to the insured prior to policy renewal. If no changes are required and the insured is satisfied that the statements on the form are correct, it will not be necessary for the insured to return the form to the agent or company. For more information about the renewal form, refer to the Massachusetts Automobile Insurance Bureau.
IDENTIFICATION SECTION Issued By 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.
IDENTIFICATION SECTION Name And Address Of Insured Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Enter text: The named insured’s physical address line one.
IDENTIFICATION SECTION Enter text: The named insured’s physical address line two.
IDENTIFICATION SECTION Enter text: The named insured’s physical address city name.
IDENTIFICATION SECTION Enter text: The applicant’s physical address county name.
IDENTIFICATION SECTION Enter code: The named insured’s physical address state or province code.
IDENTIFICATION SECTION Enter code: The named insured’s physical address postal code.
IDENTIFICATION SECTION Policy # 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 [Producer] Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION Policy Renewal Date Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. As used here, this is the renewal date.
VEHICLE INFORMATION 1. Used in Business – Auto 1 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Is any auto used in business?”.
VEHICLE INFORMATION 1. Used in Business – Auto 2 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Is any auto used in business?”.
VEHICLE INFORMATION 2. Used To Transport (for a fee) Fellow Employees, Passengers, Students or Persons Employed by You – Auto 1 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Is any auto used to transport (to or from work or school) fellow employees, passengers or students, for a fee?”. As used here, this includes persons employed by you.
VEHICLE INFORMATION 2. Used To Transport (for a fee) Fellow Employees, Passengers, Students or Persons Employed by You – Auto 2 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Is any auto used to transport (to or from work or school) fellow employees, passengers or students, for a fee?”. As used here, this includes persons employed by you.
VEHICLE INFORMATION 3. Principally Garaged In: Auto 1 (Blank Field) Enter text: The vehicle’s physical address line one.
VEHICLE INFORMATION Enter text: The vehicle’s physical address city name.
VEHICLE INFORMATION Enter code: The vehicle’s physical address state or province code.
VEHICLE INFORMATION Enter code: The vehicle’s physical address postal code.
VEHICLE INFORMATION 3. Our Information Indicates That Your Auto(s) Is Principally Garaged In: Auto 2 (Blank Field) Enter text: The vehicle’s physical address line one.
VEHICLE INFORMATION Enter text: The vehicle’s physical address city name.
VEHICLE INFORMATION Enter code: The vehicle’s physical address state or province code.
VEHICLE INFORMATION Enter code: The vehicle’s physical address postal code.
VEHICLE INFORMATION 4. (a) Equipped with Electronic Equipment That Reproduces Audio, Visual Or Data Signals That Has Been Permanently Installed But Not In The Location Used By The Auto Manufacturer – Auto 1 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Any auto equipped with electronic equipment permanently installed but not in locations used by the auto manufacturer for such equipment?”. As used here, this is electronic equipment that reproduces audio, visual or data signals.
VEHICLE INFORMATION 4. (a) Equipped with Electronic Equipment That Reproduces Audio, Visual Or Data Signals That Has Been Permanently Installed But Not In The Location Used By The Auto Manufacturer – Auto 2 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “Any auto equipped with electronic equipment permanently installed but not in locations used by the auto manufacturer for such equipment?”. As used here, this is electronic equipment that reproduces audio, visual or data signals.
VEHICLE INFORMATION 4. (b) Equipped with Custom Furnishings or Custom Equipment [applicable to vans or pick-up trucks] Auto 1 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question “Any vehicles customized, altered or with special equipment?”.
VEHICLE INFORMATION 4. (b) Equipped with Custom Furnishings or Custom Equipment [applicable to vans or pick-up trucks] Auto 2 (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question “Any vehicles customized, altered or with special equipment?”.
DRIVER INFORMATION According to Our Information, Listed Operator # (Blank Field) Has Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION (a) Had Two (2) or More “total loss”Insurance ClaimsBecause Of Auto Theft Or Fire (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator had two or more total fire or total theft losses?”.
DRIVER INFORMATION (b) Been Convicted Of Vehicular Homicide,Auto InsuranceRelated Fraud or Auto Theft (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator been convicted of vehicular homicide, auto related fraud, auto theft, or driving under the influence of alcohol or drugs?”.
DRIVER INFORMATION If This Information Is Not Accurate Please Explain: Enter text: The remarks associated with a driver. As used here, explain if the driver information shown is not accurate.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver TrainingYes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver Training Yes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver Training Yes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver Training Yes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver Training Yes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION Oper No. Enter number: The number assigned to the driver by the producer.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Date Of Birth Enter date: The birth date of the driver.
