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ACORD Form 93 Young Driver Questionnaire Instructions
 

 
Universal wording updates to improve clarity and intent were made to all FIG text for this form on 10/22/2008.
Section Name Field Name Field and/or Section Description
TITLE ACORD 93 (2004/10) Young Driver Questionnaire The title of the form. The ACORD 93 - is generally completed by drivers under the age of twenty five. The Young Driver Questionnaire provides additional underwriting information that is usually common to youthful drivers. This form should be completed and signed exclusively by the young driver with no input from the parents and/or agent. The top section of the form must be completed by the young driver in his/her own handwriting. IMPORTANT: Question # 8 may not be asked in the District of Columbia, Missouri or Ohio.
IDENTIFICATION SECTION Insured's Name Enter text: The named insured(s) as it/they will appear on the policy declarations page.
IDENTIFICATION SECTION Policy Number Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number.
QUESTIONAIRE QUESTIONS Do you have any driving limitations imposed by your parents? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you have any driving limitations imposed by your parents?",
QUESTIONAIRE QUESTIONS Do you have any driving limitations imposed by your parents? No Check the box (if applicable): Indicates a "No" response to the question, "Do you have any driving limitations imposed by your parents?",
QUESTIONAIRE QUESTIONS Do you allow others to use your car? (who and why) Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Do you allow others to use your car?".
QUESTIONAIRE QUESTIONS Do you allow others to use your car? (who and why) No Check the box (if applicable): Indicates a "No" response to the question, "Do you allow others to use your car?".
QUESTIONAIRE QUESTIONS Had your driver's license or permit ever been revoked or suspended? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Has your driver's license or permit ever been revoked or suspended?".
QUESTIONAIRE QUESTIONS Had your driver's license or permit ever been revoked or suspended? No Check the box (if applicable): Indicates a "No" response to the question, "Has your driver's license or permit ever been revoked or suspended?".
QUESTIONAIRE QUESTIONS Have you ever received a ticket, citation, or warning for any traffic violation other than parking? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Have you ever received a ticket, citation, or warning for any traffic violation other than parking?".

ACORD 93 (2004/10) 1 of 3 ACORD 93 (2004/10) 2 of 3 ACORD 93 (2004/10) 3 of 3

Section Name Field Name Field and/or Section Description
Have you ever received a ticket,
QUESTIONAIRE citation, or warning for any traffic Check the box (if applicable): Indicates a "No" response to the question, "Have you ever
QUESTIONS violation other than parking? No received a ticket, citation, or warning for any traffic violation other than parking?".
Have you ever been in an accident
QUESTIONAIRE as a driver? (give dates and Check the box (if applicable): Indicates a "Yes" response to the question, "Have you ever
QUESTIONS details) Yes been in an accident as a driver?".
Have you ever been in an accident
QUESTIONAIRE as a driver? (give dates and Check the box (if applicable): Indicates a "No" response to the question, "Have you ever
QUESTIONS details) No been in an accident as a driver?".
Have you ever been arrested or
detained for any reason, other
QUESTIONAIRE QUESTIONS than a traffic violation? (give dates and details) Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Have you ever been arrested or detained for any reason, other than a traffic violation?".
Have you ever been arrested or
detained for any reason, other
QUESTIONAIRE QUESTIONS than a traffic violation? (give dates and details) No Check the box (if applicable): Indicates a "No" response to the question, "Have you ever been arrested or detained for any reason, other than a traffic violation?".
QUESTIONAIRE QUESTIONS Is the auto you operated modified or equipped with any special equipment, have modified bodywork, or special paint? Yes Check the box (if applicable): Indicates a "Yes" response to the question, "Is the auto you operate modified or equipped with any special equipment, have modified bodywork, or special paint?".
QUESTIONAIRE QUESTIONS Is the auto you operated modified or equipped with any special equipment, have modified bodywork, or special paint? No Check the box (if applicable): Indicates a "No" response to the question, "Is the auto you operate modified or equipped with any special equipment, have modified bodywork, or special paint?".
Have you ever had auto insurance Check the box (if applicable): Indicates a "Yes" response to the question, "Have you ever
QUESTIONAIRE declined or cancelled? (give dates had auto insurance declined or cancelled? (Not applicable in the District of Columbia,
QUESTIONS and details) Yes Missouri, or Ohio)".
Have you ever had auto insurance Check the box (if applicable): Indicates a "No" response to the question, "Have you ever
QUESTIONAIRE declined or cancelled? (give dates had auto insurance declined or cancelled? (Not applicable in the District of Columbia,
QUESTIONS and details) No Missouri, or Ohio)".
Section Name Field Name Field and/or Section Description
SIGNATURE Young Driver's Signature Sign here: Accommodates the signature of the driver.
SIGNATURE Date Enter date: The date the driver signed the form.
SIGNATURE Producer's Signature Sign here: Accommodates the signature of the authorized representative (e.g. producer, agent, broker, etc.). by all companies to issue Certificates. This is required in most states.
SIGNATURE National Producer Number Enter identifier: The National Producer Number (NPN) as defined in the National Insurance Producer Registry (NIPR).
AGENTS COMMENTS Agent's Comments Enter text: The producer's comments.
Edition Date The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).