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ACORD 129 SC (2007/01) rev. 04-10-2009 1 of 24
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Section Name |
Field Name |
Field and/or Section Description |
|
TITLE ACORD 129 SC (2007/01) |
Associated Auto Insurers Plan of South Carolina - Supplemental Vehicle Schedule |
The title of the form. ACORD 129 SC / AIP 6315, Associated Auto Insurers Plan of South Carolina - Supplemental Vehicle Schedule is used in connection with insurance written through the Associated Auto Insurers Plan of South Carolina. Refer to the Plan rules to determine how the form should be used. |
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VEHICLE 1 |
Year Veh 1 |
Enter year: The model year of the vehicle. |
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Vehicle Identification Number Veh |
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the |
|
VEHICLE 1 |
1 |
manufacturer. |
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VEHICLE 1 |
Load Capacity Veh 1 |
Enter number: The load capacity of the vehicle. |
|
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Enter code: The industry code identifying the registration type of vehicle such as Truck, |
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VEHICLE 1 |
Type of Registration Veh 1 |
Private Passenger, Antique Car, Diplomatic, etc. |
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Enter number: The actual weight of the vehicle or the combined weight of tractor and |
|
VEHICLE 1 |
Gross Vehicle Weight Veh 1 |
trailer in pounds. |
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Enter code: The secondary Special Industry Class code which applies to commercial |
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VEHICLE 1 |
Spec. Industry Veh 1 |
vehicles as determined by industry rating manuals. |
|
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Enter number: The seating capacity of the vehicle. Required for rating public passenger |
|
VEHICLE 1 |
Seating Capacity Veh 1 |
vehicles. |
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VEHICLE 1 |
Loss Payee Name Veh 1 |
Enter text: The additional interest's full name. |
|
VEHICLE 1 |
Trade Name/Model # Veh 1 |
Enter text: The manufacturer's model name for the vehicle. |
|
VEHICLE 1 |
Garage Location Veh 1 |
Enter text: The vehicle's physical address city name. |
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VEHICLE 1 |
|
Enter code: The vehicle's physical address state or province code. |
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VEHICLE 1 |
State of Registration Veh 1 |
Enter code: The state or province in which the vehicle is registered. |
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Enter code: The rate class of the vehicle. If two rate classes are required, this element |
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VEHICLE 1 |
Rating Classification Veh 1 |
should be used to enter the liability code. |
|
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Enter number: The actual weight of the vehicle or the combined weight of tractor and |
|
VEHICLE 1 |
Gross Comb. Weight Veh 1 |
trailer in pounds. |
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VEHICLE 1 |
For Size Bus Radius Veh 1 |
Enter number: The radius in whole numbers within which this vehicle is operated. |
|
VEHICLE 1 |
Tank Capacity Veh 1 |
Enter number: The capacity of the fuel tank in gallons. |
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VEHICLE 1 |
Loss Payee Street Address Veh 1 |
Enter text: The additional interest's mailing address line one. |
|
VEHICLE 1 |
Type(1) Veh 1 |
Enter code: The predominant type of the vehicle. |
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Name of Registered Owner of |
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VEHICLE 1 |
Vehicle Veh 1 |
Enter text: The additional interest's full name. |
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VEHICLE 1 |
Rating Territory(2) Veh 1 |
Enter code: The rating territory code where the vehicle is principally garaged. |
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VEHICLE 1 |
Original Cost New Veh 1 |
Enter amount: The original cost of the vehicle. |
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Enter code: The predominant type/weight of the vehicle (e.g. Light, Medium, Heavy, Extra |
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VEHICLE 1 |
Size Veh 1 |
Heavy). |
ACORD 129 SC (2007/01) rev. 04-10-2009 2 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
VEHICLE 1 |
Final Rating Veh 1 |
Enter code: The final rating for the vehicle. |
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VEHICLE 1 |
How Veh. Is Licensed Veh 1 |
Enter code: The code indicating how the vehicle was licensed. |
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VEHICLE 1 |
Loss Payee City, State, Zip Code Veh 1 |
Enter text: The additional interest's mailing address line two. |
|
VEHICLE 1 |
Where Vehicle is Permitted to Veh 1 |
Enter text: The description of where the vehicle is permitted to operate. |
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VEHICLE 1 |
List all Cities Through and in which Vehicles Veh 1 |
Enter text: The description of the cities through and in which the vehicle operates. |
|
VEHICLE 2 |
Year Veh 2 |
Enter year: The model year of the vehicle. |
|
VEHICLE 2 |
Vehicle Identification Number Veh 2 |
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
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VEHICLE 2 |
Load Capacity Veh 2 |
Enter number: The load capacity of the vehicle. |
