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ACORD 90 WA (2009/01) 1 of 38
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Universal wording updates to improve clarity and intent were made to all FIG text for this form on 01/30/2009. |
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Section Name |
Field Name |
Field and/or Section Description |
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TITLE ACORD 90 WA (2009/01) |
Washington Personal Auto Application Section |
The title of the form. ACORD 90 WA, Washington Personal Auto Application Section, is used when insurance is desired for personal vehicles. Following are the unique state characteristics of ACORD 90 WA, Washington Personal Auto Application Section: * 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. * State Specific Fraud Warning * Statement added to Page 3 of the form referring to the options available under Underinsured Motorists and the applicant's right to reject this coverage. * Mandatory Offer of Personal Injury Protection is on Page 4 of the application. |
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IDENTIFICATION SECTION |
Agency Customer ID |
Enter identifier: The customer's identification number assigned by the producer (e.g. agency or brokerage). |
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IDENTIFICATION SECTION |
Date |
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY) |
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IDENTIFICATION SECTION |
Agency |
Enter text: The full name of the producer/agency. |
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IDENTIFICATION SECTION |
Policy Number |
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. |
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IDENTIFICATION SECTION |
Effective Date |
Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. |
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IDENTIFICATION SECTION |
Named Insured(s) |
Enter text: The named insured(s) as it/they will appear on the policy declarations page. |
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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. |
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IDENTIFICATION SECTION |
NAIC Code |
Enter code: The identification code assigned to the insurer by the NAIC. |
ACORD 90 WA (2009/01) 2 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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GARAGING ADDRESS (from ACORD 88) |
Location # |
Enter number: The producer assigned number of the location. |
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GARAGING ADDRESS (from ACORD 88) |
Veh # |
Enter number: The producer assigned vehicle number. |
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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. |
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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. |
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GARAGING ADDRESS (from ACORD 88) |
County |
Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
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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. |
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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. |
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GARAGING ADDRESS (from ACORD 88) |
Location # |
Enter number: The producer assigned number of the location. |
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GARAGING ADDRESS (from ACORD 88) |
Veh # |
Enter number: The producer assigned vehicle number. |
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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. |
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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. |
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GARAGING ADDRESS (from ACORD 88) |
County |
Enter text: The county of the location. As used here, this is the garaging location of the vehicle. |
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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. |
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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. |
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GARAGING ADDRESS (from ACORD 88) |
Location # |
Enter number: The producer assigned number of the location. |
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GARAGING ADDRESS (from ACORD 88) |
Veh # |
Enter number: The producer assigned vehicle number. |
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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. |
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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. |
ACORD 90 WA (2009/01) 3 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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GARAGING ADDRESS |
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Enter text: The county of the location. As used here, this is the garaging location of the |
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(from ACORD 88) |
County |
vehicle. |
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GARAGING ADDRESS |
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Enter code: The state or province of the physical location. As used here, this is the |
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(from ACORD 88) |
State |
garaging location of the vehicle. |
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GARAGING ADDRESS |
|
Enter code: The postal code of the physical location. As used here, this is the garaging |
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(from ACORD 88) |
Zip + 4 |
location of the vehicle. |
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GARAGING ADDRESS |
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|
(from ACORD 88) |
Location # |
Enter number: The producer assigned number of the location. |
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GARAGING ADDRESS |
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(from ACORD 88) |
Veh # |
Enter number: The producer assigned vehicle number. |
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GARAGING ADDRESS |
|
Enter text: The first address line of the physical location. As used here, this is the garaging |
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(from ACORD 88) |
Street |
location of the vehicle. |
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GARAGING ADDRESS |
