ACORD Form 90 GA Georgia Personal Automobile Application Instructions

 

ACORD 90 GA (2009/01) 1 of 36

Section Name	Field Name	Field and/or Section Description
		The title of the form. ACORD 90 GA, Georgia Personal Auto Application Section, was designed to be used in conjunction with ACORD 88, Personal Insurance Application -Applicant Information Section. ACORD 90 GA must be attached to ACORD 88 for a completed application submission.
		Following are the unique state characteristics of ACORD 90 GA, Georgia Personal Auto Application Section:
		* Personal Injury Protection coverage does not apply; this is not a "no-fault" state.
TITLE ACORD 90 GA (2009/01)	Georgia Personal Auto Application Section	* Uninsured Motorist coverage includes Underinsured Motorist coverage; provision is made for per-accident deductibles under Uninsured Motorist coverage.
		* Required statements have been added to the back of the form:
		- Indicating that Traditional (Reduced) Uninsured Motorist and New (Added On)
		Uninsured Motorist coverage have been offered and explained to the applicant.
		- Traditional and New Uninsured Motorist Coverage Mandatory Offer and Explanation
		is page 4 of the application.
		- Additional 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
TITLE		has been no lapse in coverage.
		Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION	Agency Customer ID	agency or brokerage).
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.
		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
IDENTIFICATION SECTION	Policy Number	required for self-insurance, the self-insured license or contract number.
		Enter date: The effective date of the policy. The date that the terms and conditions of the
IDENTIFICATION SECTION	Effective Date	policy commence.
IDENTIFICATION SECTION	Named Insured(s)	Enter text: The named insured(s) as it/they will appear on the policy declarations page.

ACORD 90 GA (2009/01) 2 of 36

Section Name	Field Name	Field and/or Section Description
IDENTIFICATION SECTION	Carrier	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. As used here, this may contain the name of the residual market plan.
IDENTIFICATION SECTION	NAIC Code	Enter code: The identification code assigned to the insurer by the NAIC.
GARAGING ADDRESS (from ACORD 88)	Location #	Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88)	Veh #	Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88)	Street	Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	City	Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	County	Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	State	Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	Zip + 4	Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	Location #	Enter number: The producer assigned number of the location.
GARAGING ADDRESS (from ACORD 88)	Veh #	Enter number: The producer assigned vehicle number.
GARAGING ADDRESS (from ACORD 88)	Street	Enter text: The first address line of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	City	Enter text: The city of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	County	Enter text: The county of the location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	State	Enter code: The state or province of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	Zip + 4	Enter code: The postal code of the physical location. As used here, this is the garaging location of the vehicle.
GARAGING ADDRESS (from ACORD 88)	Location #	Enter number: The producer assigned number of the location.

ACORD 90 GA (2009/01) 3 of 36

Section Name	Field Name	Field and/or Section Description
GARAGING ADDRESS
(from ACORD 88)	Veh #	Enter number: The producer assigned vehicle number.
GARAGING ADDRESS		Enter text: The first address line of the physical location. As used here, this is the garaging
(from ACORD 88)	Street	location of the vehicle.
GARAGING ADDRESS		Enter text: The city of the physical location. As used here, this is the garaging location of
(from ACORD 88)	City	the vehicle.
GARAGING ADDRESS		Enter text: The county of the location. As used here, this is the garaging location of the
(from ACORD 88)	County	vehicle.
GARAGING ADDRESS		Enter code: The state or province of the physical location. As used here, this is the
(from ACORD 88)	State	garaging location of the vehicle.
GARAGING ADDRESS		Enter code: The postal code of the physical location. As used here, this is the garaging
(from ACORD 88)	Zip + 4	location of the vehicle.
GARAGING ADDRESS
(from ACORD 88)	Location #	Enter number: The producer assigned number of the location.
GARAGING ADDRESS
(from ACORD 88)	Veh #	Enter number: The producer assigned vehicle number.
GARAGING ADDRESS		Enter text: The first address line of the physical location. As used here, this is the garaging
(from ACORD 88)	Street	location of the vehicle.
GARAGING ADDRESS		Enter text: The city of the physical location. As used here, this is the garaging location of
(from ACORD 88)	City	the vehicle.
GARAGING ADDRESS		Enter text: The county of the location. As used here, this is the garaging location of the
(from ACORD 88)	County	vehicle.
GARAGING ADDRESS		Enter code: The state or province of the physical location. As used here, this is the
(from ACORD 88)	State	garaging location of the vehicle.
GARAGING ADDRESS		Enter code: The postal code of the physical location. As used here, this is the garaging
(from ACORD 88)	Zip + 4	location of the vehicle.
VEHICLE DESCRIPTION /	Total Number of Vehicles in	Enter number: The total number of vehicles in the household. As used here, this is the
USE	Household	garaging location of the vehicle.
VEHICLE DESCRIPTION /
USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION /
USE	Year	Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION /
USE	Make	Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION /
USE	Model	Enter text: The manufacturer's model name for the vehicle.