DRIVER INFORMATION Driver’s License Number Enter identifier: The driver’s license number.
DRIVER INFORMATION Lic. State Enter code: The state the driver is licensed in.
DRIVER INFORMATION Date First Licensed In Any State/Country – Auto Enter date: The original date on which a driver’s license was issued to this driver in a state other than the in which insurance is being requested.
DRIVER INFORMATION Date First Licensed In Any State/Country – Motor Cycle Enter date: The original date on which a motorcycle driver’s license was issued to this driver.
DRIVER INFORMATION Driver Training Yes/No 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 % Of Use – Auto 1 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION % Of Use – Auto 2 Enter percentage: Indicates the percentage of driving done by this driver in the primary vehicle that this driver uses.
DRIVER INFORMATION Please Indicate Reason For Change Enter text: The reason the driver information is being changed.
DRIVER INFORMATION (A) Been Involved In Any Motor Vehicle Accident Or Been Found Guilty Of Any Moving Violation? Yes (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator been involved in any motor vehicle accident or been found guilty of any moving violation?”. As used here, answer this question for newly added drivers.
DRIVER INFORMATION (A) Been Involved In Any Motor Vehicle Accident Or Been Found Guilty Of Any Moving Violation? No (Checkbox) Check the box (if applicable): Indicates a “No” response to the question, “During the last specified number of years have you or any listed operator been involved in any motor vehicle accident or been found guilty of any moving violation?”.
DRIVER INFORMATION (B) Been Assigned To An Alcohol Education Program? Yes (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator been assigned to an alcohol education Program?”. As used here, answer this question for newly added drivers.
DRIVER INFORMATION (B) Been Assigned To An Alcohol Education Program? Yes (Checkbox) Check the box (if applicable): Indicates a “No” response to the question, “During the last specified number of years have you or any listed operator been assigned to an alcohol education Program?”.
DRIVER INFORMATION C) Had Two (2) or More ‘Total Loss Insurance Claims Because Of Auto Theft Or Fire? Yes (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator had two or more total fire or total theft losses?”. As used here, answer this question for newly added drivers.
DRIVER INFORMATION C) Had Two (2) or More ‘Total Loss Insurance Claims Because Of Auto Theft Or Fire? No (Checkbox) Check the box (if applicable): Indicates a “No” response to the question, “During the last specified number of years have you or any listed operator had two or more total fire or total theft losses?”.
DRIVER INFORMATION (D) Been Convicted Of Vehicular Homicide, Auto Insurance related Fraud Or Auto Theft? Yes (Checkbox) Check the box (if applicable): Indicates a “Yes” response to the question, “During the last specified number of years have you or any listed operator been convicted of vehicular homicide, auto related fraud, auto theft, or driving under the influence of alcohol or drugs?”. As used here, answer this question for newly added drivers.
DRIVER INFORMATION (D) Been Convicted Of Vehicular Homicide, Auto Insurance related Fraud Or Auto Theft? No (Checkbox) Check the box (if applicable): Indicates a “No” response to the question, “During the last specified number of years have you or any listed operator been convicted of vehicular homicide, auto related fraud, auto theft, or driving under the influence of alcohol or drugs?”.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Description Of Incident Enter text: The remarks associated with a driver. As used here, the description of any motor vehicle accident, moving violation, alcohol education program, two or more total loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto theft involving the driver.
DRIVER INFORMATION Date Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Description Of Incident Enter text: The remarks associated with a driver. As used here, the description of any motor vehicle accident, moving violation, alcohol education program, two or more total loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto theft involving the driver.
DRIVER INFORMATION Date Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Description Of Incident Enter text: The remarks associated with a driver. As used here, the description of any motor vehicle accident, moving violation, alcohol education program, two or more total loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto theft involving the driver.
DRIVER INFORMATION Date Enter date: The date of the incident associated with remarks.
DRIVER INFORMATION Operator Name Enter text: The driver’s full name.
DRIVER INFORMATION Description Of Incident Enter text: The remarks associated with a driver. As used here, the description of any motor vehicle accident, moving violation, alcohol education program, two or more total loss claims of auto theft or fire, vehicular homicide conviction, auto insurance fraud or auto theft involving the driver.
DRIVER INFORMATION Date Enter date: The date of the incident associated with remarks.
REMARKS Indicate Any Additional Changes Enter text: The remarks associated with a policy change. Attach ACORD 101, Additional Remarks Schedule, if more space is required.
SIGNATURE Date Enter date: The date the form was signed by the named insured.
SIGNATURE Signature Sign here: Accommodates the signature of the applicant or named insured.