ACORD 2 (2011/07)

ACORD 2 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 2 (2011/07)
Automobile Loss Notice
ACORD 2, Automobile Loss Notice, is used to report both
commercial and personal lines automobile losses.
IDENTIFICATION SECTION Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line one of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address line two of the producer/agency.
IDENTIFICATION SECTION
Enter text: The mailing address city name of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address state or province code of the producer/agency.
IDENTIFICATION SECTION
Enter code: The mailing address postal code of the producer/agency.
IDENTIFICATION SECTION Contact Name
Enter text: The name of the individual at the producer's establishment that is the primary
contact.
IDENTIFICATION SECTION Phone (A/C, No, Ext)
Enter number: The producer's contact person's phone number. If applicable, include the
area code and extension.
IDENTIFICATION SECTION FAX
Enter number: The fax number of the producer/agency.
IDENTIFICATION SECTION E-Mail Address
Enter text: The producer's contact person e-mail address.
IDENTIFICATION SECTION Code
Enter code: The identification code assigned to the producer (e.g. agency or brokerage
firm) by the insurer.
IDENTIFICATION SECTION Subcode
Enter code: The identification code assigned by the insurer to the sub-producer (e.g.
person) within a producer's office (e.g. agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Insured Location Code
Enter code: The code the policyholder defines that is used to allocate loss experience to
cost centers. For example, if a grocery store chain is insured and the entire chain was
under one policy, the grocery store chain might choose to allocate the losses for each
store. To do this they would provide a store number or store code (something the insured
defines) when they report a claim. The insured would include that store number in the
Insured Location Code field so that the carrier can record the code in their claim system
and then the right store is assessed the loss experience.
IDENTIFICATION SECTION Date of Loss
Enter date: The date that the loss occurred.
IDENTIFICATION SECTION Time of Loss
Enter time: The approximate time that the loss occurred.
IDENTIFICATION SECTION AM
Check the box (if applicable): Indicates the loss occurred in the morning.
IDENTIFICATION SECTION PM
Check the box (if applicable): Indicates the loss occurred in the afternoon or evening.
IDENTIFICATION SECTION Company
Enter text: The insurer's full legal company name(s) as found in the file 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 NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
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.
IDENTIFICATION SECTION Policy Type
Enter text: The type of policy issued to the insured (e. g., personal auto, truckers, garage
liability, commercial property, builders risk, etc.).
IDENTIFICATION SECTION Name of Insured
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
INSURED
Date of Birth
Enter date: The date of birth of the insured.
INSURED
FEIN (if applicable)
Enter identifier: The tax identifier of the named insured. As used here, this contains the
Federal Employer Identification Number (FEIN), if applicable, for the insured.
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Section Name
Field Name
Field and/or Section Description
IDENTIFICATION SECTION Marital Status
Enter code: The insured's marital status. The applicable codes are:
* S Single
* M Married
* D Divorced
* P Separated
* W Widowed
* C Domestic Partner (unmarried)
* V Civil Union
* U Unknown
* O Other
IDENTIFICATION SECTION Primary Phone
Enter number: The named insured's primary phone number.
INSURED
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
INSURED
Business
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
INSURED
Secondary Phone
Enter number: The named insured's secondary phone number.
INSURED
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
INSURED
Business
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
INSURED
Cell
Check the box (if applicable): Indicates the phone number is for a cell phone.
IDENTIFICATION SECTION Insured's Mailing Address
Enter text: The named insured's mailing address line one. As used here, the mailing
address as found on the declarations page of the policy.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address line two.
IDENTIFICATION SECTION
Enter text: The named insured's mailing address city name.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address state or province code.
IDENTIFICATION SECTION
Enter code: The named insured's mailing address postal code.
INSURED
Primary E-Mail Address
Enter text: The named insured's primary e-mail address.
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Section Name
Field Name
Field and/or Section Description
INSURED
Secondary E-Mail Address
Enter text: The named insured's secondary e-mail address.
CONTACT
Contact Insured
Check the box (if applicable): Indicates If the individual to contact is the same as the
insured, check this box and leave blank the areas for contact name, address and phone
numbers.