ACORD 90 GA (2009/01) 4 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Body Type	Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE	VIN	Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE	Registered State	Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE	HP/CC	Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE	Date Leased	Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE	Date Purch	Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE	New/Used	Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Cost New	Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE	Symbol Age Grp	Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE	Terr	Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE	Miles 1 Way Wk/Schl	Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE	# Days Week	Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE	# Weeks/ Mo.	Enter number: The 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.
VEHICLE DESCRIPTION / USE	Usage	Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F -Farm).
VEHICLE DESCRIPTION / USE	Perform	Enter code: The performance level of the vehicle (i.e. B - Basic, H - High, I - Intermediate, P - Sport Premium, S - Sports car).
VEHICLE DESCRIPTION / USE	Multi-Car	Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.

ACORD 90 GA (2009/01) 5 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Carpool	Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE	Gar Code	Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options:� A - Garaged at School� B - Off street at school� C - On street at school� D - Driveway� G - Garaged� N - Not garaged (if other options do not apply)� O - Off street� P - Parking Lot� R - Carport� S - Street
VEHICLE DESCRIPTION / USE	Odometer Reading	Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE	Annual Mileage	Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE	Govern Driver	Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.

ACORD 90 GA (2009/01) 6 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Number	Enter number: The producer assigned driver number of the driver using the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Class	Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Passive Seat Belt	Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE	Air Bag Drv/Both	Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE	Anti-Lock Brakes 2/4	Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE	Anti-Theft Devices	Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE	Credits and Surcharges	Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Year	Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE	Make	Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE	Model	Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION / USE	Body Type	Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE	VIN	Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.

ACORD 90 GA (2009/01) 7 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Registered State	Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE	HP/CC	Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE	Date Leased	Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE	Date Purch	Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE	New/Used	Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Cost New	Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE	Symbol Age Grp	Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE	Terr	Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE	Miles 1 Way Wk/Schl	Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE	# Days Week	Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE	# Weeks/ Mo.	Enter number: The 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.
VEHICLE DESCRIPTION / USE	Usage	Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F -Farm).
VEHICLE DESCRIPTION / USE	Perform	Enter code: The performance level of the vehicle (i.e. B - Basic, H - High, I - Intermediate, P - Sport Premium, S - Sports car).
VEHICLE DESCRIPTION / USE	Multi-Car	Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE	Carpool	Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.

ACORD 90 GA (2009/01) 8 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Gar Code	Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options:� A - Garaged at School� B - Off street at school� C - On street at school� D - Driveway� G - Garaged� N - Not garaged (if other options do not apply)� O - Off street� P - Parking Lot� R - Carport� S - Street
VEHICLE DESCRIPTION / USE	Odometer Reading	Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE	Annual Mileage	Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE	Govern Driver	Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Class	Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Passive Seat Belt	Enter code: The type of seat belts in the vehicle.

ACORD 90 GA (2009/01) 9 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Air Bag Drv/Both	Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE	Anti-Lock Brakes 2/4	Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE	Anti-Theft Devices	Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE	Credits and Surcharges	Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Year	Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE	Make	Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).
VEHICLE DESCRIPTION / USE	Model	Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION / USE	Body Type	Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE	VIN	Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE	Registered State	Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE	HP/CC	Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE	Date Leased	Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE	Date Purch	Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE	New/Used	Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Cost New	Enter amount: The original cost of the vehicle.

ACORD 90 GA (2009/01) 10 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Symbol Age Grp	Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE	Terr	Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE	Miles 1 Way Wk/Schl	Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE	# Days Week	Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE	# Weeks/ Mo.	Enter number: The 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.
VEHICLE DESCRIPTION / USE	Usage	Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F -Farm).
VEHICLE DESCRIPTION / USE	Perform	Enter code: The performance level of the vehicle (i.e. B - Basic, H - High, I - Intermediate, P - Sport Premium, S - Sports car).
VEHICLE DESCRIPTION / USE	Multi-Car	Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE	Carpool	Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE	Gar Code	Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options:� A - Garaged at School� B - Off street at school� C - On street at school� D - Driveway� G - Garaged� N - Not garaged (if other options do not apply)� O - Off street� P - Parking Lot� R - Carport� S - Street
VEHICLE DESCRIPTION / USE	Odometer Reading	Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE	Annual Mileage	Enter number: The total estimated annual mileage for the vehicle.

ACORD 90 GA (2009/01) 11 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Govern Driver	Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Class	Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Passive Seat Belt	Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE	Air Bag Drv/Both	Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE	Anti-Lock Brakes 2/4	Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE	Anti-Theft Devices	Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE	Credits and Surcharges	Enter text: A credit or surcharge represented as text.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Year	Enter year: The model year of the vehicle.
VEHICLE DESCRIPTION / USE	Make	Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy).

