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ACORD Form 90 Personal Automobile Application Instructions

 

Personal Automobile Application 90

 

The underwriting process for any personal lines policy begins with the submission of a completed application. This guide provides assistance in completing the ACORD Personal Auto Application.  The generic sections of each personal lines form are explained in the Personal Lines Generic Section at the beginning of the Personal Lines Section of the Forms Instruction Guide.

 

IMPORTANT - State-specific personal auto applications, together with all necessary required supplements and notices, have been provided for all states.  All comply with current state statutes and regulations, and all will be revised as necessary to comply with future changes in state requirements.  The original ACORD 90, Personal Auto Application, was withdrawn July 1, 1996, two years after the introduction of all of the state-specific forms.  The original ACORD 90 was not acceptable because of laws or regulations in thirty-three states. However, the state-specific applications developed by ACORD to replace the original ACORD 90 are acceptable in each respective state.

 

The unique sections of the state applications are the Coverages/Premium section on the front of the form, and the Fair Credit, Fraud, coverage acceptance/rejection, and other disclosure requirements on the bottom of the back of the form.  The balance of each state form is identical to all the others.  The following pages include a depiction of the common sections, and instructions relating to the completion of these sections.  Refer to the State Forms section of this Guide, and your company rating manual, for information about the state-unique coverage and requirements.

 

RESIDENCE

Number of Years at Address Current and Previous  

Number of years present at both the applicant's current and previous addresses.

 

Previous Address  

Physical address of the first named insured if the applicant has been at the current address for less than three years.

 

GARAGE LOCATION

Indicate vehicle number and complete address including ZIP code for any vehicle not kept at the mailing address. Also, provide this information if the mailing address is a post office box or rural route address, or when a driver is at school with a vehicle.

 

VEHICLE DESCRIPTION/USE

Total # Vehicles In Household

All owned, leased, or regularly used vehicles in household, including non-registered and non-insured vehicles.

 

Year

Model year of the vehicle.

 

Make, Model and Body Type  

Manufacturer's trade name for the vehicle, including number of doors (e.g., Ford Taurus, 4 door sedan).

 

VIN/Registered State  

Vehicle identification number as it appears on the title certificate or registration. Also enter the state where the vehicle is registered. If the vehicle is registered in a state different from where it is garaged, provide an explanation in the Remarks section.

 

HP/CC  

Horsepower, or the number of cubic centimeters of displacement.

 

Date Purch  

Year the applicant acquired the vehicle in YYYY format.

 

New/Used  

Enter "N" if the applicant bought the vehicle new, "U" if the vehicle was used.

 

Cost New  

Original cost of the vehicle.

 

Symbol Age Grp  

If the vehicle requires physical damage coverage, enter the symbol group code. Refer to rating manual.

 

Terr  

Rating territory code where the vehicle is principally garaged. Refer to rating manual.

 

Miles 1 Way Wk/Schl  

Number of miles from the garage location to school or work. 

 

# Days Week  

Number of days per week the vehicle is used to commute from the garage location to work or school. This includes driving to and from a commuter lot or transit station.

 

# Weeks/ Mo.

Number of weeks per month the vehicle is used to commute from the garage location to work or school.  This includes driving to and from a commuter lot or transit station.

 

Usage  

Enter pleasure (P), business (B) or farm (F). Use business (except for farming) if the vehicle is involved in the occupation, profession or business of the applicant or any other operator of the vehicle. Going to or from the principal place of occupation, profession or business is considered pleasure.

 

Perform  

Vehicle's performance level. Indicate High (H), Intermediate (I) or Sport (S).

 

Multi-Car  

Check box only if multi-car credit applies.

 

Carpool  

Indicate if any vehicle is used in a car pool for travel to work or school.

 

Garaged  

Indicate if the vehicle is parked in a garage at night. If the vehicle is left on the street, at school or some other equally exposed place, provide this information in Remarks. Examples of exposures are:

 

  Off street (driveway)

  Off street (school)

  On street (at residence)

  On street (at school)

 

Odometer Reading  

Current number of miles on the odometer.

 

Annual Mileage  

Total estimated annual mileage for each vehicle.

 

Govern Driver  

Driver to be assigned to each vehicle for rating purposes.

 

Driver Use %  

Percentage that each driver uses each vehicle. Each vehicle should total 100 percent. If any driver has 0 percent use for all vehicles, indicate why in the Remarks section.

 

Class  

Rate classification for each vehicle. Refer to manual; some companies determine class automatically from information provided in Vehicle Use and Driver Information sections.

 

Seat Belt  

Check the box if the vehicle is equipped with automatic seat belts.

 

Air Bag  

Indicate D for driver side air bag, B for vehicle equipped with air bag for both front driver and passenger.

 

Anti-Lock Brakes 2/4  

For vehicles with anti-lock brakes, indicate whether the car is equipped with a 2-wheel or 4-wheel anti-lock braking system.

 

Anti-Theft Devices 

If vehicle is equipped with an anti-theft device, indicate type.

 

Credits and Surcharges  

Enter any other credits and/or surcharges that are to apply to any or all vehicles.

 

COVERAGES/PREMIUMS

For information relating to each state's unique coverages, refer to the State Forms section in this guide, and your company's rating manual.