CONTACT
Contact Name
Enter text: The full name (First, Middle, Last) of the individual to be contacted as a
representative of the insured on all subsequent business relating to this incident. No entry
is needed if the 'Contact Insured' option is checked.
CONTACT
Primary Phone
Enter number: The loss contact's primary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number is for a home phone.
CONTACT
Business
Check the box (if applicable): Indicates the primary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number is for a cell phone.
CONTACT
Secondary Phone
Enter number: The loss contact's secondary telephone number including area code.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number is for a home phone.
CONTACT
Business
Check the box (if applicable): Indicates the secondary phone number is for a business
phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number is for a cell phone.
CONTACT
When to Contact
Enter text: The best time of the day to contact this individual (e.g., evenings, days, noon to
3:00 P.M.).
CONTACT
Contact's Mailing Address
Enter text: The loss contact's first address line.
CONTACT
Enter text: The loss contact's second address line.
CONTACT
Enter text: The loss contact's city.
CONTACT
Enter code: The loss contact's state.
CONTACT
Enter code: The loss contact's postal code.
CONTACT
Primary E-Mail Address
Enter text: The loss contact's primary e-mail address.
CONTACT
Secondary E-Mail Address
Enter text: The loss contact's secondary e-mail address.
LOSS
Location of Loss Street
Enter text: The loss location's physical street address.
LOSS
Location of Loss City, State, Zip
Enter text: The loss location's city.
LOSS
Enter code: The loss location's state or province code.
LOSS
Enter code: The loss location's postal code.
LOSS
Location of Loss Country
Enter code: The loss location's country code.
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Section Name
Field Name
Field and/or Section Description
LOSS
Describe Location of Loss if not at
Specific Street Address
Enter text: The description of the location of loss if not at a specific street address.
LOSS
Police or Fire Department
Contacted
Enter text: The name of the municipal, county or other police department, fire department
or other authority to which the accident was reported, including any precinct or station
number, if available.
LOSS
Report #
Enter identifier: The report number assigned by the authority contacted. For example, the
number of the vehicle incident report filed by the police after an automobile accident.
LOSS
Description of Accident
Enter text: An explanation of how the loss occurred. As used here, this is the description
of the accident. Attach ACORD 101, Additional Remarks Schedule, if more space is
required.
INSURED VEHICLE
Veh. No.
Enter number: The producer assigned vehicle number.
INSURED VEHICLE
Year
Enter year: The model year of the vehicle.
INSURED VEHICLE
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
INSURED VEHICLE
Model
Enter text: The manufacturer's model name for the vehicle.
INSURED VEHICLE
Body Type
Enter code: The body type of the vehicle.
INSURED VEHICLE
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
INSURED VEHICLE
Plate No.
Enter number: The license plate number.
INSURED VEHICLE
State
Enter code: The state or province in which the vehicle is registered.
INSURED VEHICLE
Owner is insured
Check the box (if applicable): Indicates if the owner of the insured vehicle or aircraft is the
same as the named insured.
INSURED VEHICLE
Owners Name & Address
Enter text: The full name of the individual or business that is the owner of the vehicle or
property.
INSURED VEHICLE
Enter text: The first address line of the owner of the vehicle or property.
INSURED VEHICLE
Enter text: The city of the owner of the vehicle or property.
INSURED VEHICLE
Enter code: The state or province code of the owner of the vehicle or property.
INSURED VEHICLE
Enter code: The postal code of the owner of the vehicle or property.
INSURED VEHICLE
Primary Phone
Enter number: The primary phone number for the owner of the vehicle or property.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number for the owner is a home
phone.
CONTACT
Business
Check the box (if applicable): Indicates the primary phone number for the owner is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number for the owner is a cell
phone.
CONTACT
Secondary Phone
Enter number: The secondary phone number for the owner of the vehicle or property.
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Section Name
Field Name
Field and/or Section Description
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number for the owner is a
home phone.
CONTACT
Business
Check the box (if applicable): Indicates the secondary phone number for the owner is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number for the owner is a
cell phone.
CONTACT
Primary E-Mail Address
Enter text: The primary e-mail address of the owner of the vehicle or property.
CONTACT
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
INSURED VEHICLE
Driver is owner
Check the box (if applicable): Indicates if the driver of the insured vehicle is the same as
the owner.
