Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 860 CA (2004/12)
California Auto Supplement -
Driver Self Certification
Use this form with personal auto applications when an applicant applies for the Good
Driver Discount and intends to self certify his or her driving record.
IDENTIFICATION SECTION Agency
Agency's name and address.
IDENTIFICATION SECTION Code
Identification code assigned to the agency or brokerage firm by the insurance company
receiving this form.
IDENTIFICATION SECTION Subcode
If the agency uses a subcode identification system with the company, enter the
appropriate code.
IDENTIFICATION SECTION Applicant (First Named Insured)
First Named Insured as it appears on the auto application.
IDENTIFICATION SECTION Company
Name of the insurance company (or residual market plan) that will receive the application.
Do not use group names, use the actual name of the company within the group in which
you wish to have the policy issued.
IDENTIFICATION SECTION Policy #
The number assigned by the insurance company for the policy. In general, policy numbers
will not appear on new business applications since they are not known at that point in time.
IDENTIFICATION SECTION Effective Date
Enter the Effective date on which the terms and conditions of the policy will commence.
DRIVER SELF
CERTIFICATION
Use this section to describe all accidents in which you have been involved within the last
three years. Indicate whether or not the accident was your fault.
DRIVER SELF
CERTIFICATION
Drv #
Driver number as it appears in the auto application.
DRIVER SELF
CERTIFICATION
Date of Accident
Date the accident or conviction occurred. (MM/DD/YYYY)
DRIVER SELF
CERTIFICATION
Description of Accident
A complete description of the accident. This would include the number of vehicles involved
and the type of vehicles (private passenger or commercial).
DRIVER SELF
CERTIFICATION
Place of Accident
City and state where the accident occurred.
DRIVER SELF
CERTIFICATION
My Fault
Indicate whether or not the accident was your fault.
DRIVER SELF
CERTIFICATION
BI or Death
Indicate whether or not the accident resulted in bodily injury or death.
DRIVER SELF
CERTIFICATION
Amount of Property Damage
Indicate the amount of property damage as a result of the accident.
APPLICANT'S SIGNATURE Applicant's Signature
Applicant must sign and date the certification.
ACORD 860 CA (2004/12)
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