 

DRIVER INFORMATION

Name  

Name of each licensed operator (resident or not) as it appears on their drivers licenses, and every resident of the household regardless of age. Enter the surname only if different from the applicant's. Show the applicant as driver #1, even if not an operator.

 

Sex  

Enter F for female, M for male.

 

Mar Stat  

Enter the marital status of each listed driver. Examples:

 

S=Single

M=Married

D=Divorced

SP=Separated

W=Widowed

 

Relation to Applicant  

Driver's relationship to the applicant. Examples:

 

I=Insured

Sp=Spouse

C=Child 

Sib=Brother/Sister

P=Parent

E=Employee

 

Date of Birth  

Date of birth of each driver and household resident (MM/DD/YY) (e.g., March 7, 1944 should be 03/07/44).

 

Occupation  

Occupation of each operator.

 

Date Lic  

Date (MM/YY) each driver was permanently licensed.

 

Stdt >> 100

Indicate if any youthful driver is residing at a school over 100 road miles from the principal place of garaging. Show name of institution and address in the Remarks section.

 

Good Stdt  

Indicate if any driver qualifies for a good student credit (verify that company offers this credit). Complete and attach a Good Student Certificate (ACORD 91) for each operator who qualifies.

 

Drv Train  

Indicate if driver training credit applies to the driver, if required by the company. Refer to the company's manual to verify if a credit or surcharge should be applied. Attach a Driver Training Certificate for any operator under age 21 who has successfully completed this training and qualifies for the credit.

 

Acc Prev Cse 

Date on which the driver successfully completed an approved motor vehicle accident prevention course (or a similarly recognized defensive driving course).  Attach a completion certificate for each driver who qualifies.

 

Drivers License #/ Licensed State

Complete drivers license number and licensed state for each licensed operator. Copy directly from license if possible.

 

Social Security #

Social security number for each named driver and household resident.

 

ACCIDENTS/CONVICTIONS

It is important that this section be completed fully and accurately. Many companies verify driving records with state motor vehicle departments. Discrepancies between the application and the report may result in processing delays and unnecessary correspondence with the company. If there have not been any accidents, convictions or comprehensive losses during the indicated time period, enter "None". Be sure to enter the number of years reviewed, in accordance with the company's and state's requirements, as the experience period.

 

Drv #

Driver number as found in the driver information section.

 

Date of Accident/Conviction  

Date the accident or conviction occurred.

 

Description of Accident or Conviction  

A complete description of the accident or conviction. This would include the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgement of guilty, plea of nolo contendere or forfeiture of bail. Use the Remarks section or an additional piece of paper if necessary.

 

Place of Accident/Conviction  

City and state of the accident or conviction.

 

BI or Death  

Indicate whether bodily injury or death occurred. Include details in the description of accident.

 

Amount of Property Damage  

Total amount of property damage, both the applicant's and all claimant's combined damages. Refer to company manual.

 

ADDITIONAL INTEREST

Indicate if additional interest is an additional insured-lessor, certificate holder or a loss payee. Show complete name and mailing address. Provide the following information for each entity having an interest in the personal automobile(s) to be insured. The interest number or rank (1st, 2nd), whether additional interest or loss payee, the name and address of the interest (e.g., Loans Are Us Bank, 123 Main St, Anytown, NY 10010) and loan number.

 

EMPLOYMENT INFORMATION

Applicant's/Co-Applicant's Employer

Name of the organization that employs the applicant(s) named in the identification section. 

 

Applicant's Employment Location

Applicant's employment location. This may differ from where the main office/plant is situated.

 

Work Phone Number  

Work phone number at which the applicant/co-applicant may be reached.

 

Yrs Empl  

The number of years the applicant(s) have been with the employer indicated above. If less than 2 years, provide the number of years previous employment. Provide the name of the previous employer and previous occupantion in the remarks section.

 

PRIOR COVERAGE

Provide the prior insurance company's name, producer, number of years with the company, policy number and the date the prior policy expired.

 

GENERAL INFORMATION

If there are any Yes responses, provide a complete explanation in the Remarks section. Use an additional sheet of paper if the room in the Remarks section is not adequate.

 

1. Vehicle not registered to applicant?  

Provide the vehicle number and the name of any vehicle not owned by or registered to the applicant.

 

2. Any car modified/special equipment?  

Indicate which vehicles have been altered, customized or equipped with special equipment or racing items. Include any customized painting such as murals or pin striping, any equipment installed to overcome a physical handicap. Indicate vehicle number, a description of the modifications and the cost of the special equipment.

 

3. Any existing damage?  

Indicate if any vehicle has been damaged and not repaired as of the date of application. Indicate the vehicle number and a complete description of the damage.

 

4. Any other losses incurred?  

Any other losses, such as glass damage, vandalism, fire or theft, not shown in the Accident/Conviction section, incurred within the last three years. Provide description and amount of loss.

 

5. Any car kept at school?  

Identify the household member and the name and location of the school. Provide the distance between the school and the residence garage location.

 

6. Any car parked on street?  

Determine if any vehicle is parked on the street or kept in other than an enclosed garage when not in use. Indicate vehicle number from vehicle description area and where the vehicle is parked.

 

7. Any other automobile insurance?  

Provide the insured's name, vehicle description, insurance company, type of coverage and policy number for any other household resident's automobile insurance.

 

8. Any other insurance with company?  

Indicate the type and policy number of any other insurance the applicant has with the company.

