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ACORD Form 128 Garage and Dealers
Section Instructions

 

 
ACORD 128 (2008/05) 1 of 9
Section Name Field Name Field and/or Section Description
TITLE ACORD 128 (2008/05) Garage and Dealers Section The following provides the user with basic instructions for completing ACORD 128, Garage & Dealers Section. This form has been designed to handle the basic underwriting needs for automobile service operations and automobile dealers. Space is provided to enter driver information for up to eight (8) drivers. For additional drivers, ACORD 163, Commercial Auto Driver Information Schedule, can be attached. Insurance coverage, "no fault" and uninsured/underinsured motorists coverages in particular, varies widely from state to state. In addition, there are numerous state-specific requirements that apply to Garage and Dealers applications. ACORD 128 cannot address these various unique specifications. Therefore, state specific forms, ACORD 138, have been developed to respond to these requirements. Use the ACORD 138 for your state to provide coverages/limits information, as well as the required disclosure and other data unique to the state.
TITLE This form was also designed to be used in conjunction with ACORD 125, Commercial Insurance Application - Applicant Information Section and ACORD 129, Vehicle Schedule. Many states require supplements to all auto applications, to provide specific coverage explanations or to allow applicants to accept or reject certain coverages. In some cases, the applicant must be allowed to select among various options. In others, laws or regulations require disclosure of information pertinent to auto insurance. ACORD has provided the necessary supplements in most states.
TITLE Much of the information for the Identification Section should match the data found within the Applicant Information Section of ACORD 125. Nevertheless, it is still important to complete it. Many companies separate the applications by line of business for rating purposes. Not completing this portion of the application makes it difficult to keep track of the full account.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
IDENTIFICATION SECTION Date Month/day/year on which the form is completed.

ACORD 128 (2008/05) 2 of 9

Section Name Field Name Field and/or Section Description
IDENTIFICATION SECTION Agency Producer's name.
The number assigned by the insurance company for the policy. In general, policy numbers
IDENTIFICATION SECTION Policy Number will not appear on new business applications since they are not known at that point in time.
Name of the insurance company (or residual market plan) that will receive the application.
Do not use group names, use the actual name of the company within the group in which
IDENTIFICATION SECTION Carrier you wish to have the policy issued.
IDENTIFICATION SECTION NAIC Code The identification code assigned to the company by the NAIC.
IDENTIFICATION SECTION Named Insured(s) Full name of the applicant as it should appear on the policy. The First Named Insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and any additional insureds identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).
BUSINESS / VEHICLE
STORAGE INFORMATION This section is used to identify the type of insurance necessary for the applicant.
BUSINESS / VEHICLE Auto Service Operations or Check all applicable boxes to identify the type of operations in which the applicant is
STORAGE INFORMATION Trailer Sales involved.
BUSINESS / VEHICLE
STORAGE INFORMATION Auto Dealers Indicate if the dealership is franchised or if it is a non-franchised dealer.
BUSINESS / VEHICLE
STORAGE INFORMATION Check Boxes (Vehicle Types) Check the applicable vehicle type(s).
BUSINESS / VEHICLE
STORAGE INFORMATION % Indicate the percentage of vehicle type in relation to total inventory.
BUSINESS / VEHICLE
STORAGE INFORMATION Vehicle Storage Use this section to identify where the applicant's vehicles are stored.
BUSINESS / VEHICLE Enter the requested information for the type of facility listed. A blank check box is
STORAGE INFORMATION Type of Facility provided for other options. Identify the other type of facility.
BUSINESS / VEHICLE Enter the location number as it relates to the numbers found on the ACORD 125. For each
STORAGE INFORMATION Location Number location, identify where the vehicles are stored.
BUSINESS / VEHICLE
STORAGE INFORMATION Building Vehicles are stored within a building.
BUSINESS / VEHICLE
STORAGE INFORMATION % Indicate the percentage of the applicant's vehicles stored within a building.