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VEHICLE 2 |
Type of Registration Veh 2 |
Enter code: The industry code identifying the registration type of vehicle such as Truck, Private Passenger, Antique Car, Diplomatic, etc. |
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VEHICLE 2 |
Gross Vehicle Weight Veh 2 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
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VEHICLE 2 |
Spec. Industry Veh 2 |
Enter code: The secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. |
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VEHICLE 2 |
Seating Capacity Veh 2 |
Enter number: The seating capacity of the vehicle. Required for rating public passenger vehicles. |
|
VEHICLE 2 |
Loss Payee Name Veh 2 |
Enter text: The additional interest's full name. |
|
VEHICLE 2 |
Trade Name/Model # Veh 2 |
Enter text: The manufacturer's model name for the vehicle. |
|
VEHICLE 2 |
Garage Location Veh 2 |
Enter text: The vehicle's physical address city name. |
|
VEHICLE 1 |
|
Enter code: The vehicle's physical address state or province code. |
|
VEHICLE 2 |
State of Registration Veh 2 |
Enter code: The state or province in which the vehicle is registered. |
|
VEHICLE 2 |
Rating Classification Veh 2 |
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 2 |
Gross Comb. Weight Veh 2 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 2 |
For Size Bus Radius Veh 2 |
Enter number: The radius in whole numbers within which this vehicle is operated. |
|
VEHICLE 2 |
Tank Capacity Veh 2 |
Enter number: The capacity of the fuel tank in gallons. |
|
VEHICLE 2 |
Loss Payee Street Address Veh 2 |
Enter text: The additional interest's mailing address line one. |
|
VEHICLE 2 |
Type(1) Veh 2 |
Enter code: The predominant type of the vehicle. |
|
VEHICLE 2 |
Name of Registered Owner of Vehicle Veh 2 |
Enter text: The additional interest's full name. |
ACORD 129 SC (2007/01) rev. 04-10-2009 3 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
VEHICLE 2 |
Rating Territory(2) Veh 2 |
Enter code: The rating territory code where the vehicle is principally garaged. |
|
VEHICLE 2 |
Original Cost New Veh 2 |
Enter amount: The original cost of the vehicle. |
|
VEHICLE 2 |
Size Veh 2 |
Enter code: The predominant type/weight of the vehicle (e.g. Light, Medium, Heavy, Extra Heavy). |
|
VEHICLE 2 |
Final Rating Veh 2 |
Enter code: The final rating for the vehicle. |
|
VEHICLE 2 |
How Veh. Is Licensed Veh 2 |
Enter code: The code indicating how the vehicle was licensed. |
|
VEHICLE 2 |
Loss Payee City, State, Zip Code Veh 2 |
Enter text: The additional interest's mailing address line two. |
|
VEHICLE 2 |
Where Vehicle is Permitted to Veh 2 |
Enter text: The description of where the vehicle is permitted to operate. |
|
VEHICLE 2 |
List all Cities Through and in which Vehicles Veh 2 |
Enter text: The description of the cities through and in which the vehicle operates. |
|
VEHICLE 3 |
Year Veh 3 |
Enter year: The model year of the vehicle. |
|
VEHICLE 3 |
Vehicle Identification Number Veh 3 |
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
|
VEHICLE 3 |
Load Capacity Veh 3 |
Enter number: The load capacity of the vehicle. |
|
VEHICLE 3 |
Type of Registration Veh 3 |
Enter code: The industry code identifying the registration type of vehicle such as Truck, Private Passenger, Antique Car, Diplomatic, etc. |
|
VEHICLE 3 |
Gross Vehicle Weight Veh 3 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 3 |
Spec. Industry Veh 3 |
Enter code: The secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. |
|
VEHICLE 3 |
Seating Capacity Veh 3 |
Enter number: The seating capacity of the vehicle. Required for rating public passenger vehicles. |
|
VEHICLE 3 |
Loss Payee Name Veh 3 |
Enter text: The additional interest's full name. |
|
VEHICLE 3 |
Trade Name/Model # Veh 3 |
Enter text: The manufacturer's model name for the vehicle. |
|
VEHICLE 3 |
Garage Location Veh 3 |
Enter text: The vehicle's physical address city name. |
|
VEHICLE 1 |
|
Enter code: The vehicle's physical address state or province code. |
|
VEHICLE 3 |
State of Registration Veh 3 |
Enter code: The state or province in which the vehicle is registered. |
|
VEHICLE 3 |
Rating Classification Veh 3 |
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 3 |
Gross Comb. Weight Veh 3 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 3 |
For Size Bus Radius Veh 3 |
Enter number: The radius in whole numbers within which this vehicle is operated. |
|
VEHICLE 3 |
Tank Capacity Veh 3 |
Enter number: The capacity of the fuel tank in gallons. |
ACORD 129 SC (2007/01) rev. 04-10-2009 4 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
VEHICLE 3 |
Loss Payee Street Address Veh 3 |
Enter text: The additional interest's mailing address line one. |
|
VEHICLE 3 |
Type(1) Veh 3 |
Enter code: The predominant type of the vehicle. |
|
VEHICLE 3 |
Name of Registered Owner of Vehicle Veh 3 |
Enter text: The additional interest's full name. |
|
VEHICLE 3 |
Rating Territory(2) Veh 3 |
Enter code: The rating territory code where the vehicle is principally garaged. |
|
VEHICLE 3 |
Original Cost New Veh 3 |
Enter amount: The original cost of the vehicle. |
|
VEHICLE 3 |
Size Veh 3 |
Enter code: The predominant type/weight of the vehicle (e.g. Light, Medium, Heavy, Extra Heavy). |
|
VEHICLE 3 |
Final Rating Veh 3 |
Enter code: The final rating for the vehicle. |
|
VEHICLE 3 |
How Veh. Is Licensed Veh 3 |
Enter code: The code indicating how the vehicle was licensed. |
|
VEHICLE 3 |
Loss Payee City, State, Zip Code Veh 3 |