|
Enter text: The city of the physical location. As used here, this is the garaging location of |
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(from ACORD 88) |
City |
the vehicle. |
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GARAGING ADDRESS |
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Enter text: The county of the location. As used here, this is the garaging location of the |
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(from ACORD 88) |
County |
vehicle. |
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GARAGING ADDRESS |
|
Enter code: The state or province of the physical location. As used here, this is the |
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(from ACORD 88) |
State |
garaging location of the vehicle. |
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GARAGING ADDRESS |
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Enter code: The postal code of the physical location. As used here, this is the garaging |
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(from ACORD 88) |
Zip + 4 |
location of the vehicle. |
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VEHICLE DESCRIPTION / |
Total Number of Vehicles in |
Enter number: The total number of vehicles in the household. As used here, this is the |
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USE |
Household |
garaging location of the vehicle. |
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VEHICLE DESCRIPTION / |
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USE |
Veh # |
Enter number: The producer assigned vehicle number. |
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VEHICLE DESCRIPTION / |
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USE |
Year |
Enter year: The model year of the vehicle. |
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VEHICLE DESCRIPTION / |
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USE |
Make |
Enter text: The manufacturer of the vehicle (e.g. Ford, Chevy). |
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VEHICLE DESCRIPTION / |
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USE |
Model |
Enter text: The manufacturer's model name for the vehicle. |
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VEHICLE DESCRIPTION / |
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USE |
Body Type |
Enter code: The body type of the vehicle. |
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VEHICLE DESCRIPTION / |
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Enter identifier: The vehicle identification number (VIN) or serial number assigned by the |
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USE |
VIN |
manufacturer. |
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VEHICLE DESCRIPTION / |
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USE |
Registered State |
Enter code: The state or province in which the vehicle is registered. |
ACORD 90 WA (2009/01) 4 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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VEHICLE DESCRIPTION / USE |
HP/CC |
Enter number: The amount of horsepower or the number of cubic centimeters of displacement. |
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VEHICLE DESCRIPTION / USE |
Date Leased |
Enter date: The date the insured leased the vehicle. |
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VEHICLE DESCRIPTION / USE |
Date Purch |
Enter date: The date the vehicle was purchased. |
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VEHICLE DESCRIPTION / USE |
New/Used |
Enter code: A code indicating if the vehicle was purchased new or used. |
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VEHICLE DESCRIPTION / USE |
Veh # |
Enter number: The producer assigned vehicle number. |
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VEHICLE DESCRIPTION / USE |
Cost New |
Enter amount: The original cost of the vehicle. |
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VEHICLE DESCRIPTION / USE |
Symbol Age Grp |
Enter code: The symbol required for physical damage coverage. |
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VEHICLE DESCRIPTION / USE |
Terr |
Enter code: The rating territory code where the vehicle is principally garaged. |
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VEHICLE DESCRIPTION / USE |
Miles 1 Way Wk/Schl |
Enter number: The number of miles from the garage location to school or work. |
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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. |
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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. |
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VEHICLE DESCRIPTION / USE |
Usage |
Enter code: The predominant use of the vehicle (e.g. P - Pleasure, B - Business, F -Farm). |
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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). |
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VEHICLE DESCRIPTION / USE |
Multi-Car |
Check the box (if applicable): Indicates if the vehicle is subject to consideration for multi-car discount. |
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VEHICLE DESCRIPTION / USE |
Carpool |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if a carpool discount applies. |
ACORD 90 WA (2009/01) 5 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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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 |
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VEHICLE DESCRIPTION / USE |
Odometer Reading |
Enter number: The odometer reading at the time the insurance policy is applied for. |
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VEHICLE DESCRIPTION / USE |
Annual Mileage |
Enter number: The total estimated annual mileage for the vehicle. |
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VEHICLE DESCRIPTION / USE |
Govern Driver |
Enter number: The producer assigned driver number of the driver assigned to the vehicle for rating purposes. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
ACORD 90 WA (2009/01) 6 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Number |
Enter number: The producer assigned driver number of the driver using the vehicle. |
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VEHICLE DESCRIPTION / USE |
Driver Use % |
Enter percentage: The percentage of time a particular driver uses the vehicle. |