ACORD 128 (2008/05) 3 of 9

Section Name Field Name Field and/or Section Description
BUSINESS / VEHICLE The lot is enclosed by walls or fences at least six feet in height, with openings securely
STORAGE INFORMATION Standard Open Lot locked when unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION % Indicate the percentage of the applicant's vehicles stored in a standard open lot.
BUSINESS / VEHICLE The lot is either an open lot or an unroofed space and the building is not securely enclosed
STORAGE INFORMATION Non-Standard Open Lot or locked when unattended.
BUSINESS / VEHICLE
STORAGE INFORMATION % Indicate the percentage of the applicant's vehicles stored in a non-standard open lot.
COVERAGES / LIMITS Coverage / Limits Use ACORD 138 for your state to provide Coverages / Limits Information.
Garage or Dealers policies use numeric symbols on the policy declarations to indicate the
type(s) of vehicles for which coverage is in effect. Be sure to check the appropriate box for
each type of coverage. Only those symbols specified for a coverage may be used.
Symbols 21 through 26 provide fleet automatic coverage. Symbol 21 includes Hired and
Non-Owned auto coverage. If symbol 21 is not used and Hired Auto (symbol 28) or Non-
Owned Auto (symbol 29) coverage is desired, those symbols must be checked. The
symbols indicate the automobiles to which each coverage applies. The symbol "triggers"
the coverage. For exact policy definitions of the symbols, please refer to the company's
COVERAGES / LIMITS Covered Auto Symbols policy declarations page.
Can only be used for Liability insurance and/or Medical Payments insurance. Its use
provides coverage for any auto the insured will have contact with, including owned & non-
owned & hired vehicles. It includes coverage for non-owned autos, no-fault, uninsured
motorists or physical damage insurance. Damage to customers' autos is provided by using
COVERAGES / LIMITS Symbol 21 - Any Auto Symbol 30, Garage Keepers Insurance.
Provides coverage for owned autos only and includes automatic coverage for autos you
newly acquire. This symbol cannot be used to provide liability coverage for dealers, but
can be used to provide liability for non-dealers. It can also be used for dealers and non-
dealers to provide any of the physical damage coverages or uninsured motorist's
COVERAGES / LIMITS Symbol 22 - All Owned Autos insurance.
Provides coverage for owned private passenger autos only and includes automatic
coverage for private passenger autos you newly acquire. It can be used for dealers and
Symbol 23 - Owned Private non-dealers to provide uninsured motorist's insurance and physical damage coverages. It
COVERAGES / LIMITS Passenger Autos Only may also be used to provide medical payments insurance for non-dealers.
ACORD 128 (2008/05) 4 of 9
Section Name Field Name Field and/or Section Description
Provides coverage for owned autos other than private passenger autos and includes
automatic coverage for autos you newly acquire, other than private passenger autos. It is
not limited to trucks or truck tractors, but also includes taxis, motorcycles, emergency
Symbol 24 - Owned Autos Other vehicles, trailers and buses. Any vehicle which is not a private passenger auto fits within
COVERAGES / LIMITS Than Private Passenger this symbol.
Symbol 25 - Owned Autos Applies to owned autos where no-fault is required by law including automatic coverage for
COVERAGES / LIMITS Subject to No-Fault Laws autos you newly acquire.
Symbol 26 - Owned Autos Applies to owned autos where there is a compulsory uninsured motorist's law including
Subject to Uninsured Motorist automatic coverage for autos you newly acquire where rejection of UM is not permitted by
COVERAGES / LIMITS Laws law.
Provides coverage for scheduled autos only with no automatic coverage for autos you
Symbol 27 - Specifically newly acquire. Use Vehicle Schedule, ACORD 129, to provide information on individual
COVERAGES / LIMITS Described Autos vehicles.
Provides coverage only for autos leased, hired, rented or borrowed by the named insured.
COVERAGES / LIMITS Symbol 28 - Hired Autos Only This does not include autos owned by employees or members of their families.
Symbol 29 - Non-Owned Autos Provides liability coverage for autos not owned by the named insured but used in
COVERAGES / LIMITS Used in Garage Business connection with the garage business. This includes autos owned by employees.
Provides coverage for customer's autos which are in the care, custody, and control of the
Symbol 30 - Autos Left for named insured. It provides garage keepers insurance for dealers and non-dealers when
COVERAGES / LIMITS Service/Repairs/Storage autos are left for service, repair or storage.
Symbol 31 - Autos On Provides physical damage coverages for autos consigned to dealer or held for sale in
COVERAGES / LIMITS Consignment and Dealer Autos possession of non-dealer.
This is a company specific code. It can be used to provide coverage when no other symbol applies (e.g., to provide coverage for Long Term Leased Vehicles). It will be necessary to write in this symbol if used.
COVERAGES / LIMITS Symbol 32 - Company Use Coverages & Limits - Use ACORD 138
The Insurance Services Office developed the Dealers Class Plan to rate liability and collision coverages. The basis for rating involves assigning rating factors and rating units for employees and non-employees.
AUTO DEALERS OPERATORS Enter the location number as it appears on the ACORD 125 and the number of persons within each category. If rating the policy, refer to the Commercial Lines Manual for additional information
Section Name Field Name Field and/or Section Description
DEALERS PHYSICAL Indicate if the autos to be covered are New or Used for each coverage and check the
DAMAGE interest to be insured.
Payroll is the basis for rating this coverage. Enter the location number as it appears on the
NON-DEALERS PREMISES ACORD 125, the estimated annual remuneration and number of employees at each
& OPERATIONS location. See the appropriate manual for the payroll limitations that apply.
NON-DEALERS PREMISES
& OPERATIONS LOC # Enter the location number as it relates to the numbers found on the ACORD 125.
Total annual payroll for the class. Payroll means money or substitutes for money, such as
the value of meals or lodging if provided. Accurate payroll estimates help avoid additional
NON-DEALERS PREMISES premium requirements being discovered during an audit. Do not include overtime
& OPERATIONS Estimated Annual Remuneration premium.
NON-DEALERS PREMISES
& OPERATIONS # Employees Indicate the number of employees at this location.
SERVICE OR REPAIR
SHOPS Annual Gross Sales $ Indicate Annual Gross Sales.
SERVICE OR REPAIR Number of Gallons Of Gas
SHOPS Pumped Per Year Indicate the number of gallons of gasoline pumped per year.
This section is used to collect information on all the drivers that will be covered under this
DRIVER INFORMATION account. The driver list should include any family member who will be driving company vehicles and employees who regularly drive their own vehicles for company business.
Check Box - ACORD 163 attached If more space is required for Additional Drivers, attach ACORD 163, Commercial Auto
DRIVER INFORMATION for additional drivers Driver Information Schedule, and check the applicable box.
DRIVER INFORMATION Driver # Assign a number to each driver.
DRIVER INFORMATION Name Enter the driver's full name. If the company requires the address, enter it as well.
DRIVER INFORMATION Sex Enter F for female, M for male.