INSURED VEHICLE
Drivers Name & Address
Enter text: The driver's first name (given name).
INSURED VEHICLE
Enter text: The driver's middle name or initial (other given name).
INSURED VEHICLE
Enter text: The driver's last name (surname).
INSURED VEHICLE
Enter text: The first address line of the driver.
INSURED VEHICLE
Enter text: The city of the driver.
INSURED VEHICLE
Enter code: The state or province of the driver.
INSURED VEHICLE
Enter code: The postal code of the driver.
CONTACT
Primary Phone
Enter number: The primary phone number of the driver.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number for the driver is a home
phone.
CONTACT
Business
Check the box (if applicable): Indicates the primary phone number for the driver is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number for the driver is a cell
phone.
CONTACT
Secondary Phone
Enter number: The secondary phone number for the driver.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number for the driver is a
home phone.
CONTACT
Business
Check the box (if applicable): Indicates the secondary phone number for the driver is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number for the driver is a cell
phone.
CONTACT
Primary E-Mail Address
Enter text: The primary e-mail address for the driver.
CONTACT
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
INSURED VEHICLE
Relation to Insured
Enter code: The relationship of the driver to the named insured. Examples are: I -
Insured; S - Spouse; C - Child; SIB - Brother or Sister; P - Parent; E - Employee.
INSURED VEHICLE
Date of Birth
Enter date: The birth date of the driver.
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Section Name
Field Name
Field and/or Section Description
INSURED VEHICLE
Drivers License Number
Enter identifier: The driver's license number.
INSURED VEHICLE
State
Enter code: The state in which the driver is licensed.
INSURED VEHICLE
Purpose of Use
Enter text: A short description of the purpose of the trip during which the accident occurred
(e.g., trip to store or commuting to work).
INSURED VEHICLE
Used With Permission?
Enter code: Indicates if the driver had permission to use the vehicle.
INSURED VEHICLE
Describe Damage
Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender
crushed).
INSURED VEHICLE
Was a standard child passenger
restraint system (child seat)
installed in the vehicle at the time
of the accident?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Was a standard child passenger restraint system (child seat) installed in the
vehicle at the time of the accident?.
INSURED VEHICLE
Was the child passenger restraint
system (child seat) in use by a
child during the time of the
accident?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Was the child passenger restraint system (child seat) in use by a child during
the time of the accident?.
INSURED VEHICLE
Did the child passenger restraint
system (child seat) sustain a loss
at the time of the accident?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Did the child passenger restraint system (child seat) sustain a loss at the time
of the accident?.
INSURED VEHICLE
Estimate Amount
Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property.
INSURED VEHICLE
Where Can Vehicle Be Seen?
Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If
other than at the insureds address, include the address.
INSURED VEHICLE
When Can Vehicle Be Seen?
Enter text: The time period the vehicle, aircraft or property is available for inspection.
INSURED VEHICLE
Other Insurance On Vehicle-
Carrier
Enter text: The insurer name on any other applicable insurance. As used here, enter N/A
if none.
INSURED VEHICLE
Other Insurance On Vehicle-Policy
Number
Enter identifier: The policy number on any other applicable insurance. As used here, enter
N/A if none.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
PROPERTY DAMAGED
Non-Vehicle ?
Check the box (if applicable): Indicates the damage is not to a vehicle.
PROPERTY DAMAGED
Veh #
Enter number: The producer assigned vehicle number.
PROPERTY DAMAGED
Year
Enter year: The model year of the vehicle.
PROPERTY DAMAGED
Make
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
PROPERTY DAMAGED
Model
Enter text: The manufacturer's model name for the vehicle.
PROPERTY DAMAGED
Body Type
Enter code: The body type of the vehicle.
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Section Name
Field Name
Field and/or Section Description
PROPERTY DAMAGED
V.I.N.
Enter identifier: The vehicle identification number (VIN) or serial number assigned by the
manufacturer.
PROPERTY DAMAGED
Plate Number
Enter number: The license plate number.
PROPERTY DAMAGED
State
Enter code: The state or province in which the vehicle is registered.
PROPERTY DAMAGED
Describe Property
Enter text: A brief description of the type of property damaged, such as home or fence.