Enter text: The additional interest's mailing address line two. |
|
VEHICLE 3 |
Where Vehicle is Permitted to Veh 3 |
Enter text: The description of where the vehicle is permitted to operate. |
|
VEHICLE 3 |
List all Cities Through and in which Vehicles Veh 3 |
Enter text: The description of the cities through and in which the vehicle operates. |
|
VEHICLE 4 |
Year Veh 4 |
Enter year: The model year of the vehicle. |
|
VEHICLE 4 |
Vehicle Identification Number Veh 4 |
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
|
VEHICLE 4 |
Load Capacity Veh 4 |
Enter number: The load capacity of the vehicle. |
|
VEHICLE 4 |
Type of Registration Veh 4 |
Enter code: The industry code identifying the registration type of vehicle such as Truck, Private Passenger, Antique Car, Diplomatic, etc. |
|
VEHICLE 4 |
Gross Vehicle Weight Veh 4 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 4 |
Spec. Industry Veh 4 |
Enter code: The secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. |
|
VEHICLE 4 |
Seating Capacity Veh 4 |
Enter number: The seating capacity of the vehicle. Required for rating public passenger vehicles. |
|
VEHICLE 4 |
Loss Payee Name Veh 4 |
Enter text: The additional interest's full name. |
|
VEHICLE 4 |
Trade Name/Model # Veh 4 |
Enter text: The manufacturer's model name for the vehicle. |
|
VEHICLE 4 |
Garage Location Veh 4 |
Enter text: The vehicle's physical address city name. |
|
VEHICLE 1 |
|
Enter code: The vehicle's physical address state or province code. |
|
VEHICLE 4 |
State of Registration Veh 4 |
Enter code: The state or province in which the vehicle is registered. |
|
VEHICLE 4 |
Rating Classification Veh 4 |
Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code. |
ACORD 129 SC (2007/01) rev. 04-10-2009 5 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
VEHICLE 4 |
Gross Comb. Weight Veh 4 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 4 |
For Size Bus Radius Veh 4 |
Enter number: The radius in whole numbers within which this vehicle is operated. |
|
VEHICLE 4 |
Tank Capacity Veh 4 |
Enter number: The capacity of the fuel tank in gallons. |
|
VEHICLE 4 |
Loss Payee Street Address Veh 4 |
Enter text: The additional interest's mailing address line one. |
|
VEHICLE 4 |
Type(1) Veh 4 |
Enter code: The predominant type of the vehicle. |
|
VEHICLE 4 |
Name of Registered Owner of Vehicle Veh 4 |
Enter text: The additional interest's full name. |
|
VEHICLE 4 |
Rating Territory(2) Veh 4 |
Enter code: The rating territory code where the vehicle is principally garaged. |
|
VEHICLE 4 |
Original Cost New Veh 4 |
Enter amount: The original cost of the vehicle. |
|
VEHICLE 4 |
Size Veh 4 |
Enter code: The predominant type/weight of the vehicle (e.g. Light, Medium, Heavy, Extra Heavy). |
|
VEHICLE 4 |
Final Rating Veh 4 |
Enter code: The final rating for the vehicle. |
|
VEHICLE 4 |
How Veh. Is Licensed Veh 4 |
Enter code: The code indicating how the vehicle was licensed. |
|
VEHICLE 4 |
Loss Payee City, State, Zip Code Veh 4 |
Enter text: The additional interest's mailing address line two. |
|
VEHICLE 4 |
Where Vehicle is Permitted to Veh 4 |
Enter text: The description of where the vehicle is permitted to operate. |
|
VEHICLE 4 |
List all Cities Through and in which Vehicles Veh 4 |
Enter text: The description of the cities through and in which the vehicle operates. |
|
VEHICLE 5 |
Year Veh 5 |
Enter year: The model year of the vehicle. |
|
VEHICLE 5 |
Vehicle Identification Number Veh 5 |
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer. |
|
VEHICLE 5 |
Load Capacity Veh 5 |
Enter number: The load capacity of the vehicle. |
|
VEHICLE 5 |
Type of Registration Veh 5 |
Enter code: The industry code identifying the registration type of vehicle such as Truck, Private Passenger, Antique Car, Diplomatic, etc. |
|
VEHICLE 5 |
Gross Vehicle Weight Veh 5 |
Enter number: The actual weight of the vehicle or the combined weight of tractor and trailer in pounds. |
|
VEHICLE 5 |
Spec. Industry Veh 5 |
Enter code: The secondary Special Industry Class code which applies to commercial vehicles as determined by industry rating manuals. |
|
VEHICLE 5 |
Seating Capacity Veh 5 |
Enter number: The seating capacity of the vehicle. Required for rating public passenger vehicles. |
|
VEHICLE 5 |
Loss Payee Name Veh 5 |
Enter text: The additional interest's full name. |
|
VEHICLE 5 |
Trade Name/Model # Veh 5 |
Enter text: The manufacturer's model name for the vehicle. |
|
VEHICLE 5 |
Garage Location Veh 5 |
Enter text: The vehicle's physical address city name. |
ACORD 129 SC (2007/01) rev. 04-10-2009 6 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
VEHICLE 1 |
|
Enter code: The vehicle's physical address state or province code. |
|
VEHICLE 5 |
State of Registration Veh 5 |
Enter code: The state or province in which the vehicle is registered. |
|
|
Enter code: The rate class of the vehicle. If two rate classes are required, this element |
|
VEHICLE 5 |
Rating Classification Veh 5 |
should be used to enter the liability code. |
|
|
Enter number: The actual weight of the vehicle or the combined weight of tractor and |
|
VEHICLE 5 |
Gross Comb. Weight Veh 5 |
trailer in pounds. |
|
VEHICLE 5 |
For Size Bus Radius Veh 5 |
Enter number: The radius in whole numbers within which this vehicle is operated. |
|
VEHICLE 5 |
Tank Capacity Veh 5 |
Enter number: The capacity of the fuel tank in gallons. |
|
VEHICLE 5 |
Loss Payee Street Address Veh 5 |
Enter text: The additional interest's mailing address line one. |
|
VEHICLE 5 |
Type(1) Veh 5 |
Enter code: The predominant type of the vehicle. |
|
Name of Registered Owner of |