 

9. Any household member in military service?  

Provide details on branch of service, rank, and location of base for any household member in active military service. Determine if any vehicle is at the military location.

 

10. Any license suspended/revoked?  

Indicate the driver number, the period of suspension, the reason for suspension, and the date the license was reinstated.

 

11. Any physical/mental impairments?  

List any operator with a physical or medical impairment which could hinder the safe operation of a vehicle ( amputation, epilepsy). If impaired, enter the name of the driver, a description of any special equipment installed, and treatment or medication being administered.  This question cannot be asked in some states. In those states, the question does not appear on the application.

 

12. Any financial responsibility filing? 

Indicate the driver's name, the reason for the filing, and the date of original filing.

 

13. Has insurance been transferred within agency?

Indicate if prior carrier and previous policy number information shown on the front of the application represents a policy being transferred within the agency. If Yes, give reason for transfer.

 

14. Any insurance declined/cancelled?  

Indicate if any resident in the household has been declined, cancelled or non-renewed through a previous carrier within the last three years. List the person's name and why the action was taken.  This question cannot be asked in some states.  n those states, the question does not appear on the application.

 

15. Is this brokered business to the agent? 

Indicate if the application came through a broker not part of the agency.

 

Alabama Personal Auto Application ACORD 90 AL (2/2001)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is not available; this is not a "no-fault" state.  Uninsured Motorists Bodily Injury coverage includes Underinsured Motorists Bodily Injury coverage; Uninsured or Underinsured Motorists Property Damage coverage is not available.  Statement added to the back of the form referencing the explanation and offer of Uninsured Motorists Bodily Injury coverage up to the policy's Bodily Injury Liability limits, and the right of the applicant to reject this coverage. The statement must be initialed by the applicant.

 

Alaska Personal Auto Application ACORD 90 AK (2/2001)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90, the generic Personal Auto Application, on this website.

  • Personal Injury Protection coverage does not apply; this is not a "no-fault"state. 
  • A required statement has been added to the back of the form with respect to the offer of Rental Vehicle Damage coverage if Comprehensive and/or Collision coverage has been rejected by the applicant.

 

Arizona Personal Auto Application ACORD 90 AZ (3/97)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  Statement added to the back of the form, referencing the Arizona Supplement, ACORD 61 AZ, which must be signed by the applicant.

 

Arkansas Personal Auto Application ACORD 90 AR (10/2000)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.

 

  Personal Injury Protection coverages are revised to reflect unique Arkansas coverages and options. Refer to your state manual.

  Provision made for Uninsured Motorists Property Damage deductible; Underinsured Motorists Property Damage is not available.

  Statement added to the back of the form, referencing the Arkansas Supplement, ACORD 61 AR, which must be used if the applicant chooses Uninsured or Underinsured Motorists Bodily Injury coverages less than the limits of the policy's basic Bodily Injury Liability limits.

 

California Personal Auto Application ACORD 90 CA (1/2000)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage does not apply. This is not a "no-fault" state.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  Reference to "Waiver of Collision Deductible" is added.  Statement added referring to the offer of Uninsured Motorists coverage up to the Bodily Injury Liability coverage in the policy, and the applicant's right to select lower limits, reject coverage for certain drivers, or reject UM coverage entirely. If the applicant chooses any option other than limits equal to the policy's BI limits, the California Auto Supplement, ACORD 61 CA, must be signed.  Statement added referring to the offering of a Waiver of the Collision deductible.  A column titled "Good DRV" is added to the Resident and Driver Information section, to recognize "Good Drivers" as required by California Law.  The column titled "Defensive Driving Date" is retitled "ACC Prev CSE Date" (Accident Prevention Course Date).  A General Information question (No. 15) is added, relating to brokered business.  The Fair Credit Reporting Act on the back of the form is editorially revised.  The generic fraud statement is replaced by a fraud statement now mandated by California law.  A statement is added to the back of the form as required by California law, advising the applicant of his or her rights with respect to "good driver" policies.

 

Provision is made in the Applicants section to record the name of the registered owner if different from the applicant.  A field to record date leased, if applicable, is added to the Vehicle Description/Use section.  An instruction is added to General Information question 2 requiring that the cost of special equipment be provided.  An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments).  A new General Information question 17 is added to capture the years licensed to drive motorcycles, when such vehicles are to be insured. This complies with a new California requirement.

 

Colorado Personal Auto Application ACORD 90 CO (1/99)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are replaced with Colorado's unique coverages and options. Refer to your state manual.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  Statements added referring to the explanation and offer to the applicant of Uninsured Motorists coverage, and the right of the applicant to select/reject coverage. If Uninsured Motorists Bodily Injury coverage is rejected entirely, the applicant must initial the statement.

 

Connecticut Personal Auto Application ACORD 90 CT (10/96)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Although the Connecticut legislature revised the state's no-fault law January 1, 1994, so that these coverages are no longer mandatory, coverage can still be made available. Many companies are continuing to offer Basic Reparations Benefits and/or Added Basic Reparations Benefits (no-fault coverages). Consequently, these items are included in to the Coverages/Premium section.  Uninsured Motorists and Underinsured Motorists coverages are combined.  Uninsured Motorists Conversion coverage is added to the Coverages/Premiums section.  This coverage can be purchased instead of Uninsured/Underinsured Motorists coverage.  Full Glass Optional coverage added to Comprehensive.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.

