Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 187 SC (2003/03)
Associated Auto Insurers Plan of
South Carolina - Name and/or
Ownership Change
ACORD 187 SC (AIP 6313), Associated Auto Insurers Plan of South
Carolina - Name and/or Ownership Change, 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.
IDENTIFICATION SECTION Date (Mo/Day/Yr)
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Insured's Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
FORM PURPOSE
Combination Of Separate Entitles
with common ownership. (Enter
current ownership information for
each entity in separate columns
below) [Checkbox]
Check the box (if applicable): Indicates the request is being made because there has been
a combination of separate entities. As used here, this form must be completed at the
request of the assigned company and returned within 10 days. Failure to return the
completed and signed form following two written requests may result in loss of coverage
under the cancellation provisions of the Plan. All questions must be answered completely.
The purpose of this request is as follows:
FORM PURPOSE
Change of Ownership - Complete
Column A indicating ownership
before change and Column B
indicating ownership after change.
[Checkbox]
Check the box (if applicable): Indicates the request is being made because there has been
a change in ownership.
FORM PURPOSE
Merger or Consolidation -
Complete Column A & B indicating
ownership before change and
Column C indicating ownership
after change. [Checkbox]
Check the box (if applicable): Indicates the request is being made because there has been
a merger or consolidation.
FORM PURPOSE
Indicate date of actual change
Enter date: The actual date of ownership change.
FORM PURPOSE
Name and Location Of Entity (A)
Enter text: The name and location of the entity.
FORM PURPOSE
Name and Location Of Entity (B)
Enter text: The name and location of the entity.
FORM PURPOSE
Name and Location Of Entity (C)
Enter text: The name and location of the entity.
FORM PURPOSE
Type of Entity (Corp, Partnership,
etc) (A)
Enter text: The description of the legal entity (e.g. Corporation, Partnership, etc.).
FORM PURPOSE
Type of Entity (Corp, Partnership,
etc) (B)
Enter text: The description of the legal entity (e.g. Corporation, Partnership, etc.).
ACORD 187 SC (2003/03) rev. 05-08-2009
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Section Name
Field Name
Field and/or Section Description
FORM PURPOSE
Type of Entity (Corp, Partnership,
etc) (C)
Enter text: The description of the legal entity (e.g. Corporation, Partnership, etc.).
FORM PURPOSE
Total shares of voting stock
issued (A)
Enter number: The total number of voting shares issued.
FORM PURPOSE
Total shares of voting stock
issued (B)
Enter number: The total number of voting shares issued.
FORM PURPOSE
Total shares of voting stock
issued (C)
Enter number: The total number of voting shares issued.
OWNERSHIP
Ownership: Corporations;
Partnership; Other
Enter text: The description of the owners, partners or board of directors members. See
state guidelines for specific instructions.
OWNERSHIP
Ownership: Corporations;
Partnership; Other
Enter text: The description of the owners, partners or board of directors members. See
state guidelines for specific instructions.
OWNERSHIP
Ownership: Corporations;
Partnership; Other
Enter text: The description of the owners, partners or board of directors members. See
state guidelines for specific instructions.
SIGNATURE
Name of Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE
Signature of Owner, Partner Or
Executive Officer.
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Title
Enter text: The title of the individual in the organization or his relationship to the
organization.
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).
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