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