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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. |
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VEHICLE DESCRIPTION / USE |
Veh # |
Enter number: The producer assigned vehicle number. |
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VEHICLE DESCRIPTION / USE |
Passive Seat Belt |
Enter code: The type of seat belts in the vehicle. |
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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. |
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VEHICLE DESCRIPTION / USE |
Anti-Lock Brakes 2/4 |
Enter code: The type of anti-lock brakes in the vehicle. |
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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. |
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VEHICLE DESCRIPTION / USE |
Credits and Surcharges |
Enter text: A credit or surcharge represented as text. |
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VEHICLE DESCRIPTION / USE |
Veh # |
Enter number: The producer assigned vehicle number. |
|
VEHICLE DESCRIPTION / USE |
Year |
Enter year: The model year of the vehicle. |
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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. |
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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. |
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VEHICLE DESCRIPTION / USE |
Registered State |
Enter code: The state or province in which the vehicle is registered. |
ACORD 90 WA (2009/01) 7 of 38
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Section Name |
Field Name |
Field and/or Section Description |
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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. |
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VEHICLE DESCRIPTION / USE |
Veh # |
Enter number: The producer assigned vehicle number. |
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VEHICLE DESCRIPTION / USE |
Cost New |
Enter amount: The original cost of the vehicle. |
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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 WA (2009/01) 8 of 38
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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 |
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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 WA (2009/01) 9 of 38
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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 WA (2009/01) 10 of 38
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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 WA (2009/01) 11 of 38
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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 WA (2009/01) 12 of 38
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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 WA (2009/01) 13 of 38
|
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 WA (2009/01) 14 of 38
|
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 / |
|
Enter code: The type of air bags in the vehicle. Some states may only require a Yes or No |
|
USE |
Air Bag Drv/Both |
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 / |
|
Enter code: The principal anti-theft device found on the vehicle. Some states may only |
|
USE |
Anti-Theft Devices |
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 One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
|
Enter limit: The vehicle combined single limit liability amount. Any questions about |
|
Single Limit Liability Each |
appropriate limits or applicable policy coverage(s) should be answered by the issuing |
|
COVERAGES / PREMIUMS |
Accident |
insurer(s). |
|
COVERAGES / PREMIUMS |
Single Limit Liability Amount One |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES / PREMIUMS |
Single Limit Liability Amount Two |
Enter amount: The vehicle combined single limit liability premium amount. |
|
Single Limit Liability Amount |
|
|
COVERAGES / PREMIUMS |
Three |
Enter amount: The vehicle combined single limit liability premium amount. |
|
COVERAGES / PREMIUMS |
Single Limit Liability Amount Four |
Enter amount: The vehicle combined single limit liability premium amount. |
|
|
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 |
|
COVERAGES / PREMIUMS |
Bodily Injury Each Person |
insurer(s). |
|
|
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 |
|
COVERAGES / PREMIUMS |
Bodily Injury Each Accident |
insurer(s). |
|
COVERAGES / PREMIUMS |
Bodily Injury Amount One |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES / PREMIUMS |
Bodily Injury Amount Two |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
ACORD 90 WA (2009/01) 15 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Bodily Injury Amount Three |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
COVERAGES / PREMIUMS |
Bodily Injury Amount Four |
Enter amount: The vehicle policy, bodily injury per accident premium amount. |
|
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 Deductible |
Enter deductible: The property damage deductible amount. |
|
COVERAGES / PREMIUMS |
Property Damage Amount Vehicle One |
Enter amount: The property damage premium amount. |
|
COVERAGES / PREMIUMS |
Property Damage Amount Vehicle Two |
Enter amount: The property damage premium amount. |
|
COVERAGES / PREMIUMS |
Property Damage Amount Vehicle Three |
Enter amount: The property damage premium amount. |
|
COVERAGES / PREMIUMS |
Property Damage Amount Vehicle Four |
Enter amount: The property damage premium amount. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Medical Expenses |
Enter limit: The personal injury protection (PIP) medical expense limit amount. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Service Loss |
Enter limit: The limit amount for the other expense - service loss benefit coverage. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Income Continuation |
Enter limit: The personal injury protection (PIP) income continuation limit amount. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Funeral Expenses |
Enter limit: The limit amount for the other expense - funeral expense coverage. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Amount Vehicle One |
Enter amount: The premium associated with personal injury protection (PIP) coverage. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Amount Vehicle Two |