 

Delaware Personal Auto Application ACORD 90 DE (8/98)

Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section.  A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable.  Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agents that charge policy fees.  Added instruction in the Resident and Driver Information section to show name as it appears on drivers license.  At the request of the Delaware Department of Insurance, "3 years" is printed in the sentence in the Accidents/Convictions section relating to information about accidents and traffic violations.  A note is added to the Employment Information section requiring that self-employed applicants state the nature of their business.  An instruction is added to General Information question 2 requiring that the cost of special equipment be provided.  An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments).  Reference to "no-fault application" is removed from the Attachments section. Such forms are no longer necessary.  The "Applicants Statement" on the back of the form is editorially revised.  These revisions will be made to all state-specific ACORD 90 forms, but only when other specific changes must be made in the individual states.

 

District of Columbia Personal Auto Application ACORD 90 DC (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to reflect D.C.'s unique coverages and options. Refer to your state manual.  Statement added referencing the offer of Uninsured and Underinsured Motorists coverages, and the applicant's right to select coverage limits, and reject Underinsured Motorists coverage.  Statement added allowing the applicant to reject Personal Injury Protection coverages.  Applicant must signify rejection by initialing the form.  Question relating to cancellation or declination of coverage is deleted; this question cannot

be asked in D.C.

 

Florida Personal Auto Application ACORD 90 FL (7/2000)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to reflect Florida's unique coverages and options. Refer to your state manual.  Underinsured Motorists/Bodily Injury coverage is included in Uninsured Motorists/Bodily Injury coverage; Uninsured and Underinsured Motorists Property Damage coverages are not available.  References to "stacked" and "non stacked" options are added to Uninsured Motorists coverage.  Statement added to the back of the form referencing the various Uninsured Motorists coverage options, and the use of the state supplement, ACORD 61 FL, if Uninsured Motorists, or non-stacked coverage, is rejected.  The fraud statement is revised to comply with a new Florida law.

 

Georgia Personal Auto Application ACORD 90 GA (10/96)

Following are the differences from ACORD 90, the generic Personal Auto Application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverage does not apply; this is not a "no-fault" state.  Uninsured Motorists coverage includes Underinsured Motorists coverage; provision is made for per-accident deductibles under Uninsured Motorists coverage.  Required statements have been added to the back of the form:

 

1. Noting if copies of the Privacy Act and Fair Credit Reporting notices have been given to the applicant

2. Referring to the state supplement containing explanation and selection options for Uninsured Motorists and Medical Payments coverages

3. Providing a statement regarding the advance payment of the first sixty days of coverage by the applicant, unless the policy is a continuation of another policy, and there has been no lapse in coverage

 

Hawaii Personal Auto Application ACORD 90 HI (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages and options available. Refer to your state manual.  The applicant can select "stacked" or "non-stacked" Uninsured and Underinsured Motorists BI coverage; however, there is no UM or UIM PD coverage available.

 

Idaho Personal Auto Application ACORD 90 ID (11/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits, and the applicant's right to select other limits, or to reject coverage entirely.

 

Illinois Personal Auto Application ACORD 90 IL (8/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages deleted; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Bodily Injury coverages are combined; Underinsured Motorists Property Damage coverage does not apply; Uninsured Motorists Property Damage coverage is shown separately.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  Statement added referring to the state supplement, ACORD 61 IL, with respect to the selection of Uninsured/Underinsured Motorists Bodily Injury Liability coverage lower than the Bodily Injury Liability coverage in the policy, or the selection of Uninsured Motorists Property Damage coverage for vehicles not covered by collision insurance.

 

Indiana Personal Auto Application ACORD 90 IN (8/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury and Property Damage coverages.  The applicant must initial the statement if any coverage is rejected.

 

Iowa Personal Auto Application ACORD 90 IA (10/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured Motorists and Underinsured Motorists coverage sections include reference to "stacked" and "non-stacked" coverages; Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statement added to the back of the form, referencing the state supplement, ACORD 61 IA, the offer of various Uninsured and Underinsured Motorists Bodily Injury coverage options, and the applicant's right to select or to reject coverage entirely. If the insured decides to select "stacked" UM or UIM, or to reject either UM or UIM coverage, the state supplement must be signed.

 

Kansas Personal Auto Application ACORD 90 KS (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide. Personal Injury Protection coverages have been revised to allow for Kansas options. Refer to your state manual.  Uninsured Motorists coverage includes Underinsured Motorists coverage; however, there is no Property Damage coverage available.  Information relating to accidents or convictions on the front of the form is limited to the last 3 years, as is information regarding license suspension/revocation on the back of the form.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  A required statement has been added to the back of the form, advising the applicant that auto liability insurance may be available through the Kansas Automobile Insurance Plan.  In addition, a statement has been added to the back of the form requiring the applicant to acknowledge available Uninsured Motorists coverage options, including the option of rejecting UM limits higher than the mandatory minimum limits.

 

Kentucky Personal Auto Application ACORD 90 KY (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Provision is made to report the "Tax Territory" as required by Kentucky Law.  Personal Injury Protection coverages are revised to reflect Kentucky's unique coverages and options. Refer to your state manual.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Added section to the back of the form to allow descriptions of motorcycles, and named individuals to be covered, as required under PIP options.  Provided statement referencing the explanation to the applicant of Uninsured and Underinsured Motorists coverages and available options; provided space to allow the applicant to reject UM and/or UIM.  The fraud statement on the back of the form is revised to reflect a new Kentucky law.