|
|
VEHICLE 5 |
Vehicle Veh 5 |
Enter text: The additional interest's full name. |
|
VEHICLE 5 |
Rating Territory(2) Veh 5 |
Enter code: The rating territory code where the vehicle is principally garaged. |
|
VEHICLE 5 |
Original Cost New Veh 5 |
Enter amount: The original cost of the vehicle. |
|
|
Enter code: The predominant type/weight of the vehicle (e.g. Light, Medium, Heavy, Extra |
|
VEHICLE 5 |
Size Veh 5 |
Heavy). |
|
VEHICLE 5 |
Final Rating Veh 5 |
Enter code: The final rating for the vehicle. |
|
VEHICLE 5 |
How Veh. Is Licensed Veh 5 |
Enter code: The code indicating how the vehicle was licensed. |
|
Loss Payee City, State, Zip Code |
|
|
VEHICLE 5 |
Veh 5 |
Enter text: The additional interest's mailing address line two. |
|
Where Vehicle is Permitted to Veh |
|
|
VEHICLE 5 |
5 |
Enter text: The description of where the vehicle is permitted to operate. |
|
List all Cities Through and in |
|
|
VEHICLE 5 |
which Vehicles Veh 5 |
Enter text: The description of the cities through and in which the vehicle operates. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the combined single limit coverage is |
|
PREMIUMS |
CSL $75,000 |
$75,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the combined single limit coverage is |
|
PREMIUMS |
CSL $100,000 |
$100,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the combined single limit coverage is |
|
PREMIUMS |
CSL $250,000 |
$250,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the combined single limit coverage is |
|
PREMIUMS |
CSL $350,000 |
$350,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the combined single limit coverage is |
|
PREMIUMS |
CSL $500,000 |
$500,000. |
ACORD 129 SC (2007/01) rev. 04-10-2009 7 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 1 Est Prem |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 2 Est Prem |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 3 Est Prem |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 4 Est Prem |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 5 Est Prem |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are |
|
PREMIUMS |
Bodily Injury Liability $25 / 50000 |
$25,000 each person and $50,000 each accident. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are |
|
PREMIUMS |
Bodily Injury Liability $50 / 100000 |
$50,000 each person and $100,000 each accident. |
|
COVERAGES AND |
Bodily Injury Liability $100 / |
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are |
|
PREMIUMS |
300000 |
$100,000 each person and $300,000 each accident. |
|
COVERAGES AND |
Bodily Injury Liability $250 / |
Check the box (if applicable): Indicates the limits for the bodily injury liability coverage are |
|
PREMIUMS |
500000 |
$250,000 each person and $500,000 each accident. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 1 Est Prem |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 2 Est Prem |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 3 Est Prem |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 4 Est Prem |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 5 Est Prem |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the property damage liability coverage |
|
PREMIUMS |
Property Damage Liability $25,000 |
is $25,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the property damage liability coverage |
|
PREMIUMS |
Property Damage Liability $50,000 |
is $50,000. |
|
COVERAGES AND |
Property Damage Liability |
Check the box (if applicable): Indicates the limit for the property damage liability coverage |
|
PREMIUMS |
$100,000 |
is $100,000. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 1 Est Prem |
Enter amount: The property damage premium amount. |
ACORD 129 SC (2007/01) rev. 04-10-2009 8 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 2 Est Prem |
Enter amount: The property damage premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 3 Est Prem |
Enter amount: The property damage premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 4 Est Prem |
Enter amount: The property damage premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 5 Est Prem |
Enter amount: The property damage premium amount. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$100 |
$100. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$200 |
$200. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$250 |
$250. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$500 |
$500. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$1,000 |
$1000. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$2,500 |
$2500. |
|
COVERAGES AND |
Physical Damage Comprehensive |
Check the box (if applicable): Indicates the deductible for comprehensive coverage is |
|
PREMIUMS |
$5,000 |
$5000. |
|
COVERAGES AND |
|
Enter amount: The comprehensive or other than collision premium amount. In Texas this |
|
PREMIUMS |
Vehicle 1 Est Prem |
is the comprehensive premium amount only. |
|
COVERAGES AND |
|
Enter amount: The comprehensive or other than collision premium amount. In Texas this |
|
PREMIUMS |
Vehicle 2 Est Prem |
is the comprehensive premium amount only. |
|
COVERAGES AND |
|
Enter amount: The comprehensive or other than collision premium amount. In Texas this |
|
PREMIUMS |
Vehicle 3 Est Prem |
is the comprehensive premium amount only. |
|
COVERAGES AND |
|
Enter amount: The comprehensive or other than collision premium amount. In Texas this |
|
PREMIUMS |
Vehicle 4 Est Prem |
is the comprehensive premium amount only. |
|
COVERAGES AND |
|
Enter amount: The comprehensive or other than collision premium amount. In Texas this |
|