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ACORD 128 (2008/05) 6 of 9
Section Name Field Name Field and/or Section Description
DRIVER INFORMATION Marital Stat Marital status of each named applicant. Codes: S . . . . . . . . . . . . . . . . . . . . . . . . . . . . Single M. . . . . . . . . . . . . . . . . . . . . . . . . . . . Married D . . . . . . . . . . . . . . . . . . . . . . . . . . . . Divorced P . . . . . . . . . . . . . . . . . . . . . . . . . . . . Separated W. . . . . . . . . . . . . . . . . . . . . . . . . . . . Widowed C. . . . . . . . . . . . . . . . . . . . . . . . . . . . Domestic Partner (unmarried) V . . . . . . . . . . . . . . . . . . . . . . . . . . . . Civil Union U . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unknown O . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other
DRIVER INFORMATION Date of Birth Enter the driver's birth date.
DRIVER INFORMATION Yrs Exp Enter the number of years of driving experience for each driver.
DRIVER INFORMATION Year Licensed Enter the year in which the driver was first licensed.
DRIVER INFORMATION Driver's License Number/Soc. Sec. # Enter the complete driver's license number. If a license number is unavailable, enter the driver's social security number.
DRIVER INFORMATION State Lic. Enter the state in which the license was issued.
DRIVER INFORMATION Date Hire Enter the date of hire for each driver.
DRIVER INFORMATION Use Vehicle # Enter the vehicle number that this driver primarily uses.
DRIVER INFORMATION % Use Enter the percentage of driving done by this driver in this vehicle.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
GENERAL INFORMATION Use the space provided below each question to provide additional information for any questions answered with a "YES" response. The overview below lists the expected information that should be provided for "YES" responses.
GENERAL INFORMATION 1. Does applicant rent, lease or loan vehicles to others? List the frequency, who receives the vehicles and if this is part of the normal business operations. Indicate if insurance is provided.
GENERAL INFORMATION 2. Does applicant pick-up or deliver customer's cars? Indicate how many cars per day, and how the employee commutes to the location.
GENERAL INFORMATION 3. Does pick-up or delivery exceed 50 miles? Indicate the radius of this operation if it exceeds 50 miles, and how often.
GENERAL INFORMATION 4. Is tire recapping or retreading performed? List the percentage of gross sales this operation represents. Indicate if the applicant sends out for retreads, or if the applicant performs the operation.
GENERAL INFORMATION 5. Does applicant own or sponsor a car for racing? Provide a description of the car. Indicate how frequently the car is raced, who drives the car and how the car is transported.