ACORD 90 GA (2009/01) 12 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Model	Enter text: The manufacturer's model name for the vehicle.
VEHICLE DESCRIPTION / USE	Body Type	Enter code: The body type of the vehicle.
VEHICLE DESCRIPTION / USE	VIN	Enter identifier: The vehicle identification number (VIN) or serial number assigned by the manufacturer.
VEHICLE DESCRIPTION / USE	Registered State	Enter code: The state or province in which the vehicle is registered.
VEHICLE DESCRIPTION / USE	HP/CC	Enter number: The amount of horsepower or the number of cubic centimeters of displacement.
VEHICLE DESCRIPTION / USE	Date Leased	Enter date: The date the insured leased the vehicle.
VEHICLE DESCRIPTION / USE	Date Purch	Enter date: The date the vehicle was purchased.
VEHICLE DESCRIPTION / USE	New/Used	Enter code: A code indicating if the vehicle was purchased new or used.
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Cost New	Enter amount: The original cost of the vehicle.
VEHICLE DESCRIPTION / USE	Symbol Age Grp	Enter code: The symbol required for physical damage coverage.
VEHICLE DESCRIPTION / USE	Terr	Enter code: The rating territory code where the vehicle is principally garaged.
VEHICLE DESCRIPTION / USE	Miles 1 Way Wk/Schl	Enter number: The number of miles from the garage location to school or work.
VEHICLE DESCRIPTION / USE	# Days Week	Enter number: The number of days per week the vehicle is used to commute from the garage location to work or school including driving to and from a commuter lot or transit station.
VEHICLE DESCRIPTION / USE	# Weeks/ Mo.	Enter number: The 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.
VEHICLE DESCRIPTION / USE	Usage	Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F -Farm).
VEHICLE DESCRIPTION / USE	Perform	Enter code: The performance level of the vehicle (i.e. B - Basic, H - High, I - Intermediate, P - Sport Premium, S - Sports car).

ACORD 90 GA (2009/01) 13 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Multi-Car	Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount.
VEHICLE DESCRIPTION / USE	Carpool	Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies.
VEHICLE DESCRIPTION / USE	Gar Code	Enter code: The garaging code of the vehicle (where the vehicle is parked at night). Select from the following options:� A - Garaged at School� B - Off street at school� C - On street at school� D - Driveway� G - Garaged� N - Not garaged (if other options do not apply)� O - Off street� P - Parking Lot� R - Carport� S - Street
VEHICLE DESCRIPTION / USE	Odometer Reading	Enter number: The odometer reading at the time the insurance policy is applied for.
VEHICLE DESCRIPTION / USE	Annual Mileage	Enter number: The total estimated annual mileage for the vehicle.
VEHICLE DESCRIPTION / USE	Govern Driver	Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Driver Use %	Enter percentage: The percentage of time a particular driver uses the vehicle.
VEHICLE DESCRIPTION / USE	Class	Enter code: The rate class of the vehicle. If two rate classes are required, this element should be used to enter the liability code.

ACORD 90 GA (2009/01) 14 of 36

Section Name	Field Name	Field and/or Section Description
VEHICLE DESCRIPTION / USE	Veh #	Enter number: The producer assigned vehicle number.
VEHICLE DESCRIPTION / USE	Passive Seat Belt	Enter code: The type of seat belts in the vehicle.
VEHICLE DESCRIPTION / USE	Air Bag Drv/Both	Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No response to indicate airbags exists.
VEHICLE DESCRIPTION / USE	Anti-Lock Brakes 2/4	Enter code: The type of anti-lock brakes in the vehicle.
VEHICLE DESCRIPTION / USE	Anti-Theft Devices	Enter code: The principal anti-theft device found on the vehicle. Some states may only require a Yes or No response to indicates there is an anti-theft device on the vehicle.
VEHICLE DESCRIPTION / USE	Credits and Surcharges	Enter text: A credit or surcharge represented as text.
COVERAGES / PREMIUMS	Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Single Limit Liability	Enter limit: The vehicle combined single limit liability amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES / PREMIUMS	Single Limit Liability Amount	Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS	Single Limit Liability Amount	Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS	Single Limit Liability Amount	Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS	Single Limit Liability Amount	Enter amount: The vehicle combined single limit liability premium amount.
COVERAGES / PREMIUMS	Bodily Injury Each Person	Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES / PREMIUMS	Bodily Injury Each Accident	Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES / PREMIUMS	Bodily Injury Amount	Enter amount: The vehicle policy, bodily injury per accident premium amount.
COVERAGES / PREMIUMS	Bodily Injury Amount	Enter amount: The vehicle policy, bodily injury per accident premium amount.
COVERAGES / PREMIUMS	Bodily Injury Amount	Enter amount: The vehicle policy, bodily injury per accident premium amount.
COVERAGES / PREMIUMS	Bodily Injury Amount	Enter amount: The vehicle policy, bodily injury per accident premium amount.