PROPERTY DAMAGED
Other Veh./Prop. Ins?
Enter code: Indicates if the damaged property, vehicle or aircraft is insured or not.
PROPERTY DAMAGED
Company or Agency Name
Enter text: The insurer name on any other applicable insurance.
IDENTIFICATION SECTION NAIC Code
Enter code: The NAIC code of the insurance company that issued the policy.
PROPERTY DAMAGED
Policy #
Enter identifier: The policy number on any other applicable insurance. As used here, the
policy number for this property (or vehicle) or any other applicable insurance.
PROPERTY DAMAGED
Owners' Name and address
Enter text: The full name of the individual or business that is the owner of the vehicle or
property.
PROPERTY DAMAGED
Enter text: The first address line of the owner of the vehicle or property.
PROPERTY DAMAGED
Enter text: The city of the owner of the vehicle or property.
PROPERTY DAMAGED
Enter code: The state or province code of the owner of the vehicle or property.
PROPERTY DAMAGED
Enter code: The postal code of the owner of the vehicle or property.
CONTACT
Primary Phone
Enter number: The primary phone number for the owner of the vehicle or property.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number for the owner is a home
phone.
CONTACT
Business
Check the box (if applicable): Indicates the primary phone number for the owner is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number for the owner is a cell
phone.
CONTACT
Secondary Phone
Enter number: The secondary phone number for the owner of the vehicle or property.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number for the owner is a
home phone.
CONTACT
Business
Check the box (if applicable): Indicates the secondary phone number for the owner is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number for the owner is a
cell phone.
CONTACT
Primary E-Mail Address
Enter text: The primary e-mail address of the owner of the vehicle or property.
CONTACT
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
CONTACT
Driver address same as owner
Check the box (if applicable): Indicates if the driver of the insured vehicle is the same as
the owner.
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Section Name
Field Name
Field and/or Section Description
PROPERTY DAMAGED
Drivers Name & Address
Enter text: The driver's first name (given name).
PROPERTY DAMAGED
Enter text: The driver's middle name or initial (other given name).
PROPERTY DAMAGED
Enter text: The driver's last name (surname).
PROPERTY DAMAGED
Enter text: The first address line of the driver.
PROPERTY DAMAGED
Enter text: The city of the driver.
PROPERTY DAMAGED
Enter code: The state or province of the driver.
PROPERTY DAMAGED
Enter code: The postal code of the driver.
CONTACT
Primary Phone
Enter number: The primary phone number of the driver.
CONTACT
Home
Check the box (if applicable): Indicates the primary phone number for the driver is a home
phone.
CONTACT
Business
Check the box (if applicable): Indicates the primary phone number for the driver is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the primary phone number for the driver is a cell
phone.
CONTACT
Secondary Phone
Enter number: The secondary phone number for the driver.
CONTACT
Home
Check the box (if applicable): Indicates the secondary phone number for the driver is a
home phone.
CONTACT
Business
Check the box (if applicable): Indicates the secondary phone number for the driver is a
business phone.
CONTACT
Cell
Check the box (if applicable): Indicates the secondary phone number for the driver is a cell
phone.
CONTACT
Primary E-Mail Address
Enter text: The primary e-mail address for the driver.
CONTACT
Secondary E-Mail Address
Enter text: The secondary e-mail address of the owner of the vehicle or property.
PROPERTY DAMAGED
Describe Damage
Enter text: Describe any damage to the vehicle, aircraft or property (e.g., right front fender
crushed).
PROPERTY DAMAGED
Estimate Amount
Enter amount: An estimate for the cost of repairing the vehicle, aircraft or property.
PROPERTY DAMAGED
Where Can Damage Be Seen?
Enter text: The location where the adjuster can inspect the vehicle, aircraft or property. If
other than at the insureds address, include the address.
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Phone
Enter number: The primary phone number of the injured party.
INJURED
PED
Check the box (if applicable): Indicates if the injured party was a pedestrian.
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Section Name
Field Name
Field and/or Section Description
INJURED
Ins. Veh.
Check the box (if applicable): Indicates if the injured party was in the insured's vehicle.
INJURED
Other Veh.