 

Louisiana Personal Auto Application ACORD 90 LA (6/98)

Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section.  A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable.  Provision is made to select "Economic & Non Economic" Loss coverage or "Economic Loss only" coverage in the Uninsured Motorists coverage item.  Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agent sthat charge policy fees.  Added instruction in the Resident and Driver Information section to show name as it appears on drivers license.  A note is added to the Employment Information section requiring that self-employed applicants state the nature of their business.  An instruction is added to General Information question 2 requiring that the cost of special equipment be provided.  An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments).  The "Applicants Statement" on the back of the form is editorially revised.  The statement relating to Uninsured Motorists BI and PD coverage selection and rejection is revised to refer to the new Louisiana Auto Supplement. The new supplement must be used if UMBI or UMPD coverage is rejected, or if the applicant selects UMBI coverage lower than the policy's liability limits.  These revisions will be made to all state-specific ACORD 90 forms, but only when other specific changes must be made in the individual states.

 

Maine Personal Auto Application ACORD 90 ME (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Bodily Injury coverages are combined.

Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statement added to the back of the form, referencing the offer of Uninsured/ Underinsured Motorists Bodily Injury coverages up to the policy's basic Bodily Injury Liability limits and the applicant's right to select lower limits, or to reject coverage entirely.

 

Maryland Personal Auto Application ACORD 90 MD (1/98)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to reflect Maryland's unique coverages and options. Refer to your state manual.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  A limit of three years is added to the question relating to accidents and convictions on the front of the form, as required by the Maryland Insurance Department.  Statement added to the back of the form, referencing the state supplement, ACORD 61 MD, which must be given to the applicant if Personal Injury Protection coverage is rejected, or if Uninsured Motorists' Bodily Injury coverage less than the limits of the policy's Bodily Injury Liability limits is selected.

 

Application For Massachusetts Motor Vehicle Insurance ACORD 90 MA (1/2000)

This application is entirely different than applications in other states. Therefore, all the instructions for completing the form are provided.

 

The state of Massachusetts requires personal automobile, new business and renewals, to be submitted on forms that are prescribed by the Massachusetts Commissioner of Insurance. The ACORD 90 MA, Application for Massachusetts Motor Vehicle Insurance, meets the

prescribed requirements. Questions or comments regarding this form should be directed to the Massachusetts Automobile Insurance Bureau.

 

This application is designed for up to two vehicles and six operators. If these limits are insufficient, attach an additional ACORD 90 MA.

 

Company/Producer

Name of the insurance company that will receive the application or name of the producer submitting the application. Use the actual name of the company within the group in which you wish to have the policy issued. Do not use group names.

 

Code

Identification code assigned to the agency or brokerage firm by the insurance company receiving this form.

 

Binder/Policy

Number assigned by the agent, if a binder is used, or the company, if the policy number is known.

 

Effective Date

Month, day and year on which the terms and conditions of the policy will commence.

 

Expiration Date

Month, day and year on which the terms and conditions will terminate unless renewed.

 

Applicant's Name and Residential Address

Full name of the applicant as it should appear on the policy. The first named insured is given certain rights and responsibilities by the policy contract language. If more than one insured is named, be sure the one intended to receive these rights and responsibilities is named first and the additional insured identified as such. If joint ownership, the name used may include both names (e.g., John and Mary Smith).

 

Provide the physical address (not a P.O. Box) at which the first named insured is to receive all correspondence.

 

Phone

Telephone number at which the applicant may be reached, including area code and extension, if applicable.

 

Mail Address (if different)

Address at which the applicant is to receive mail; this may be a P.O. Box.

 

Direct Bill/Agency Bill

Indicate whether the agency or the company (direct) will bill the insured or other payor for the policy.

 

Payment Plan

Indicate the plan to be used to pay the company for the policy. Use the company's specific designation for the plan where possible.

 

Deposit Premium

Deposit submitted with the application.

 

COVERAGES

 

Space is provided for two vehicles. Coverages 1-4 are compulsory and must be provided for each vehicle. Coverages 5-12 are optional. The applicant may choose all, none or any number of these optional coverages. Refer to the Massachusetts Personal Automobile Manual for descriptions of coverages.

 

Est. Total Premium

Aggregate dollar amount owed to the company for all vehicles on this policy.

 

VEHICLE INFORMATION

 

Principal Garaging - City or Town and /Zip

City or town in which vehicle number one is primarily located.

 

Year

Model year of the vehicle.

 

Make

Vehicle manufacturer.

 

Model

Manufacturer's trade name for the vehicle.

 

Motorcycle CC

Number of cubic centimeters of displacement for motorcycles.

 

Vehicle Identification Number

Full vehicle identification number appearing on the title certificate or registration.

 

Registration Plate Number

Number on the license plate for the vehicle.

 

Date of Purchase

Year the applicant acquired the vehicle.

 

Cost New

Original cost of the vehicle.

 

Estimated Annual Mileage

Total estimated annual mileage for each vehicle.

 

Odometer Reading

Current number of miles on the odometer.