ACORD 90 GA (2009/01) 15 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Property Damage Each Accident	Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).
COVERAGES / PREMIUMS	Property Damage Amount	Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS	Property Damage Amount	Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS	Property Damage Amount	Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS	Property Damage Amount	Enter amount: The property damage premium amount.
COVERAGES / PREMIUMS	Medical Payments	Enter limit: The medical payments per person limit.
COVERAGES / PREMIUMS	Medical Payments Amount	Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS	Medical Payments Amount	Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS	Medical Payments Amount	Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS	Medical Payments Amount	Enter amount: The medical payments premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist CSL Each Accident	Enter limit: The uninsured motorists combined single limit per accident limit amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist CSL Deductible	Enter deductible: The uninsured motorists combined single limit deductible amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist BI Each Person	Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist BI Each Accident	Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist BI Deductible	Enter deductible: The uninsured motorists bodily injury deductible amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.

ACORD 90 GA (2009/01) 16 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Each Accident	Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Deductible	Enter deductible: The uninsured motorists property damage deductible amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	Traditional (Reduced) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist CSL Each Accident	Enter limit: The uninsured motorists combined single limit per accident limit amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist CSL Deductible	Enter deductible: The uninsured motorists combined single limit deductible amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist BI Each Person	Enter limit: The uninsured motorists bodily injury per person limit. The use of this limit varies by state. (in some states this may contain the combined single limit per accident limit amount.)
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist BI Each Accident	Enter limit: The uninsured motorists bodily injury per accident limit (in some states this may contain the uninsured motorists combined single limit per accident limit). The use of this limit varies by state.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist BI Deductible	Enter deductible: The uninsured motorists bodily injury deductible amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist Amount	Enter amount: The uninsured motorists bodily injury or combined single limit premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Each Accident	Enter limit: The uninsured motorists property damage per accident amount. The use of this limit varies by state.

ACORD 90 GA (2009/01) 17 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Deductible	Enter deductible: The uninsured motorists property damage deductible amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	New (Added On) Uninsured Motorist PD Amount	Enter amount: The uninsured motorists property damage premium amount.
COVERAGES / PREMIUMS	Comprehensive / OTC Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS	Comprehensive / OTC Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS	Comprehensive / OTC Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS	Comprehensive / OTC Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter deductible: The comprehensive or other than collision deductible amount.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only.
COVERAGES / PREMIUMS	Comprehensive / OTC Amount	Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only.
COVERAGES / PREMIUMS	Collision Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Collision Amount	Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS	Collision Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Collision Amount	Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS	Collision Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Collision Amount	Enter deductible: The collision deductible amount.

ACORD 90 GA (2009/01) 18 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Collision Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Collision Amount	Enter deductible: The collision deductible amount.
COVERAGES / PREMIUMS	Collision Amount	Enter amount: The collision premium amount.
COVERAGES / PREMIUMS	Collision Amount	Enter amount: The collision premium amount.
COVERAGES / PREMIUMS	Collision Amount	Enter amount: The collision premium amount.
COVERAGES / PREMIUMS	Collision Amount	Enter amount: The collision premium amount.
COVERAGES / PREMIUMS	ACV unless Amount Stated Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	ACV unless Amount Stated Amount	Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS	ACV unless Amount Stated Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	ACV unless Amount Stated Amount	Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS	ACV unless Amount Stated Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	ACV unless Amount Stated Amount	Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS	ACV unless Amount Stated Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	ACV unless Amount Stated Amount	Enter limit: The limit associated with comprehensive and collision coverage is the actual cash value of the vehicle, unless an amount is stated here.
COVERAGES / PREMIUMS	Towing & Labor Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS	Towing & Labor Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS	Towing & Labor Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS	Towing & Labor Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter limit: The towing and labor limit amount.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter amount: The towing and labor premium amount.

ACORD 90 GA (2009/01) 19 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS	Towing & Labor Amount	Enter amount: The towing and labor premium amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Transportation Expense Per Day Limit	Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS	Transportation Expense Maximum Limit	Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Transportation Expense Per Day Limit	Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS	Transportation Expense Maximum Limit	Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Transportation Expense Per Day Limit	Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS	Transportation Expense Maximum Limit	Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Vehicle Number	Enter number: The producer assigned vehicle number.
COVERAGES / PREMIUMS	Transportation Expense Per Day Limit	Enter limit: The transportation expense or rental reimbursement per day limit amount.
COVERAGES / PREMIUMS	Transportation Expense Maximum Limit	Enter limit: The transportation expense or rental reimbursement maximum limit amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Amount	Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Amount	Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Amount	Enter amount: The transportation expense or rental reimbursement premium amount.

ACORD 90 GA (2009/01) 20 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Transportation Expenses And Rental Reimbursement Amount	Enter amount: The transportation expense or rental reimbursement premium amount.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.

ACORD 90 GA (2009/01) 21 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.