Enter amount: The premium associated with personal injury protection (PIP) coverage. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Amount Vehicle Three |
Enter amount: The premium associated with personal injury protection (PIP) coverage. |
|
COVERAGES / PREMIUMS |
Personal Inj Protection Amount Vehicle Four |
Enter amount: The premium associated with personal injury protection (PIP) coverage. |
|
COVERAGES / PREMIUMS |
Additional Personal Inj Protection Amount |
Enter limit: The additional personal injury protection (APIP) limit amount. |
|
COVERAGES / PREMIUMS |
Additional Personal Inj Protection Amount Vehicle One |
Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
|
COVERAGES / PREMIUMS |
Additional Personal Inj Protection Amount Vehicle Two |
Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
ACORD 90 WA (2009/01) 16 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Additional Personal Inj Protection Amount Vehicle Three |
Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
|
COVERAGES / PREMIUMS |
Additional Personal Inj Protection Amount Vehicle Four |
Enter amount: The premium associated with additional personal injury protection (APIP) coverage. |
|
COVERAGES / PREMIUMS |
Medical Payments Each Person |
Enter limit: The medical payments per person limit. |
|
COVERAGES / PREMIUMS |
Medical Payments Amount One |
Enter amount: The medical payments premium amount. |
|
COVERAGES / PREMIUMS |
Medical Payments Amount Two |
Enter amount: The medical payments premium amount. |
|
COVERAGES / PREMIUMS |
Medical Payments Amount Three |
Enter amount: The medical payments premium amount. |
|
COVERAGES / PREMIUMS |
Medical Payments Amount Four |
Enter amount: The medical payments premium amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists BI Single Each Accident |
Enter limit: The underinsured motorists combined single limit per accident limit amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists BI Split Each Person |
Enter limit: The underinsured motorists bodily injury per person limit. The use of this limit varies by state. In some states this may contain the combined single limit each accident amount |
|
COVERAGES / PREMIUMS |
Underinsured Motorists BI Split Each Accident |
Enter limit: The underinsured motorists bodily injury per accident limit (in some states this may contain the underinsured motorists combined single per accident limit). The use of this limit varies by state. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists Amount Vehicle One |
Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists Amount Vehicle Two |
Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists Amount Vehicle Three |
Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists Amount Vehicle Four |
Enter amount: The underinsured motorists bodily injury or combined single limit premium amount. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Each Accident |
Enter limit: The underinsured motorists property damage per accident amount. The use of this limit varies by state. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Deductible |
Enter deductible: The underinsured motorists property damage deductible amount. The use of this limit varies by state. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Amount Vehicle One |
Enter amount: The premium amount for underinsured motorists property damage coverage. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Amount Vehicle Two |
Enter amount: The premium amount for underinsured motorists property damage coverage. |
ACORD 90 WA (2009/01) 17 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Amount Vehicle Three |
Enter amount: The premium amount for underinsured motorists property damage coverage. |
|
COVERAGES / PREMIUMS |
Underinsured Motorists PD Amount Vehicle Four |
Enter amount: The premium amount for underinsured motorists property damage coverage. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Vehicle Number One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount One |
Enter deductible: The comprehensive or other than collision deductible amount. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Two |
Enter deductible: The comprehensive or other than collision deductible amount. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Three |
Enter deductible: The comprehensive or other than collision deductible amount. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Four |
Enter deductible: The comprehensive or other than collision deductible amount. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Vehicle One |
Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Vehicle Two |
Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Vehicle Three |
Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
|
COVERAGES / PREMIUMS |
Comprehensive / OTC Amount Vehicle Four |
Enter amount: The comprehensive or other than collision premium amount. In Texas this is the comprehensive premium amount only. |
|
COVERAGES / PREMIUMS |
Collision Vehicle Number One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Collision Amount One |
Enter deductible: The collision deductible amount. |
|
COVERAGES / PREMIUMS |
Collision Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Collision Amount Two |
Enter deductible: The collision deductible amount. |
|
COVERAGES / PREMIUMS |
Collision Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Collision Amount Three |
Enter deductible: The collision deductible amount. |
|
COVERAGES / PREMIUMS |
Collision Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Collision Amount Four |
Enter deductible: The collision deductible amount. |
ACORD 90 WA (2009/01) 18 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Collision Amount Vehicle One |
Enter amount: The collision premium amount. |
|
COVERAGES / PREMIUMS |
Collision Amount Vehicle Two |
Enter amount: The collision premium amount. |
|
COVERAGES / PREMIUMS |
Collision Amount Vehicle Three |
Enter amount: The collision premium amount. |
|
COVERAGES / PREMIUMS |
Collision Amount Vehicle Four |
Enter amount: The collision premium amount. |
|
COVERAGES / PREMIUMS |
ACV unless Amount Stated Vehicle Number One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
ACV unless Amount Stated Amount One |
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 Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
ACV unless Amount Stated Amount Two |
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 Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
ACV unless Amount Stated Amount Three |