Check the box (if applicable): Indicates if the injured party was in a vehicle other than the
insured's vehicle.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Phone
Enter number: The primary phone number of the injured party.
INJURED
PED
Check the box (if applicable): Indicates if the injured party was a pedestrian.
INJURED
Ins. Veh.
Check the box (if applicable): Indicates if the injured party was in the insured's vehicle.
INJURED
Other Veh.
Check the box (if applicable): Indicates if the injured party was in a vehicle other than the
insured's vehicle.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Phone
Enter number: The primary phone number of the injured party.
INJURED
PED
Check the box (if applicable): Indicates if the injured party was a pedestrian.
INJURED
Ins. Veh.
Check the box (if applicable): Indicates if the injured party was in the insured's vehicle.
INJURED
Other Veh.
Check the box (if applicable): Indicates if the injured party was in a vehicle other than the
insured's vehicle.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
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Section Name
Field Name
Field and/or Section Description
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
INJURED
Name & Address
Enter text: The name of a person that was injured in the incident or accident.
INJURED
Enter text: The first address line of the injured party.
INJURED
Enter text: The second address line of the injured party.
INJURED
Enter text: The city of the injured party.
INJURED
Enter code: The state or province of the injured party.
INJURED
Enter code: The postal code of the injured party.
INJURED
Phone
Enter number: The primary phone number of the injured party.
INJURED
PED
Check the box (if applicable): Indicates if the injured party was a pedestrian.
INJURED
Ins. Veh.
Check the box (if applicable): Indicates if the injured party was in the insured's vehicle.
INJURED
Other Veh.
Check the box (if applicable): Indicates if the injured party was in a vehicle other than the
insured's vehicle.
INJURED
Age
Enter number: The age, at the time of the incident, of the injured party.
INJURED
Extent of Injury
Enter text: A brief description of the injury sustained by the injured party (e.g. broken left
leg).
WITNESSES OR
PASSENGERS
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The second address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Phone
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Ins. Veh.
Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the
time of the incident.
WITNESSES OR
PASSENGERS
Other Veh.
Check the box (if applicable): Indicates if the witness was in a vehicle other than the
insured's at the time of the incident.
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Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS
Other
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
WITNESSES OR
PASSENGERS
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The second address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The postal code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Phone
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Ins. Veh.
Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the
time of the incident.
WITNESSES OR
PASSENGERS
Other Veh.
Check the box (if applicable): Indicates if the witness was in a vehicle other than the
insured's at the time of the incident.
WITNESSES OR
PASSENGERS
Other
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
WITNESSES OR
PASSENGERS
Name & Address
Enter text: The name of a person that was a witness to the incident or an uninjured
passenger.
WITNESSES OR
PASSENGERS
Enter text: The first address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The second address line of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter text: The city of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The state or province code of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Enter code: The postal code of a person that was a witness to the incident.
ACORD 2 (2011/07) rev. 6-30-2011
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Section Name
Field Name
Field and/or Section Description
WITNESSES OR
PASSENGERS
Phone
Enter number: The primary phone number of a person that was a witness to the incident.
WITNESSES OR
PASSENGERS
Ins. Veh.
Check the box (if applicable): Indicates if the witness was in the insured's vehicle at the
time of the incident.
WITNESSES OR
PASSENGERS
Other Veh.
Check the box (if applicable): Indicates if the witness was in a vehicle other than the
insured's at the time of the incident.
WITNESSES OR
PASSENGERS
Other
Enter text: A description of the location of the witness if the witness was not in the
insured's vehicle or aircraft or other involved vehicle or aircraft at the time of the incident.
WITNESSES OR
PASSENGERS
Reported By
Enter text: The name of the individual that reported the loss.
WITNESSES OR
PASSENGERS
Reported To
Enter text: The name of the individual within the agency or company to whom this loss
was reported.
WITNESSES OR
PASSENGERS
Remarks (Attach ACORD 101,
Additional Remarks Schedule, if
more space is required)
Enter text: The automobile loss notice general remarks. Describe any other additional
information that will assist in properly reporting and settling
this claim. Include the adjusters name if known. Attach ACORD 101, Additional Remarks
Schedule, if more space is required.
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
Edition
Date
The edition identifier of the form including the form number and edition (the date is
typically formatted YYYY/MM).