ACORD 90 GA (2009/01) 22 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Coverage Code	Enter code: The coverage code of the other coverage or adjustment.
COVERAGES / PREMIUMS	Description	Enter text: The description of the coverage.
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Limit	Enter limit: The limit amount of the other coverage.
COVERAGES / PREMIUMS	Limit Applies To	Enter code: The code indicating what the limit applies to (e.g. per accident, per person).
COVERAGES / PREMIUMS	Deductible $	Enter deductible: The deductible amount of the coverage.
COVERAGES / PREMIUMS	Deductible %	Enter percentage: The deductible percentage for the coverage.
COVERAGES / PREMIUMS	Option 1	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 2	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 3	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Option 4	Enter code: The option applicable to this coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.

ACORD 90 GA (2009/01) 23 of 36

Section Name	Field Name	Field and/or Section Description
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Amount	Enter amount: The premium amount associated with the coverage.
COVERAGES / PREMIUMS	Total Per Vehicle	Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS	Total Per Vehicle	Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS	Total Per Vehicle	Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS	Total Per Vehicle	Enter amount: The total amount for the vehicle.
COVERAGES / PREMIUMS	Estimated Total	Enter amount: The estimated total cost amount of the policy.
COVERAGES / PREMIUMS	Policy Fee	Enter amount: The amount of fee associated with the policy.
IDENTIFICATION SECTION	Initials	Initial here: The named insured's initials.
IDENTIFICATION SECTION	Agency Customer ID	Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage).
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.

ACORD 90 GA (2009/01) 24 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Stdt > 100	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION	Good Stdt	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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.
RESIDENT & DRIVER INFORMATION	Drv Train	Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION	Acc Prev Cse Date	Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.

ACORD 90 GA (2009/01) 25 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & DRIVER INFORMATION	Stdt > 100	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION	Good Stdt	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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.
RESIDENT & DRIVER INFORMATION	Drv Train	Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION	Acc Prev Cse Date	Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).

ACORD 90 GA (2009/01) 26 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & DRIVER INFORMATION	Stdt > 100	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION	Good Stdt	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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.
RESIDENT & DRIVER INFORMATION	Drv Train	Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION	Acc Prev Cse Date	Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.

ACORD 90 GA (2009/01) 27 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & DRIVER INFORMATION	Stdt > 100	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.
RESIDENT & DRIVER INFORMATION	Good Stdt	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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.
RESIDENT & DRIVER INFORMATION	Drv Train	Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.

ACORD 90 GA (2009/01) 28 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Acc Prev Cse Date	Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.
RESIDENT & DRIVER INFORMATION	Stdt > 100	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a school over 100 road miles from the principal place of garaging. In the Remarks section, show name of institution and address.

ACORD 90 GA (2009/01) 29 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER INFORMATION	Good Stdt	Enter Y for a “Yes” response. Input N for “No” response. Indicate if the 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.
RESIDENT & DRIVER INFORMATION	Drv Train	Enter Y for a “Yes” response. Input N for “No” response. 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 (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies for the credit.
RESIDENT & DRIVER INFORMATION	Acc Prev Cse Date	Enter date: The date on which the driver successfully completed an approved accident prevention or defensive driver course. Attach a Course Completion Certificate if the driver qualifies.
RESIDENT & DRIVER INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.
RESIDENT & DRIVER INFORMATION	First Name	Enter text: The driver's first name (given name).
RESIDENT & DRIVER INFORMATION	Middle Name	Enter text: The driver's middle name or initial (other given name).
RESIDENT & DRIVER INFORMATION	Last Name	Enter text: The driver's last name (surname).
RESIDENT & DRIVER INFORMATION	Sex	Enter code: The gender of the driver.
RESIDENT & DRIVER INFORMATION	Mar Stat	Enter code: The marital status of the driver. Examples are: S - Single; M - Married; D -Divorced; P - Separated; W - Widowed, C - Domestic Partner (unmarried), V - Civil Union, U - Unknown, O - Other
RESIDENT & DRIVER INFORMATION	Relation to Applicant	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.
RESIDENT & DRIVER INFORMATION	Date of Birth	Enter date: The birth date of the driver.
RESIDENT & DRIVER INFORMATION	Number (#)	Enter number: The number assigned to the driver by the producer.