PREMIUMS |
Vehicle 5 Est Prem |
is the comprehensive premium amount only. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $100 |
Check the box (if applicable): Indicates the deductible for collision coverage is $100. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $200 |
Check the box (if applicable): Indicates the deductible for collision coverage is $200. |
ACORD 129 SC (2007/01) rev. 04-10-2009 9 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $250 |
Check the box (if applicable): Indicates the deductible for collision coverage is $250. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $500 |
Check the box (if applicable): Indicates the deductible for collision coverage is $500. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $1,000 |
Check the box (if applicable): Indicates the deductible for collision coverage is $1000. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $2,500 |
Check the box (if applicable): Indicates the deductible for collision coverage is $2500. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Physical Damage Collision $5,000 |
Check the box (if applicable): Indicates the deductible for collision coverage is $5000. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 1 Est Prem |
Enter amount: The collision premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 2 Est Prem |
Enter amount: The collision premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 3 Est Prem |
Enter amount: The collision premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 4 Est Prem |
Enter amount: The collision premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 5 Est Prem |
Enter amount: The collision premium amount. |
|
COVERAGES AND |
Medical Payments Coverage |
Check the box (if applicable): Indicates the limit for the medical payments coverage is |
|
PREMIUMS |
$1,000 |
$1,000. |
|
COVERAGES AND |
Medical Payments Coverage |
Check the box (if applicable): Indicates the limit for the medical payments coverage is |
|
PREMIUMS |
$2,000 |
$2,000. |
|
COVERAGES AND |
Medical Payments Coverage |
Check the box (if applicable): Indicates the limit for the medical payments coverage is |
|
PREMIUMS |
$5,000 |
$5,000. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 1 Est Prem |
Enter amount: The medical payments premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 2 Est Prem |
Enter amount: The medical payments premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 3 Est Prem |
Enter amount: The medical payments premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 4 Est Prem |
Enter amount: The medical payments premium amount. |
|
COVERAGES AND |
|
|
|
PREMIUMS |
Vehicle 5 Est Prem |
Enter amount: The medical payments premium amount. |
ACORD 129 SC (2007/01) rev. 04-10-2009 10 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists combined |
|
PREMIUMS |
UM CSL $75,000 |
single limit coverage is $75,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists combined |
|
PREMIUMS |
UM CSL $100,000 |
single limit coverage is $100,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists combined |
|
PREMIUMS |
UM CSL $250,000 |
single limit coverage is $250,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists combined |
|
PREMIUMS |
UM CSL $350,000 |
single limit coverage is $350,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists combined |
|
PREMIUMS |
UM CSL $500,000 |
single limit coverage is $500,000. |
|
COVERAGES AND |
Split Limits Bodily Injury $25 / |
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are |
|
PREMIUMS |
50000 |
$25,000 each person and $50,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $50 / |
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are |
|
PREMIUMS |
100000 |
$50,000 each person and $100,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $100 / |
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are |
|
PREMIUMS |
300000 |
$100,000 each person and $300,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $250 / |
Check the box (if applicable): Indicates the limits for the uninsured motorists coverage are |
|
PREMIUMS |
500000 |
$250,000 each person and $500,000 each accident. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists property |
|
PREMIUMS |
Split Limits ($200 Ded) $25,000 |
damage liability coverage is $25,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists property |
|
PREMIUMS |
Split Limits ($200 Ded) $50,000 |
damage liability coverage is $50,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the uninsured motorists property |
|
PREMIUMS |
Split Limits ($200 Ded) $100,000 |
damage liability coverage is $100,000. |
|
COVERAGES AND |
|
Enter amount: The uninsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 1 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The uninsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 2 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The uninsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 3 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The uninsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 4 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The uninsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 5 Est Prem |
amount. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the underinsured motorists combined |
|
PREMIUMS |
UIM CSL $75,000 |
single limit coverage is $75,000. |
ACORD 129 SC (2007/01) rev. 04-10-2009 11 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the underinsured motorists combined |
|
PREMIUMS |
UIM CSL $100,000 |