ACORD 128 (2008/05) 7 of 9

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 6. Does applicant handle butane, propane or other gases? State what type of storage facilities are used, what gases are involved and if they are for sale to the general public.
GENERAL INFORMATION 7. Are any vehicles furnished for groups or organizations? Identify the group (school, hospital, church, or civic organization) to which the vehicle is loaned. Indicate if there is a charge.
GENERAL INFORMATION 8. Does applicant perform spray painting or welding? Indicate how frequently this type of operation is performed, and if the applicant has approved booths or ventilated spray areas. Describe the type of welding or painting job handled and where in the building each job is located.
GENERAL INFORMATION 9. Does applicant drive away or haul away vehicles from factory distributing point or other dealers? Describe circumstances causing drive-aways. Indicate if this is a regular operation, how many cars are involved, and give the radius of operation.
GENERAL INFORMATION 10. Does applicant dismantle autos or have salvage operation? Describe this type of operation completely. If there is a salvage operation on premises, so indicate.
GENERAL INFORMATION 11. Does applicant use tow trucks? Indicate how many trucks are owned or used by the applicant and describe towing operations. These trucks may be listed on ACORD 129, Vehicle Schedule and attached to the Garage Section.
GENERAL INFORMATION 12. Do employees regularly use their own autos on company business? List who, what vehicle and for what operations.
GENERAL INFORMATION 13. Does applicant park customers' vehicles on public streets or off premises? Describe any type of off-premises parking of vehicles.
GENERAL INFORMATION 14. Is a charge made for parking? Indicate how much is charged, how many attendants are on duty, and the hours of operation. Indicate if employees drive vehicles or if customers self-park.
GENERAL INFORMATION 15. Any private protection systems? Describe all such systems in detail.
GENERAL INFORMATION 16. Is applicant involved in any "non-garage" operations? If a retail operation, mini-mart, liquor store, or other operation is run on the premises, list the operation and annual gross sales from this portion of the business. Indicate if there is any insurance for this operation.
GENERAL INFORMATION 17. Does applicant perform any road emergency services? Indicate if the applicant is on call for any highway or other emergencies, and if towing operations are available around the clock.

ACORD 128 (2008/05) 8 of 9

Section Name Field Name Field and/or Section Description
GENERAL INFORMATION 18. Any drivers with convictions for moving traffic violations? Give driver name and number, date, type and place for each conviction. Enter the number of years reviewed, in accordance with the company's and state's requirements. In Kansas, certain traffic violations are not required to be reported to insurers.
IDENTIFICATION SECTION Agency Customer ID Customer's identification number assigned by the agency or brokerage.
ADDITIONAL INTEREST / Use this section to collect information on any additional interest or receiver of Certificates
CERTIFICATE RECIPIENT of Insurance.
ADDITIONAL INTERESTS / Check Box - ACORD 45 attached If more space is required for Additional Interests or Certificate Recipients, attach ACORD
CERTIFICATE RECIPIENTS for additional names 45, Additional Interest and check the applicable box.
ADDITIONAL INTEREST / Check all appropriate boxes that apply to the additional interest. If the interest is other than
CERTIFICATE RECIPIENT Interest the listed options, check the last box and list the interest type after it.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT Rank Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee.
ADDITIONAL INTEREST / Enter the complete name and address for the additional interest, including the city, state
CERTIFICATE RECIPIENT Name and Address and country.
ADDITIONAL INTEREST / List any reference number, such as a loan number, that may be beneficial in tying the
CERTIFICATE RECIPIENT Reference # additional interest to item.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT Certificate Required If a Certificate of Insurance is required, check this box.
Use this section to indicate what the additional interest has an interest in. Examples:
*For a Mortgagee, list the location and building number. *For an automobile lienholder, list the vehicle number.
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Interest in Item If the additional interest has an interest in multiple items, such as a lienholder on multiple vehicles, list all of the numbers associated with the additional interest.
If needed, further clarify the item of interest in this field. For a vehicle, list the make,
ADDITIONAL INTEREST / model and VIN number. For a scheduled item, list the description, such as three carat
CERTIFICATE RECIPIENT Item Description diamond in six point setting.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT Interest Indicate all appropriate options for the individual named.
ADDITIONAL INTEREST /
CERTIFICATE RECIPIENT Rank Primarily used for Mortgagees. Indicate the ranking such as 1st, 2nd or 3rd mortgagee.
Section Name Field Name Field and/or Section Description
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Name and Address List the additional interest's name and address.
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Reference # Indicate the additional interest's reference number for this applicant such as the loan or mortgage number.
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Certificate Required If a Certificate of Insurance is required, check this box.
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Interest in Item Number List the item number corresponding with the application for the item of interest for this additional insured.
ADDITIONAL INTEREST / CERTIFICATE RECIPIENT Item Description If needed, further clarify the item of interest in this field. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting.
REMARKS Use this section to provide any additional information required for underwriting or rating.