ACORD 90 GA (2009/01) 30 of 36

Section Name	Field Name	Field and/or Section Description
RESIDENT & DRIVER
INFORMATION	Occupation	Enter text: The occupation of the driver.
RESIDENT & DRIVER
INFORMATION	Date Lic	Enter date: The original date on which a driver's license was issued to this driver.
		Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver resides at a
RESIDENT & DRIVER		school over 100 road miles from the principal place of garaging. In the Remarks section,
INFORMATION	Stdt > 100	show name of institution and address.
		Enter Y for a “Yes” response. Input N for “No” response. Indicate if the driver qualifies for
RESIDENT & DRIVER		a good student credit (verify that company offers this credit). Complete and attach a Good
INFORMATION	Good Stdt	Student Certificate (ACORD 91) for each operator who qualifies.
		Enter Y for a “Yes” response. Input N for “No” response. Indicate if driver training credit
		applies to the driver, if required by the company. Refer to the company's manual to verify if
RESIDENT & DRIVER		a credit or surcharge should be applied. Attach a Driver Training Certificate (ACORD 91) if the operator is under age 21 and has successfully completed this training and qualifies
INFORMATION	Drv Train	for the credit.
		Enter date: The date on which the driver successfully completed an approved accident
RESIDENT & DRIVER		prevention or defensive driver course. Attach a Course Completion Certificate if the driver
INFORMATION	Acc Prev Cse Date	qualifies.
RESIDENT & DRIVER
INFORMATION	Drivers License #	Enter identifier: The driver's license number.
RESIDENT & DRIVER
INFORMATION	Licensed State	Enter code: The state the driver is licensed in.
RESIDENT & DRIVER
INFORMATION	Social Security #	Enter identifier: The tax identifier (social security number) of the driver.
		Enter number: The number of years associated with "… an accident... or convicted of a
ACCIDENTS/CONVICTIONS	Within Last_Years?	moving violation" question.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if any driver has had an
CONVICTIONS	Yes/No	accident or been convicted of a moving violation in the mandated number of years.
ACCIDENTS /		Enter number: The producer's driver number for the driver involved in the accident or
CONVICTIONS	Drv #	conviction.
ACCIDENTS /
CONVICTIONS	Date of Accident / Conviction	Enter date: The date of the accident or conviction.
ACCIDENTS /	Description of Accident or	Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
CONVICTIONS	Conviction	Remarks Schedule, if more space is needed.

ACORD 90 GA (2009/01) 31 of 36

Section Name	Field Name	Field and/or Section Description
ACCIDENTS /
CONVICTIONS	Place of Accident / Conviction	Enter text: The place of the accident or conviction.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or
CONVICTIONS	BI or Death Yes / No	conviction resulted in bodily injury or death.
ACCIDENTS /
CONVICTIONS	Amount of Property Damage	Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS /		Enter number: The producer's driver number for the driver involved in the accident or
CONVICTIONS	Drv #	conviction.
ACCIDENTS /
CONVICTIONS	Date of Accident / Conviction	Enter date: The date of the accident or conviction.
ACCIDENTS /	Description of Accident or	Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
CONVICTIONS	Conviction	Remarks Schedule, if more space is needed.
ACCIDENTS /
CONVICTIONS	Place of Accident / Conviction	Enter text: The place of the accident or conviction.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or
CONVICTIONS	BI or Death Yes / No	conviction resulted in bodily injury or death.
ACCIDENTS /
CONVICTIONS	Amount of Property Damage	Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS /		Enter number: The producer's driver number for the driver involved in the accident or
CONVICTIONS	Drv #	conviction.
ACCIDENTS /
CONVICTIONS	Date of Accident / Conviction	Enter date: The date of the accident or conviction.
ACCIDENTS /	Description of Accident or	Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
CONVICTIONS	Conviction	Remarks Schedule, if more space is needed.
ACCIDENTS /
CONVICTIONS	Place of Accident / Conviction	Enter text: The place of the accident or conviction.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or
CONVICTIONS	BI or Death Yes / No	conviction resulted in bodily injury or death.
ACCIDENTS /
CONVICTIONS	Amount of Property Damage	Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS /		Enter number: The producer's driver number for the driver involved in the accident or
CONVICTIONS	Drv #	conviction.
ACCIDENTS /
CONVICTIONS	Date of Accident / Conviction	Enter date: The date of the accident or conviction.
ACCIDENTS /	Description of Accident or	Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
CONVICTIONS	Conviction	Remarks Schedule, if more space is needed.