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 Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
ACV unless Amount Stated Amount Four |
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 One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount One |
Enter limit: The towing and labor limit amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Two |
Enter limit: The towing and labor limit amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Three |
Enter limit: The towing and labor limit amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Four |
Enter limit: The towing and labor limit amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Vehicle One |
Enter amount: The towing and labor premium amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Vehicle Two |
Enter amount: The towing and labor premium amount. |
ACORD 90 WA (2009/01) 19 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Vehicle Three |
Enter amount: The towing and labor premium amount. |
|
COVERAGES / PREMIUMS |
Towing & Labor Amount Vehicle Four |
Enter amount: The towing and labor premium amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Vehicle Number One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Transportation Expense Per Day Limit One |
Enter limit: The transportation expense or rental reimbursement per day limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expense Maximum Limit One |
Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Transportation Expense Per Day Limit Two |
Enter limit: The transportation expense or rental reimbursement per day limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expense Maximum Limit Two |
Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Transportation Expense Per Day Limit Three |
Enter limit: The transportation expense or rental reimbursement per day limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expense Maximum Limit Three |
Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Transportation Expense Per Day Limit Four |
Enter limit: The transportation expense or rental reimbursement per day limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expense Maximum Limit Four |
Enter limit: The transportation expense or rental reimbursement maximum limit amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Amount Vehicle One |
Enter amount: The transportation expense or rental reimbursement premium amount. |
ACORD 90 WA (2009/01) 20 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Amount Vehicle Two |
Enter amount: The transportation expense or rental reimbursement premium amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Amount Vehicle Three |
Enter amount: The transportation expense or rental reimbursement premium amount. |
|
COVERAGES / PREMIUMS |
Transportation Expenses And Rental Reimbursement Amount Vehicle Four |
Enter amount: The transportation expense or rental reimbursement premium amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Vehicle Number One |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount One |
Enter limit: The auto loan coverage limit amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Vehicle Number Two |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Two |
Enter limit: The auto loan coverage limit amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Vehicle Number Three |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Three |
Enter limit: The auto loan coverage limit amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Vehicle Number Four |
Enter number: The producer assigned vehicle number. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Four |
Enter limit: The auto loan coverage limit amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Vehicle One |
Enter amount: The auto loan coverage premium amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Vehicle Two |
Enter amount: The auto loan coverage premium amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Vehicle Three |
Enter amount: The auto loan coverage premium amount. |
|
COVERAGES / PREMIUMS |
Auto Loan Amount Vehicle Four |
Enter amount: The auto loan coverage 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. |
ACORD 90 WA (2009/01) 21 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 22 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 23 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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 |
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. |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 24 of 38
|
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. |
|
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. |
ACORD 90 WA (2009/01) 25 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
RESIDENT & DRIVER INFORMATION |
Number (#) |
Enter number: The number assigned to the driver by the producer. |
ACORD 90 WA (2009/01) 26 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 27 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 28 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
RESIDENT & DRIVER INFORMATION |
Occupation |
Enter text: The occupation of the driver. |
ACORD 90 WA (2009/01) 29 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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). |
|
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 |
ACORD 90 WA (2009/01) 30 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
ACCIDENTS / CONVICTIONS |
Within Last_Years? |
Enter number: The number of years associated with "… an accident... or convicted of a moving violation" question. |
|
ACCIDENTS / CONVICTIONS |
Y / N |
Enter Y for a “Yes” response. Input N for “No” response. Indicates if any driver has had an accident or been convicted of a moving violation in the mandated number of years. |
ACORD 90 WA (2009/01) 31 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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 |
|
|
CONVICTIONS |
Conviction |
Enter text: The description of the accident or conviction. |
|
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 Y / N |
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 |
|
|
CONVICTIONS |
Conviction |
Enter text: The description of the accident or conviction. |
|
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 Y / N |
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 |
|
|
CONVICTIONS |
Conviction |
Enter text: The description of the accident or conviction. |
|
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 Y / N |
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. |