single limit coverage is $100,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the underinsured motorists combined |
|
PREMIUMS |
UIM CSL $250,000 |
single limit coverage is $250,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the underinsured motorists combined |
|
PREMIUMS |
UIM CSL $350,000 |
single limit coverage is $350,000. |
|
COVERAGES AND |
|
Check the box (if applicable): Indicates the limit for the underinsured motorists combined |
|
PREMIUMS |
UIM CSL $500,000 |
single limit coverage is $500,000. |
|
COVERAGES AND |
Split Limits Bodily Injury $25 / |
Check the box (if applicable): Indicates the limits for the underinsured motorists coverage |
|
PREMIUMS |
50000 |
are $25,000 each person and $50,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $50 / |
Check the box (if applicable): Indicates the limits for the underinsured motorists coverage |
|
PREMIUMS |
100000 |
are $50,000 each person and $100,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $100 / |
Check the box (if applicable): Indicates the limits for the underinsured motorists coverage |
|
PREMIUMS |
300000 |
are $100,000 each person and $300,000 each accident. |
|
COVERAGES AND |
Split Limits Bodily Injury $250 / |
Check the box (if applicable): Indicates the limits for the underinsured motorists coverage |
|
PREMIUMS |
500000 |
are $250,000 each person and $500,000 each accident. |
|
COVERAGES AND |
Split Limits Property Damage |
Check the box (if applicable): Indicates the limit for the underinsured motorists property |
|
PREMIUMS |
$25,000 |
damage liability coverage is $25,000. |
|
COVERAGES AND |
Split Limits Property Damage |
Check the box (if applicable): Indicates the limit for the underinsured motorists property |
|
PREMIUMS |
$50,000 |
damage liability coverage is $50,000. |
|
COVERAGES AND |
Split Limits Property Damage |
Check the box (if applicable): Indicates the limit for the underinsured motorists property |
|
PREMIUMS |
$100,000 |
damage liability coverage is $100,000. |
|
COVERAGES AND |
|
Enter amount: The underinsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 1 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The underinsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 2 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The underinsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 3 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The underinsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 4 Est Prem |
amount. |
|
COVERAGES AND |
|
Enter amount: The underinsured motorists bodily injury or combined single limit premium |
|
PREMIUMS |
Vehicle 5 Est Prem |
amount. |
|
COVERAGES AND |
Estimated Total Premium Per |
|
|
PREMIUMS |
Vehicle Vehicle 1 |
Enter amount: The total amount for the vehicle. |
|
COVERAGES AND |
Estimated Total Premium Per |
|
|
PREMIUMS |
Vehicle Vehicle 2 |
Enter amount: The total amount for the vehicle. |
ACORD 129 SC (2007/01) rev. 04-10-2009 12 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES AND PREMIUMS |
Estimated Total Premium Per Vehicle Vehicle 3 |
Enter amount: The total amount for the vehicle. |
|
COVERAGES AND PREMIUMS |
Estimated Total Premium Per Vehicle Vehicle 4 |
Enter amount: The total amount for the vehicle. |
|
COVERAGES AND PREMIUMS |
Estimated Total Premium Per Vehicle Vehicle 5 |
Enter amount: The total amount for the vehicle. |
|
OPERATOR INFORMATION |
Last Name One |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name One |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I One |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) One |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number One |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State One |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Two |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Two |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Two |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Two |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Two |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Two |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Three |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Three |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Three |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 13 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Three |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Three |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Three |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Four |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Four |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Four |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Four |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Four |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Four |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Five |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Five |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Five |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Five |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Five |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Five |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Six |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Six |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Six |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 14 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Six |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Six |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Six |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Seven |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Seven |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Seven |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Seven |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Seven |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Seven |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Eight |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Eight |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Eight |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Eight |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Eight |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Eight |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Nine |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Nine |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Nine |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 15 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Nine |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Nine |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Nine |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Ten |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Ten |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Ten |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Ten |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Ten |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Ten |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Eleven |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Eleven |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Eleven |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Eleven |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Eleven |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Eleven |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twelve |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twelve |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twelve |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 16 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twelve |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twelve |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twelve |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirteen |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Fourteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Fourteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Fourteen |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Fourteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Fourteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Fourteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Fifteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Fifteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Fifteen |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 17 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Fifteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Fifteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Fifteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Sixteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Sixteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Sixteen |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Sixteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Sixteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Sixteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Seventeen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Seventeen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Seventeen |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Seventeen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Seventeen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Seventeen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Eighteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Eighteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Eighteen |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 18 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Eighteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Eighteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Eighteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Nineteen |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Nineteen |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Nineteen |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Nineteen |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Nineteen |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Nineteen |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-One |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-One |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-One |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 19 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-One |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-One |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-One |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Two |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Two |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Two |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Two |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Two |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Two |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Three |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Three |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Three |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Three |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Three |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Three |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Four |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Four |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Four |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 20 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Four |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Four |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Four |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Five |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Five |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Five |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Five |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Five |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Five |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Six |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Six |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Six |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Six |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Six |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Six |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Seven |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Seven |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Seven |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 21 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Seven |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Seven |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Seven |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Eight |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Eight |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Eight |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Eight |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Eight |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Eight |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Twenty-Nine |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Twenty-Nine |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Twenty-Nine |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Twenty-Nine |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Twenty-Nine |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Twenty-Nine |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 22 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-One |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-One |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-One |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-One |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-One |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-One |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Two |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Two |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Two |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Two |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Two |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Two |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Three |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Three |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Three |
Enter text: The driver's middle name or initial (other given name). |
ACORD 129 SC (2007/01) rev. 04-10-2009 23 of 24
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Three |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Three |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Three |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Four |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Four |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Four |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Four |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Four |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Four |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Five |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Five |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Five |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Five |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Five |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Five |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Six |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Six |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Six |
Enter text: The driver's middle name or initial (other given name). |
|
Section Name |
Field Name |
Field and/or Section Description |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Six |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Six |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Six |
Enter code: The state the driver is licensed in. |
|
OPERATOR INFORMATION |
Last Name Thirty-Seven |
Enter text: The driver's last name (surname). |
|
OPERATOR INFORMATION |
First Name Thirty-Seven |
Enter text: The driver's first name (given name). |
|
OPERATOR INFORMATION |
M I Thirty-Seven |
Enter text: The driver's middle name or initial (other given name). |
|
OPERATOR INFORMATION |
Birth Date (Mo./Day/Yr.) Thirty-Seven |
Enter date: The birth date of the driver. |
|
OPERATOR INFORMATION |
Drivers License Number Thirty-Seven |
Enter identifier: The driver's license number. |
|
OPERATOR INFORMATION |
State Thirty-Seven |
Enter code: The state the driver is licensed in. |
|
Edition |
Date |
The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM). |
ACORD 129 SC (2007/01) rev. 04-10-2009 24 of 24
|