ACORD 90 GA (2009/01) 32 of 36

Section Name	Field Name	Field and/or Section Description
ACCIDENTS /
CONVICTIONS	Place of Accident / Conviction	Enter text: The place of the accident or conviction.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or
CONVICTIONS	BI or Death Yes / No	conviction resulted in bodily injury or death.
ACCIDENTS /
CONVICTIONS	Amount of Property Damage	Enter amount: The amount of property damage resulting from the accident or conviction.
ACCIDENTS /		Enter number: The producer's driver number for the driver involved in the accident or
CONVICTIONS	Drv #	conviction.
ACCIDENTS /
CONVICTIONS	Date of Accident / Conviction	Enter date: The date of the accident or conviction.
ACCIDENTS /	Description of Accident or	Enter text: The description of the accident or conviction. Attached ACORD 101, Additional
CONVICTIONS	Conviction	Remarks Schedule, if more space is needed.
ACCIDENTS /
CONVICTIONS	Place of Accident / Conviction	Enter text: The place of the accident or conviction.
ACCIDENTS /		Enter Y for a “Yes” response. Input N for “No” response. Indicates if the accident or
CONVICTIONS	BI or Death Yes / No	conviction resulted in bodily injury or death.
ACCIDENTS /
CONVICTIONS	Amount of Property Damage	Enter amount: The amount of property damage resulting from the accident or conviction.
		Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
	1. Vehicle not registered to	question "With the exception of encumbrances, are any vehicles not solely owned by and
GENERAL INFORMATION	applicant?	registered to the applicant?".
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
		Enter text: The additional interest's full name. As used here, this is the name of the other
GENERAL INFORMATION	Name of Other Owner	owner of the vehicle.
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
		Enter text: The additional interest's full name. As used here, this is the name of the other
GENERAL INFORMATION	Name of Other Owner	owner of the vehicle.
	2. Any car modified / special	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
GENERAL INFORMATION	equipment?	question "Any vehicles customized, altered or with special equipment?".
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
GENERAL INFORMATION	Description	Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION	Cost	Enter amount: The cost of the modified or special equipment on the vehicle.
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
GENERAL INFORMATION	Description	Enter text: The description of modified or special equipment on the vehicle.
GENERAL INFORMATION	Cost	Enter amount: The cost of the modified or special equipment on the vehicle.

ACORD 90 GA (2009/01) 33 of 36

Section Name	Field Name	Field and/or Section Description
GENERAL INFORMATION	3. Any existing damage?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any existing damage to vehicle? (Include damaged glass)".
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
GENERAL INFORMATION	Description	Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION	Veh #	Enter number: The producer assigned vehicle number.
GENERAL INFORMATION	Description	Enter text: The description of existing damage on the vehicle.
GENERAL INFORMATION	4. Any other losses incurred?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any other losses incurred (not shown in Accident/Convictions area)?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Description	Enter text: The description of any other losses incurred.
GENERAL INFORMATION	Cost	Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Description	Enter text: The description of any other losses incurred.
GENERAL INFORMATION	Cost	Enter amount: The cost of any other losses incurred.
GENERAL INFORMATION	5. Any other automobile insurance?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any other auto insurance in household? (Include any provided by employer)".
GENERAL INFORMATION	Name Insured	Enter text: The named insured on other insurance.
GENERAL INFORMATION	Year	Enter year: The model year of the vehicle. As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION	Make	Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION	Model	Enter text: The manufacturer's model name for the vehicle. As used here, this is a vehicle covered by other insurance.
GENERAL INFORMATION	Carrier	Enter text: The insurer name on any other applicable insurance.
GENERAL INFORMATION	NAIC #	Enter code: The NAIC code of the insurance company that issued the policy.
GENERAL INFORMATION	Policy #	Enter identifier: The policy number on any other applicable insurance.
GENERAL INFORMATION	6. Any household member in military service?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any household member in military service?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Branch	Enter text: The branch of military service.
GENERAL INFORMATION	Rank	Enter text: The driver's rank in the military.
GENERAL INFORMATION	Base Location - Street	Enter text: The military base's first address line.
GENERAL INFORMATION	Base Location - City	Enter text: The city of the military base.
GENERAL INFORMATION	Base Location - State	Enter code: The state or province code of the military base.
GENERAL INFORMATION	Base Location - Zip	Enter code: The postal code of the military base.

ACORD 90 GA (2009/01) 34 of 36

Section Name	Field Name	Field and/or Section Description
GENERAL INFORMATION	Base Location - Country	Enter code: The country code of the military base.
GENERAL INFORMATION	Veh at Base Y/N	Enter Y for a “Yes” response. Input N for “No” response. Indicates if the driver has a vehicle at a military base.
GENERAL INFORMATION	7. Any license suspended / revoked?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any drivers license been suspended/revoked?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Suspension Period Start Date	Enter date: The date the driver's license suspension became effective.
GENERAL INFORMATION	Suspension Period End Date	Enter date: The date the driver's license suspension is scheduled to end.
GENERAL INFORMATION	Explanation	Enter text: The reason the driver's license was suspended or revoked.
GENERAL INFORMATION	Reinstatement Date	Enter date: The date a suspended or revoked driver's license was reinstated.
GENERAL INFORMATION	8. Any driver have physical / mental impairments?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any driver have physical/mental impairment?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Description of Special Equipment	Enter text: The description of any special equipment for a driver with physical or mental impairments.
GENERAL INFORMATION	Medication / Treatment	Enter text: The description of any medication or treatments for a driver with physical or mental impairments.
GENERAL INFORMATION	9. Any financial responsibility filing?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any financial responsibility filing?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Reason for Filing	Enter text: The description of why a financial responsibility filing is required.
GENERAL INFORMATION	Filing Date	Enter date: The date on which the financial responsibility filing was originally required.
GENERAL INFORMATION	10. Any coverage declined, cancelled or non-renewed during the last three (3) years?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Any policy or coverage declined, cancelled or non-renewed during the mandated number of years?".
GENERAL INFORMATION	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION	Reason declined, cancelled, or non-renewed	Enter text: The description of the reason for coverage being declined, cancelled or non-renewed within the last mandated number of years.
GENERAL INFORMATION	11. Is this brokered business to the agent?	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the question "Is this brokered business to the agent?".
GENERAL INFORMATION	Remarks	Enter text: An explanation of a response to a general information or underwriting question. Normally, "Yes" responses require an explanation.
IDENTIFICATION SECTION	Initials	Initial here: The named insured's initials.