 

Air Bag/Passive Seat Belt

Answer "Yes" if the vehicle is equipped with an air bag or automatic shoulder harness seat belt.

 

Anti-Theft Device

Answer "Yes" if the vehicle is equipped with an anti-theft device.

 

Vehicle Recovery System

Answer "Yes" if the vehicle is equipped with a vehicle recovery system.

 

Leased Auto

Answer "Yes" if the vehicle is currently provided through a leasing program.

 

Secured Lender/Lessor

Provide complete name and mailing address of the lending institution holding the loan on the vehicle.

 

Date of Final Payment

Date on which the vehicle's loan payments will be completed.

 

DRIVER INFORMATION

 

Operator Name

Name of each licensed operator (resident or not). Show the applicant as driver #1, even if not an operator.

 

Date of Birth

Birth date of each driver and household resident (MM/DD/YY). (e.g., March 7, 1944 should be 03/07/44).

 

Driver's License #/Licensed State

The complete driver's license number for each licensed operator. Copy directly from license if possible. List the licensed state for each operator.

 

Date First Licensed

Month and year in which each operator became licensed. Enter both dates if applicable.

 

Approved Driver Training

Answer "Yes" if the operator has completed an approved driver training course.

 

% of Use

Indicate how much each vehicle is driven by each operator. Usage for each operator should total to 100%.

 

Driver Information Questions

Answer questions A through F with respect to all listed operators. Explain "Yes" responses in the Description of Incident section.

 

Fully describe accidents or convictions, including the number of vehicles involved and the type of vehicles (private passenger or commercial). Convictions constitute a judgment of guilty, plea of nolo contendere or forfeiture of bail. Use Remarks section or an additional piece of paper if necessary.

 

Location

City and state of the accident or conviction.

 

Date

Date of the incident.

 

GENERAL INFORMATION

 

Provide a complete explanation in the Remarks section for any "Yes" responses for questions 1-7. Use additional paper if space in the Remarks section is inadequate. Respond to questions 8-12 in the spaces provided.

 

 

Michigan Personal Auto Application ACORD 90 MI (10/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Additional Property Damage Liability coverage in the amount of $500.00 is a basic liability coverage.  Personal Injury Protection coverages have been revised to allow for unique Michigan coverages and options. Refer to your state manual.  No property damage coverage is available under Uninsured or Underinsured Motorists.  Several collision options are shown. Refer to your state manual.  The "Good Student" box in the Resident and Driver Information section is deleted, as required by the Michigan Insurance Bureau.  Information relating to accidents is limited to the last 5 years, and information relating to coverage cancellation or declination is limited to the last 3 years.  Reference to Young Driver Questionnaire, Good Student Certificate and Medical Statement are deleted from the Attachments section.  The Fair Credit Reporting Account Statement, Fraud Statement and Applicants Statement on the back of the form have been revised to comply with Michigan law and regulations.  The question "How long have you known the applicant?" is deleted, to comply with regulations.  Provision is made to allow individuals covered under the policy who are 60 years of age or older, and who have no expectation of actual income loss in the event of an accident, to reject coverage for work loss under Personal Injury Protection coverage. Each individual eligible must sign the application.  A statement is added referencing the Michigan Collision Insurance Options Notice (ACORD 62 MI) which must be given to every applicant for auto insurance in Michigan.  A statement is added that provides the address and phone number of the Michigan Insurance Bureau.

 

Minnesota Personal Auto Application ACORD 90 MN (1/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage reflects Minnesota's unique coverages.  Uninsured and Underinsured Bodily Injury coverage is combined; there is no Property Damage coverage.  Comprehensive coverage can include "Full Glass" coverage; refer to your rating manual.  Information relating to accidents is limited to the last 5 years, and information relating to suspension or revocation of drivers licenses is limited to l0 years.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  A statement is added requiring the applicant to acknowledge receipt of a copy of the Minnesota Guaranty Association Notice (ACORD 65 MN).  A statement is added requiring the applicant to acknowledge the offering of Uninsured/Underinsured Motorists coverage up to the limits of BI Liability.  A statement is added referencing the company's right to cancel coverage during the forty-nine days following the issuance of coverage, for any reason not prohibited by law.  The fraud statement on the back of the form is revised to reflect a new Minnesota law.

 

Mississippi Personal Auto Application ACORD 90 MS (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists coverage's are combined.  Statement added to the back of the form, referencing the offer of Uninsured/Underinsured Motorists coverage's up to the limits of the policy's Liability limits, and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected.

 

Missouri Personal Auto Application ACORD 90 MO (10/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage does not apply; this is not a "no-fault" state.  Uninsured and Underinsured Motorist Property Damage coverage's are not available.  A required statement has been added to the back of the form, indicating that the premium quoted is an estimate only, and that premium charged will be in accordance with the company's filed rates.  A statement has been added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists coverage.

 

Montana Personal Auto Application ACORD 90 MT (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is not available; this is not a "no-fault" state.  Uninsured Motorists Property Damage and Underinsured Motorists coverage's are not available.  A statement has been added to the back of the form, indicating that a copy of the Privacy Act notice has been given to the applicant.  A statement has been added to the back of the form, referencing the offering of Uninsured Motorists coverage up to the limits of Bodily Injury liability coverage.