ACORD 90 WA (2009/01) 32 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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 |
|
|
CONVICTIONS |
Conviction |
Enter text: The description of the accident or conviction. |
|
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 Y / N |
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 |
|
|
CONVICTIONS |
Conviction |
Enter text: The description of the accident or conviction. |
|
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 Y / N |
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. |
ACORD 90 WA (2009/01) 33 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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. |
ACORD 90 WA (2009/01) 34 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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. |
|
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?". |
ACORD 90 WA (2009/01) 35 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
|
Enter text: An explanation of a response to a general information or underwriting question. |
|
GENERAL INFORMATION |
Remarks |
Normally, "Yes" responses require an explanation. |
|
IDENTIFICATION SECTION |
Initials |
Initial here: The named insured's initials. |
|
|
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. |
ACORD 90 WA (2009/01) 36 of 38
|
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 |
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. |
|
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. |
|
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
SIGNATURE |
I have selected UIM Limits equal to my BI and PD Coverage |
selected uninsured motorists limits equal to the bodily injury and property damage coverage. |
|
SIGNATURE |
I have selected UIM BI Limits equal to my BI Coverage, but UIM PD Limits lower than my PD Coverage |
Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury limits equal to the bodily injury coverage, but uninsured motorists property damage limits lower than the property damage coverage. |
|
SIGNATURE |
I have selected UIM BI Limits Lower than my BI Coverage, but UIM PD limits equal to my PD coverage. |
Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury limits lower than the bodily injury coverage, but uninsured motorists property damage limits equal to the property damage coverage. |
|
SIGNATURE |
I have selected UIM BI Limits and UIM PD limits lower than my BI and PD Coverage. |
Initial here: The named insured's initials. As used here, indicates the named insured has selected uninsured motorists bodily injury and uninsured motorists property damage limits lower than the bodily injury and property damage coverage. |
|
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
SIGNATURE |
I have rejected UIM BI Coverage |
rejected uninsured motorists bodily injury coverage. |
|
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
SIGNATURE |
I have rejected UIM PD Coverage |
rejected uninsured motorists property damage coverage. |
|
SIGNATURE |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
ACORD 90 WA (2009/01) 37 of 38
|
Section Name |
Field Name |
Field and/or Section Description |
|
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). |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
PROTECTION COVERAGE |
Funeral Benefits |
selected funeral benefits of $2,000 per each insured for funeral expenses. |
|
MANDATORY OFFER OF PERSONAL INJURY PROTECTION COVERAGE |
Income Continuation |
Initial here: The named insured's initials. As used here, indicates the named insured has selected up to $10,000 per each insured to cover income losses incurred within one year after the date of the insured's injury. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
PROTECTION COVERAGE |
Loss of Services Benefit |
selected Loss of Services Benefit. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit $ amount |
Enter limit: The per insured person limit amount for the other expense - service loss |
|
PROTECTION COVERAGE |
per each insured |
benefit coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit $ amount |
|
|
PROTECTION COVERAGE |
per day |
Enter limit: The per day limit amount for the other expense - service loss benefit coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit not to |
Enter limit: The per week limit amount for the other expense - service loss benefit |
|
PROTECTION COVERAGE |
exceed $ amount per week |
coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
PROTECTION COVERAGE |
Health and Hospital Benefits |
selected Health and Hospital Benefits of $35,000 per each insured. |
|
MANDATORY OFFER OF PERSONAL INJURY PROTECTION COVERAGE |
Income Continuation |
Initial here: The named insured's initials. As used here, indicates the named insured has selected up to $35,000 per each insured to cover income losses incurred within one year after the date of the insured's injury. |
|
|
|
|
Section Name |
Field Name |
Field and/or Section Description |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
PROTECTION COVERAGE |
Loss of Services Benefit |
selected Loss of Services Benefit. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit $ amount |
Enter limit: The per insured person limit amount for the other expense - service loss |
|
PROTECTION COVERAGE |
per each insured |
benefit coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit $ amount |
|
|
PROTECTION COVERAGE |
per day |
Enter limit: The per day limit amount for the other expense - service loss benefit coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
Loss of Services Benefit not to |
Enter limit: The per week limit amount for the other expense - service loss benefit |
|
PROTECTION COVERAGE |
exceed $ amount per week |
coverage. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
I reject Personal Injury Protection |
Initial here: The named insured's initials. As used here, indicates the named insured has |
|
PROTECTION COVERAGE |
in its entirety |
rejected Personal Injury Protection Coverage in its entirety. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
|
|
PROTECTION COVERAGE |
Applicant's Signature |
Sign here: Accommodates the signature of the applicant or named insured. |
|
MANDATORY OFFER OF |
|
|
|
PERSONAL INJURY |
|
|
|
PROTECTION COVERAGE |
Date |
Enter date: The date the form was signed by the named insured. |
|
|
The edition identifier of the form including the form number and edition (the date is |
|
Edition |
Date |
typically formatted YYYY/MM). |
ACORD 90 WA (2009/01) 38 of 38
|