ACORD 90 GA (2009/01) 35 of 36

Section Name	Field Name	Field and/or Section Description
		Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION	Agency Customer ID	agency or brokerage).
GENERAL INFORMATION		Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
(continued)	12. Has agent inspected vehicle?	question "Has agent inspected vehicles?".
GENERAL INFORMATION		Enter text: An explanation of a response to a general information or underwriting question.
(continued)	Remarks	Normally, "Yes" responses require an explanation.
	13. Has any named insured driven	Enter Y for a “Yes” response. Input N for “No” response. Indicates the response to the
GENERAL INFORMATION	without liability insurance during	question, "Has any named insured driven without liability insurance during any part of the
(continued)	any part of the last six (6) months?	last specified period of time?".
GENERAL INFORMATION
(continued)	Drv #	Enter number: The number assigned to the driver by the producer.
GENERAL INFORMATION		Enter text: The explanation of why the driver has driven with no liability insurance within
(continued)	Explanation	the last mandated time.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a young
ATTACHMENTS	Young Driver Questionnaire	driver questionnaire.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a driver
ATTACHMENTS	Driver Training Certificate	training certificate.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a good
ATTACHMENTS	Good Student Certificate	student certificate.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing an anti-theft
ATTACHMENTS	Anti-Theft Device Certificate	device certificate.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a medical
ATTACHMENTS	Medical Statement	statement.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a motor
ATTACHMENTS	Motor Vehicle Report	vehicle report.
REMARKS /		Check the box (if applicable): Indicates if an attachment will follow containing a
ATTACHMENTS	Photograph	photograph.
REMARKS /
ATTACHMENTS	Bill of Sale	Check the box (if applicable): Indicates if an attachment will follow containing a bill of sale.
REMARKS /
ATTACHMENTS	Other	Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS /
ATTACHMENTS	Other Description	Enter text: The description of the attachment.
REMARKS /
ATTACHMENTS	Other	Check the box (if applicable): Indicates there are attachments other than those listed.

ACORD 90 GA (2009/01) 36 of 36

Section Name	Field Name	Field and/or Section Description
REMARKS /
ATTACHMENTS	Other Description	Enter text: The description of the attachment.
REMARKS /
ATTACHMENTS	Other	Check the box (if applicable): Indicates there are attachments other than those listed.
REMARKS /
ATTACHMENTS	Other Description	Enter text: The description of the attachment.
REMARKS /
ATTACHMENTS	Remarks	Enter text: The personal vehicle line of business remarks.
SIGNATURE	Producer's Statement	Enter text: The length of time the named insured has been known by the producer.
SIGNATURE	Applicant's Signature	Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE	Date	Enter date: The date the form was signed by the named insured.
		Sign here: Accommodates the signature of the authorized representative (e.g. producer,
SIGNATURE	Producer's Signature	agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
		Enter identifier: The National Producer Number (NPN) as defined in the National
		Insurance Producer Registry (NIPR). Note: The NPN is not the same as the producer
SIGNATURE	National Producer Number	state license number.
		Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION	Agency Customer ID	agency or brokerage).
	I accept Traditional Uninsured	Initial here: The named insured's initials. As used here, indicates the named insured
INITIALS	Motorist Coverage	accepts traditional uninsured motorists coverage.
	I accept New Uninsured Motorist	Initial here: The named insured's initials. As used here, indicates the named insured
INITIALS	Coverage	accepts new uninsured motorists coverage.
	I reject ALL Uninsured Motorist	Initial here: The named insured's initials. As used here, indicates the named insured
INITIALS	Coverage	rejects all uninsured motorists coverage.
SIGNATURE	Applicant's Signature	Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE	Date	Enter date: The date the form was signed by the named insured.
		Enter identifier: The customer's identification number assigned by the producer (e.g.
IDENTIFICATION SECTION	Agency Customer ID	agency or brokerage).
IDENTIFICATION SECTION	Initials	Initial here: The named insured's initials.
		The edition identifier of the form including the form number and edition (the date is
Edition	Date	typically formatted YYYY/MM).