 

Nebraska Personal Auto Application ACORD 90 NE (8/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Fields are added to the Producer section, to identify "Producer ID" and "Agency ID," as required by Nebraska regulation.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statement added to the back of the form, referencing the offer of Uninsured and Underinsured Motorists Bodily Injury coverages up to the limits of the policy's Bodily Injury Liability limits and the applicant's right to select lower limits.  The fraud statement is removed. It does not apply in Nebraska.

 

Nevada Personal Auto Application ACORD 90 NV (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage's are not available; this is not a "no-fault" state.  Underinsured Motorists Bodily Injury coverage is included in Uninsured Motorists Bodily Injury coverage.  Uninsured and Underinsured Motorists Property Damage coverage's are not available.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  Statement added to the back of the form, referencing the state supplement, ACORD 61 NV, which must be given to the applicant to explain the available options under Medical Payments and Uninsured Motorists coverage.

 

New Hampshire Personal Auto Application ACORD 90 NH (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage's are not available; this is not a "no-fault" state.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.

 

New Jersey Personal Auto Application ACORD 90 NJ (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages have been revised to provide for unique New Jersey coverages. Refer to your State Manual.  Uninsured and Underinsured Motorists coverages are combined.  Comprehensive is changed to "other than collision coverage".  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  The fraud statement on the back of the form is revised to comply with New Jersey law.  A statement has been added referencing the offer of Uninsured/Underinsured Motorists coverage up to the policy's BI limits.  A statement has been added referencing the Insurance Inspection Report, ACORD 94. The producer will indicate if a vehicle inspection has been requested or waived, according to individual company procedures.

 

New Mexico Personal Auto Application ACORD 90 NM (11/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  Statement added to the back of the form, referencing the offer of Uninsured Motorists  Bodily Injury and Property Damage coverages up to the limits of the policy's Liability limits and the applicants right to select lower limits, or to reject coverage entirely. The applicant must initial the option selected.

 

New York Personal Auto Application ACORD 90 NY (9/2000)

Reference to "Registered Owner if different from above" in the Applicants section is deleted. This item is covered by General Information question 1.  Reference to "Supplementary Uninsured Motorists Coverage" is revised to "Supplementary Uninsured/Underinsured Motorists Coverage" in the Coverages/Premium section on the front of the form, and in the last statement on the bottom of the back of the form. These changes are required by a recent change in NY law.

 

North Carolina Personal Auto Application ACORD 90 NC (9/2000)

Reference to the mailing of the policy to the agent or to the applicant is added to the Payment Plan section.  A new field is added to the Vehicle Description/Use section to record the date the vehicle was leased, if applicable.  A field is added in the Coverages/Premiums section to record information about a new option, "Alternative Economic Loss Coverage."  Reference to "Policy Fee" is added in the Additional Coverages section, to accommodate those companies or agent sthat charge policy fees.  Added instruction in the Resident and Driver Information section to show name as it appears on drivers license.  A note is added to the Employment Information section requiring that self-employed applicants state the nature of their business.  An instruction is added to General Information question 2 requiring that the cost of special equipment be provided.  An instruction to list driver numbers is added to General Information question 11 (regarding physical/mental impairments).  These revisions will be made to all state-specific ACORD 90 forms, but only when other specific changes must be made in the individual states.

 

North Dakota Personal Auto Application ACORD 90 ND (10/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages revised to reflect North Dakota's unique coverages and options. Refer to your State Manual.  Uninsured and Underinsured Motorists Bodily Injury coverages are combined; Uninsured/Underinsured Motorists Property Damage coverages are not available.  Statement is added to the back of the form to allow the applicant to reject Additional Personal Injury Protection coverage. The applicant must initial the form.

 

Ohio Personal Auto Application 90 OH (4/98)

The statement on the back of the form relating to Uninsured Motorists coverage is revised to include reference to UMPD, in addition to UMBI.

 

Oklahoma Personal Auto Application ACORD 90 OK (10/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is not available; this is not a "no-fault" state.  Underinsured Motorists BI coverage is included in Uninsured Motorists coverage; Property Damage coverage is not available.  The fraud statement is revised to comply with Oklahoma law.

 

Oregon Personal Auto Application ACORD 90 OR (2/98)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to reflect Oregon's unique coverages and options. Refer to your State Manual.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  Statement added to the back of the form, referring to the state supplement, ACORD 61 OR, which must be given to the applicant to explain Uninsured Motorists coverage, and the options available.

 

Pennsylvania Personal Auto Application ACORD 90 PA (9/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage sections have been revised in accordance with unique Pennsylvania coverages and options. Refer to your state Manual.  Provided for the selection of "stacked" or "non-stacked" coverage under Uninsured and Underinsured Motorists BI coverages. Property Damage coverage is not available.  The Fraud Statement is revised to comply with Pennsylvania law.

 

Puerto Rico Personal Auto Application ACORD 90 PR (3/97)

Following are the differences from ACORD 90, the generic Personal Auto Application.  In the "Vehicle Description/Use" section, reference to "car pool," "odometer reading," "annual mileage," "governing driver" and "anti-lock brakes" were deleted. Reference to vehicle registration and plate number were added.  The "Coverages/Premiums" section is revised to reflect only coverages offered in Puerto Rico.  In the "Resident and Driver Information" section, reference to driver training and student discounts were deleted.

 

Rhode Island Personal Auto Application ACORD 90 RI (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists coverages are combined.  Statements are added to the back of the form that:

 

1. Allow the applicant to acknowledge the offer of Medical Payments coverage, and the options selected;

2. Reference the state supplement, ACORD 61 RI, which must be signed by the applicant if Uninsured/Underinsured Motorists Bodily Injury coverage is rejected;

3. Allow the applicant to acknowledge the offer of Uninsured/Underinsured Motorists Property Damage coverage, and the options selected. The applicant must initial the options selected.

 

South Carolina Personal Auto Application ACORD 90 SC (1/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  A box relating to "Facility Code" is added to the front of the form, to provide information relating to the re-insurance facility.  Provision is made to record the Fire District (required when Physical Damage coverage is written).  Medical Payments coverage is deleted; Medical expenses are included under Personal Injury Protection coverage.  A mandatory $200.00 deductible is shown for both Uninsured and Underinsured Motorists Property Damage coverages.

 

South Dakota Personal Auto Application ACORD 90 SD (9/98)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to reflect South Dakota's unique coverages and options. Refer to your state Manual.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statement added to the back of the form to allow the applicant to select or reject supplemental auto coverage. The applicant must initial the form.

 

Tennessee Personal Auto Application ACORD 90 TN (11/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal  Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  A mandatory $200.00 deductible is shown for Uninsured Motorists Property Damage coverage.  Statement added to the back of the form, referencing the offer of Uninsured Motorists Bodily Injury and Property Damage coverages up to the limits of the policy's Liability limits and the applicant's right to select lower limits, or to reject coverage entirely. The applicant must initial the option(s) selected.

 

Texas Personal Auto Application ACORD 90 TX (11/96)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are revised to provide for various Texas coverages and options. Refer to your state Manual.  Uninsured and Underinsured Motorists coverages are combined. The Property Damage deductible is $250.00.  Comprehensive coverage is replaced by "Other than Collision"; refer to your State Manual for options.  Statements are added to the back of the form requiring the applicant to acknowledge the explanation of Uninsured/Underinsured Motorists coverage and Personal Injury Protection, and to acknowledge selection/rejection decisions by initialing the statements.

 

Utah Personal Auto Application ACORD 90 UT (1/2001)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages reflect the unique coverages available in this state.  Underinsured Motorists Property Damage coverage is not available.  A statement is added to the back of the form explaining arbitration as an alternative to court action. This statement is required by Utah law.  A statement is added requiring the insured to initial the selection/rejection of various Uninsured and/or Underinsured Motorists coverage options.

 

ACORD 90 VI (2001/03)

Following are the differences specific to the Virgin Islands.

Checkboxes are provided to record NEW or RENEWAL in the APPLICANTS section.

Personal Injury Protection, Uninsured and Underinsured Motorists coverage fields reflect the territory's unique coverages. 

 

Vermont Personal Auto Application ACORD 90 VT (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is not available; this is not a "no-fault" state.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  The Fair Credit Reporting Act Statement is replaced with Vermont's Fair Credit law requirements.  A statement is added to the back of the form, referencing the explanation of Uninsured Motorists coverage to the applicant, and the applicants selection of coverage.

 

Virginia Personal Auto Application ACORD 90 VA (10/98)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is revised to reflect the coverages and options available in Virginia. Refer to your state Manual.  Underinsured Motorists coverage is included in Uninsured Motorists coverage.  A required statement is added referring to the Company's right to cancel the policy for any reason within the first 60 days it is in effect, and thereafter for reasons stated in the policy.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  A statement is added referencing the offering of Uninsured Motorists coverage.  Dual lines are provided for the initials of more than one named insured at the end of the statement on the back of the form relating to Uninsured Motorists coverage selection. A recent court decision determined that each named insured must acknowledge the offer of UM coverage.

 

Washington Personal Auto Application ACORD 90 WA (8/2000)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverage is revised to reflect Washington's unique coverages and options. Refer to your state Manual.  Added "Auto Loan" coverage in the coverages/Premium section.  Reference to the Privacy Act notice is added. This notice must be given to the applicant in this state.  Statement added to the back of the form referring to the options available under Underinsured Motorists and Personal Injury Protection coverages and the applicant's right to reject these coverages.

 

West Virginia Personal Auto Application ACORD 90 WV (11/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Statement added to the back of the form, referencing the state supplements, ACORD 60 WV, 61 WV, and 62 WV, with respect to the offering and selection of Uninsured and Underinsured Motorists coverages.

 

Wisconsin Personal Auto Application ACORD 90 WI (7/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection coverages are not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Property Damage coverages are not available.  Statements added to the back of the form:

 

1. Acknowledging the offer of Medical Payments coverage, and allowing the applicant to reject this coverage; the applicant must initial the form of coverage that is rejected.

2. Acknowledging the offer of Uninsured and Underinsured Motorists Bodily Injury coverages, and the options available.

 

Wyoming Personal Auto Application ACORD 90 WY (1/97)

Following are the differences from ACORD 90, the generic Personal Auto application. For instructions on completing the balance of this form, refer to ACORD 90 in the Personal Lines section of this guide.  Personal Injury Protection is not available; this is not a "no-fault" state.  Uninsured and Underinsured Motorists Property Damage coverage is not available.  A statement is added to the back of the form referencing the offering of Uninsured and Underinsured Motorists coverage.

 


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